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We need higher pay, not lower standards

We need higher pay, not lower standards

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



Please note, only GPs are permitted to add comments to articles

Michael Mullineux 13 September, 2023 5:52 pm

Comprehensive and detailed argument aginst our current professional direction of travel.
But the headlong drive to the unsafe and mediocre continues supported by most GPs who are complicit in allowing this to happen through ICSs, PCNs and CDs simply aquiescing to the next poorly evidenced demand from NHSE and HMG and taking the money for ARRS because it is the only investment currently available that is then offset against not taking on any more GPs. and increasing profits via the back door.

Not on your Nelly 13 September, 2023 6:48 pm

Really excellent and well reasoned article. Sadly , those in power won’t listen. We would never hire a PA for exactly this reason, and as they remain unregulated, the responsibility when things go wrong is TOTALLY down to the GP supervising them in OOH or the partners in surgery, even if they had nothing to do with then patient. Hire at your own risk and worry about the GMC and lawyers coming after you when things inevitably go pear shaped. Tip of the iceberg only seen so far.

David Church 13 September, 2023 8:37 pm

I remember fititng in an extra patient, who’s daughter was complaining that the cream given by an Advanced Practitioner (who thought they had more than enough expertise to manage everything I did, but better), for a burn of the hand was staining the bedsheets black.
I had often in my career through Hospital, rural A&E, and GP practice, supervised, then independent, managed burns with Silver Sulphadiazine cream, including injries to ‘special parts’ like hands, circumferential, elderly; and was well aware of the need for frequent reviews and the use of enclosed dressings (or plastic bags/rubber gloves) without constriction for appendages.
I was shocked to find that a prescription for the cream had been given, but no advice on enclosure (to protect the hand from dehydration as well as prevent staining!) had been given , for an elderly lady living alone at home, and it is unclear if any reviews had been planned other than daily creaming.
But far more, the first thing I had to do on seeing the hand was to take it (and attached patient and daughter) immediately to our State Enrolled practice Nurse in the treatment room for assistance with belated removal of the RINGS on the fingers, which had been left in place by the Advanced Practitioner.
Many of our colleagues, especially Nursing and Paramedic, but also forces medical aids and simple ‘ambulance crew’, are excellent, knowledgeable, caring, and experienced, but I agree there are some who ‘do not know what they don’t know’ and assume a competence they not have. I found it very worrying, despite my reputation for encouraging learners to become involved actively where possible. The biggest concerns are in fact in prescribing, especially repeats, and overconfidence to repeat without thought to safety and monitoring issues – often with the attitude that they do not need to because the GP is responsible for that, forgetting that if they have renewed the repeats, the flag for GP involvement is removed!

Hot Felon 14 September, 2023 3:48 pm

So, there is funding to enable practices to dumb down.
The irony.
I had the misfortune to work with a ‘PA’ a couple of years back.
They were absolutely useless, kept sending urgent screen messages and just increased my stress and workload.
I’d prefer to plough on alone than have a dangerous waste of space foisted on me.

Dr No 16 September, 2023 11:16 am

Broadly agree. But we all miss things it goes with the territory. In defence of allied professionals – I mentored an ANP who was a truly impressive and rigorous clinician who knew how to think systematically. She spotted diagnoses missed by her “betters” on multiple occasions. She was functioning at a level beyond that I can EVER imagine some of our recent STs achieving in a lifetime of practice, unfortunately. But that’s another story…

Shaba Nabi 24 September, 2023 10:11 am

Really well considered article and very scary direction of travel