Today there are about 3,500, but by 2037 there could be 10,000. The government is implementing a review of their activities, but in the meantime no corrections have been included. They are the Associate Medical Professionals (MAPs), assistants with two years of medical training working within hospitals and GP surgeries. They are expected to support clinicians by collecting a patient’s medical history, conducting some physical examinations, analyzing test results, but also diagnosing diseases and helping to define a patient’s treatment plan.
This is the United Kingdom, where there is strong concern about these figures: while NHS England makes it clear that they are not doctors and cannot replace them, in a system that is suffering from staff and facility shortages it is not always easy to provide these professionals with the necessary supervision. The case of Emily Chesterton, a girl who died at age 30 from an alleged misdiagnosis by a MAP whom she had met twice and believed to be a GP, a general practitioner, has caused much discussion.
“Medical Associate Professionals have been around in the United Kingdom since 2006. They developed out of the United States experiment of military medical assistants who had worked in other medical fields who undertook a two-year course to allow them to assist doctors at a clinical level with administrative and minor clinical interventions”, Peter Holden says to TrendSanità, a general practitioner (GP) of Derbyshire, Council member of British Medical Association (BMA) and vicepresident of European Union of General Practitioners (UEMO).
The effects of staff shortages
“Successive UK governments have made a complete mess of medical workforce planning and we find ourselves extremely short of physicians in the United Kingdom – Holden continues -. There has been a huge reliance over many years on colleagues from the former British Empire notably India and Pakistan plus in more recent years colleagues from Europe to fill the gap. The real problem we have in the United Kingdom is that unlike Australia, New Zealand and Canada the health service assumes the doctors never have annual leave, study leave, sick leave or any other problem and they are prepared to work seven days a week and cover absent colleagues. Whatever the morality of that approach whilst it might have been physically possible 30 or 40 years ago, with modern medicine it is quite impossible given the consultation rates that patients enjoy in the United Kingdom”.
Hence the attempt to pair physicians with figures who could support them. With the growing shortage of physicians in the country, however, it is becoming increasingly difficult to distinguish the activities performed by these professionals from those that are the responsibility of a physician. “With the current workforce situation in the United Kingdom, to give every doctor a proper professional work style and a 40 hour working week would mean that we would need something in excess of 75,000 family physicians working full time – Holden reports -. We actually have just over 40,000 headcount family physicians working in the United Kingdom”.
In 2004 Holden, as a vice chairman of the BMA’s general practitioners committee, warned the government that UK would run out of family doctors in around 2016. “and “I was just a year out in my calculations – the GP smiles bitterly -. Politicians forget that it takes at least 10 years before a doctor can work unsupervised and at least 13 before they can practise independently from the time of admission to medical school”. In the United Kingdom it takes 5 or 6 years for the basic medical qualification plus two years foundation working in a range of university approved hospital jobs. Only then 7 or 8 years from admission to medical school do doctors begin to specialise in one of the 61 medical sub specialties in the United Kingdom of which general practise is one. The minimum training time for a family physician is another three years, even if it has been our ambition to take it to five years for many years now and colleagues generally do a fourth year before seeking to strike out on their own.
The risk of “passing off”
Because of the shortage of doctors, successive British governments have sought ways of getting those professions supplementary to medicine to “practise at the top of their licence”. For example, nurses will take on specific disease entities such as the long term care of asthma or diabetes and have prescribing privileges in relation to that. “Such advanced practitioner colleagues have significant clinical experience before starting their advanced training – Holden remembers -. Their base profession training is three years at university they are then required to have around five years clinical experience before undertaking a masters level qualification which will then give them advanced practitioner status”.
Medical Associate Professionals lack the clinical experience and training to work independently on complex cases
In contrast, MAPs receive two years of clinical training after a scientific degree. These professionals simply don’t have the clinical experience or length of training to make them safe to work on their own seeing undifferentiated presentations of illness. They must be supervised after each case they handle.
“In some ways it is like having to supervise a medical student and it simply doesn’t save time – Holden ponders -. Some of these don’t recognise the limits of their knowledge skills and their confidence greatly exceeds their competence, some don’t recognise when they are straying beyond their safe working boundaries. There have been several serious under diagnoses and patients have died as the result of seeing such personnel”. There is also an issue of transparency: “Furthermore “Many patients thought they had seen a doctor when they had not seen any registered medical practitioner whatsoever. In many ways this is in English law legal terms “passing off” in other words leading somebody to believe that you are something that you are not by clever use of language when introducing oneself”.
A matter (also) of terms
According to the expert, the deceit has been amplified by the fact that the government wishes to have these personnel called “Medical Associates” rather than “Medical Assistants”. In the English speaking world an associate is a fully qualified professional but who does not own the business or the practise. “We have “associate solicitors” (notaries/advocates) or “associate dental surgeons”: they are fully qualified solicitors and dental surgeons respectively but they don’t own the practise from where they work. An “assistant” in English language is not fully qualified”.
There is a confusion of terms and a confusion of registration, and both “seem to be a deliberate attempt to confuse the public”
The British medical profession has become extremely concerned that the UK government has insisted on not only calling these individuals “Medical Associates” rather than “Assistants” but also registering them with the General Medical Council (GMC), which the profession believes is a deliberant ploy to dumb down the medical profession and to confuse the public.
Apart from nurses and midwives, all other medical professionals are registered with the HCPC (the Healthcare Professions Council) and nurses and midwives are registered with the Nursing And Midwifery Council. These two bodies have full regulatory power over the relevant professions and can sanction a practitioner all the way up to permanent deprivation of licenced practise. “Why else other than to mislead the public would one healthcare group be registered with the General Medical Council as opposed to the HCPC unless you wished to deliberately confuse the public?”, Holden wonders.
At the moment, the number of MAPs is relatively low, but it is expected to be about 13,000 within a year or two. Some will be employed in hospitals dealing with anesthesia, a small number will perform routine surgical procedures, and some will be employed in general practice.
The dispute within the profession have been enormous: “The Royal College of General Practitioners along with the British Medical Association now have a policy which basically makes it all but impossible for further expansion of physician assistants/associates in general practise because they are not economic. These people are unable to see undifferentiated presentations of patients treat them and discharge them. A physician needs to review every case and given that family physicians are very fully occupied there is simply not the capacity to supervise these people. The further insult to injury is physician associates are being offered salaries that exceed those of some of our resident doctors who are close to getting their certificates of completion of professional training and days away from becoming a consultant”, Holden ends.
Currently there is legal action before the High Court Against the General Medical Council brought why the British Medical Association and others
