Ken Menon is a sessional GP at the Ongar Health Centre, Ongar.
Non-medically qualified practitioners of medicine are not new. One may look at two spectacular examples of the contribution by these colleagues, Hamilton Naki and Mamitu Gashe.
In the 1960s, Naki was part of the transplant team at South Africa’s Groote Schuur Hospital in Cape Town. He worked with Christiaan Barnard, who performed the first human heart transplantation. Naki was a gardener in the grounds of Groote Schuur, who was enlisted by the transplant team to help with experimental transplant work involving animals. In this role he not only prepared animals for organ donation and transplants but also assisted with operations on animals. In the process he learned anatomy and surgical techniques.
Rosemary Hickman, a transplant surgeon at the hospital, said of Naki, ‘Despite his limited conventional education, he had an amazing ability to learn anatomical names and recognize anomalies’. Head of the Liver Research Centre at the University of Cape Town, Ralph Kirsch, said, ‘He was one of those remarkable men who really come around once in a long time. As a man without any education, he mastered surgical techniques at the highest level and passed them on to young doctors’. Barnard described Naki as ‘a better surgeon than I am’.1,2
“… non-medically qualified personnel have made an important contribution to the provision of health care at all levels.”
The life and work of Gashe was no less illustrious and particularly humane. In 1962, Gashe nearly died in childbirth at the age of 16 years and suffered an obstetric fistula or vesico-vagina (V-V) fistula. V-V fistulae are common in Africa and are a source of humiliation for women, often leading to isolation from society.
The Australian surgeon, Catherine Hamlin, and her husband, Reginald Hamlin, dedicated their lives to the management of V-V fistula in Africa, with an ambition to eradicate the condition. They helped found the Addis Ababa Fistula Hospital in Ethiopia in 1974. After successful surgery on her fistula, Gashe joined Catherine Hamlin at the Addis Ababa Fistula Hospital and assisted at fistula operations. She was subsequently trained by Catherine Hamlin on how to repair fistulae, and proceeded to operate on patients and to teach other staff and post-graduate doctors on fistula surgery. In recognition of their pioneering work, the Hamlins and Gashe were awarded the Gold Medal in 1989 by the Royal College of Surgeons of England. In 2007, the then-President of the Royal College of Surgeons, Bernard Ribeiro, described Gashe as ‘the forerunner of the non-medically qualified practitioner’.3
Physician associates and the ‘barefoot doctor’ programme
The origin of physician associates (PAs) is often described as starting in the 1960s in Duke University, NC, US. PAs were designed to meet the need for primary care. Original PAs were navy hospital corpsmen who had been trained for a medical role in the military. The training is described as having been extensive.4
From the forefront, it is readily apparent that non-medically qualified personnel have made an important contribution to the provision of health care at all levels. It is obvious that training to the required standard must precede independent work. Is this happening in the NHS, especially in primary care?
“The political decision to increase access by personnel with reduced skills and breadth of knowledge is likely to seriously undermine the management of patients with undifferentiated symptoms.”
What is happening is an inversion of provision, as described by Margaret McCartney.5 The political decision to increase access by personnel with reduced skills and breadth of knowledge is likely to seriously undermine the management of patients with undifferentiated symptoms. This move superficially resembles the provision of primary health care in China during the period of the Cultural Revolution in the 1950s.
Chairman Mao Zedong was faced with a shortage of physicians in large swathes of rural China. This inspired the ‘barefoot doctor’ (BD) programme, designed to deal with the shortage of doctors and meet Mao’s promise to the rural population. Young peasants were trained to provide basic primary health care and public health while they continued their agricultural work. The work of BDs contributed to improvements in quality of life and an increase in life expectancy.6,7
The BD programme worked in an integrated, tiered healthcare system where the former could refer on to community clinics, from whence, where appropriate, patients could be transferred to county hospitals. One recognises parallels with UK primary care with access for patients to secondary hospital and tertiary centres, when needed.
First presentations in primary care are essentially ‘red flags’, where GPs, equipped with appropriate knowledge and skills, can assess the vast majority of benign symptoms amid which the possibility of serious illness lie. One cannot but agree with the view expressed by the then-Shadow Health Secretary, Wes Streeting, that concerns about PAs, genuine as they are, are not a reason to ‘throw the baby out with the bath water’.8
That PAs, like other associated medical professionals, have a role in the NHS is without doubt, and their contributions need to be harnessed for the benefit of patients. The question is, where do they fit in? They cannot be used solely to improve access to primary care, without attention to patient safety. One not infrequently hears of practices choosing to employ PAs as an alternative to GPs, and conversely many GPs complain about the lack of opportunities for work. This is a significant regression in the quality of primary care. Incidentally, most of the BDs in China trained to become doctors.9
“Transparency is paramount; patients need to know who they are consulting with.”
To help them work independently in general practice, PAs need a broad, general practice education. As Colin Melville, Director of Education and Standards at the General Medical Council (GMC) said, ‘patient safety; maintaining standards; outcomes, not time’ among others must be applied to PAs as they are to doctors.10
To these may be added responsibility, transparency, and accountability, if they are to work as independent professionals. Anything else would be a supporting role to GPs with oversight by GPs. The latter may be seen as unviable, with GPs already under pressure. And, as many GPs would say, it is more efficient and safer to see the patient oneself that have to supervise a colleague.
Transparency is paramount; patients need to know who they are consulting with. It is a basic duty of candour. These issues were addressed by Lord Markam in the House of Lords and reported in Hansard on 26 February 2024. Lord Markham stated:
‘… the GMC will continue to submit annual reports to the Privy Council and copies will be laid before each House of Parliament, which will enable Peers and MPs to scrutinise the regulator’s activities and raise any issues in the House. There is also the Health and Social Care Select Committee, which can hold the GMC to account.’ 11
He further stated:
‘This order will give the GMC powers to register AAs [anaesthesia associates] and PAs it assesses to be appropriately qualified and competent; to set standards of practice, education and training and requirements for continual professional development and conduct for AAs and PAs; to approve AA and PA education and training programmes; and to operate fitness to practise procedures to investigate concerns and, if necessary, prevent or restrict an associate practising.’11
“That PAs [physician associates], like other associated medical professionals, have a role in the NHS is without doubt …”
The legislation provides a high-level framework for the GMC to regulate AAs and PAs and, importantly, gives the GMC autonomy to set out the details of its regulatory procedures in rules. The National Institute for Health and Care Excellence has made clear that professionals introduce their roles and titles.12 This would provide some degree of transparency. The GMC as regulator has the duty to ensure appropriate training and accreditation, and it would continue with fit-to-practice (FTP) procedures.
Accreditation must necessarily involve exit assessment at the time of completion of training. FTP implies that they would be deemed FTP independently. But there is some confusion in the Hansard statement, ‘Let me be clear: the role of associates is to work with doctors and not to replace them.’ 13 What, one may ask, would associates do independently?
The NHS Long Term Workforce Plan published in June 2023 does envisage 15 000 non-GP patient-facing appointments by 2036/2037.14 Lack of detail of their role in primary care raises questions while providing access. Would these be, for example, to follow up on long-term conditions by practitioners trained for the role like a diabetic specialist nurse? Or would these professionals deal with first presentations of undifferentiated symptoms? If the latter, one would expect competence to the level of a trained GP accompanied with transparency to the patient and accountability. This is a new role for the GMC, who would now set educational and examination standards and be accountable to UK Government for its decisions.
Many of the BDs in China re-trained and reverted to becoming doctors. While the NHS may be witnessing a form of regression, one hopes that PAs would be an educated and trained workforce capable of working independently and subject to the same risks of complaints and litigation that other professionals in the NHS endure.
References
1. Hickman R. From tennis courts to transplants. Arch Surg 1999; 134(4): 451–452.
2. Kapp C. Hamilton Naki. Lancet 2005; 366(9479): 22.
3. Ribeiro B. Africa revisited. Ann R Coll Surg Engl 2007; 89(2): 46–48.
4. Lynn É. What you need to know about physician associates. BMJ 2023; 383: 2840.
5. McCartney M. Why the fuss about physician associates? BMJ 2024; 385: q862.
6. Bien CH. The Barefoot Doctors: China’s Rural Health Care Revolution, 1968-1981. Middletown, CT: Wesleyan University, 2008.
7. Hu D, Xu S. Barefoot doctors and the “health care revolution” in rural China: a study centered on Shandong Province. Endeavour 2017; 41(3): 136–145.
8. Mahase E. Workforce and winter under Labour: Wes Streeting on his plan for the NHS and ending the strikes. BMJ 2024; 385: q992.
9. Rosenthal MM, Greiner JR. The barefoot doctors of China: from political creation to professionalization. Hum Organ 1982; 41(4): 330–341.
10. Melville C. GMC’s reform of medical education and training. BMJ 2024; 385: q929.
11. UK Parliament. Anaesthesia Associates and Physician Associates Order 2024. Volume 836: debated on Monday 26 February 2024. 2024. https://hansard.parliament.uk/lords/2024-02-26/debates/4ED09D68-187C-4325-B4F3-E9F23712FD0C/AnaesthesiaAssociatesAndPhysicianAssociatesOrder2024 (accessed 25 Jul 2024).
12. National Institute for Health and Care Excellence (NICE). Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. CG138. London: NICE, 2021. https://www.nice.org.uk/guidance/cg138 (accessed 25 Jul 2024).
13. UK Parliament. Draft Anaesthesia Associates and Physician Associates Order 2024
Debated on Wednesday 17 January 2024. 2024. https://hansard.parliament.uk/Commons/2024-01-17/debates/bde42233-6731-4370-96db-6836666abbab/details (accessed 25 Jul 2024).
14. NHS England. NHS Long Term Workforce Plan. 2023. https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf (accessed 12 Jul 2024).
Featured photo by Etienne Otto on Unsplash.
