The NHS should focus on paying GPs what they’re worth rather than investing in more non-medical professionals who are not skilled to practise independently, argues Dr Ebrahim Mulla
We GPs are experts in assessing undifferentiated complaints. Patients come to us with these, we work out what is wrong and get it fixed. As it could turn out to be anything from a blister to bladder cancer, it takes skill as well as at least a decade of medical training to do this productively and safely.
But we’re exhausted. We’re being asked to do more with fewer resources, under scrutiny and the weight of regulation. We’re not feeling valued, and it’s taking a toll on our wellbeing. Most find a better balance with part-time GP work supported by other roles, but an increasing number are voting with their feet – leaving the NHS, the country, even the profession. Although we have more GPs in training than ever before, our numbers are declining as we’re not being retained.
Responding to this, NHS England’s Long Term Plan supports a big expansion of roles for non-medical professionals in primary care. But how can non-medical professionals with a fraction of the training do this? In defined roles with clear scope and appropriate GP support, it can work well. Take for example the pharmacists undertaking medication reviews who can flag up queries out of their competence, or the paramedics carrying out home visits for acute illnesses with our support by video/phone. When clinicians are trained and directed appropriately to do limited roles within their competence, it’s a force multiplier of GP expertise and time, not to mention a clear productivity win for the NHS.
But using non-medical professionals to assess undifferentiated complaints at pace does not really work, because there is no clear scope. Undifferentiated complaints require a working knowledge of the breadth of medicine to exclude the immediately threatening, assess for cancer and then deal with the problem at hand. It’s a dynamic web of fast-paced decision-making, and it’s what our training prepares us for. It’s continuously challenging with pitfalls all around. Non-medical professionals fulfilling this role need ongoing close supervision for each case (which defeats the purpose of freeing up GP time), but even then can lead to tragic consequences. Emily Chesterton, from Salford, sadly died aged 30 from a missed pulmonary embolism by a physician associate.
‘There is a deviation from medical norms’
As doctors are pointing out, is our lengthy training required? Medical professionals will have studied medicine full-time for four to six years and trained under supervision for a further five to 10 years until they have completed their training. The path is not easy, with significant attrition, competition and great cost. So, how can a fully funded two-year part-time masters in advanced clinical practice confer the ability to non-doctors to essentially practise medicine independently in primary care? The lack of rigour means clinicians are left with a superficial grasp of medicine with unknown knowledge gaps.
I work as a senior doctor supporting independent non-medical healthcare professionals in an urgent care setting. I have been taken aback by deviation from medical norms, the absence of clinical reasoning and the lack of self-awareness about the impact of this on patient safety. The Dunning-Kruger effect is clearly evident for many, but it’s not the individual’s fault, because how are they to know otherwise? I have witnessed patients not having their medical needs being dealt with properly or being directed to make unnecessary further GP appointments, alongside unhelpful correspondence to GPs, who are asked to carry out inappropriate investigations or referrals. It’s a poor patient experience, and it uses more GP time to make things right. It’s a productivity loss for the NHS.
GPs use limited resources efficiently and are aware of the opportunity cost of a decision. Yet data analysts will find it hard to measure an unnecessary further patient contact or investigation avoided by a GP. When I was a doctor in training, every patient was discussed with a senior until it was felt safe to practise with incremental levels of independence. In all working environments, there were regular exercises to assess progression. Ultimately, the years of medical training instils competence and an uneasy sense of humility. I’m ever mindful that any one oversight or mistake can have drastic consequences for patients.
Prescribing medications on behalf of non-prescribing autonomous colleagues means that we’re held responsible for that prescription. The GMC advises us to be satisfied that it’s appropriate, and to apply a healthy level of scrutiny. I still recall with horror the time I was asked to prescribe seemingly harmless chloramphenicol eye drops. I responded to my colleague that adults can buy it over the counter, but something just didn’t feel right. I doubled back a minute later and asked my colleague to explain the case. With reticence, they stated the patient had experienced a few days of worsening right-eye soreness, which was now red, very painful and sensitive to light. The patient had blurred vision and was wearing their contact lenses. Conjunctivitis was the working diagnosis, yet even a final-year medical student would grasp the significance of the red flags. The patient was promptly recalled from the hospital car park and sent to eye casualty, where they were found to have a sight-threatening corneal ulcer.
Is it not reckless for those in charge to put those without the competence to operate autonomously assessing undifferentiated complaints? It’s one of the most hazardous areas of medicine. Imagine the outrage if Ryanair’s CEO Michael O’Leary tried to fix a pilot shortage by providing some condensed training to flight attendants to become co-pilots of large jets, rather than supporting them through proper flight school to have that thorough understanding of flying. The similarity with our jobs is that there is an ever-present risk for things to go dramatically wrong. Questions need to be asked why there are shortcuts to allow a role to be performed independently without the required skill to undertake it.
Rather than pouring money into diluting and lowering standards, why don’t we use some of it to attract, retain and value the dedicated, highly skilled medical professionals we already have?
TLDR: To solve the GP crisis, why don’t we just pay GPs what they’re worth?
Dr Ebrahim Mulla is a GP in Leicester