It’s also worth pointing out here that a newly qualified PA in London is paid more per hour than a newly qualified doctor. The former can expect a starting salary of £44,000, for 37.5 hours a week. Junior doctors regularly work around 48, for a starting salary of £32,000. The rationale behind this discrepancy was originally that PAs, unlike doctors, were unlikely to ever have “pay progression”, but that was years ago; nowadays, PAs can see their earnings increase with experience. I’ve seen job ads offering £70,000.
I say this not out of resentment, but to demonstrate that increasing the number of physician associates is not, on the face of it, a particularly good use of money. It could also hamper attempts to boost the number of experienced doctors in the NHS.
Since the overhaul in their training 10 years ago, junior doctors have had to “rotate” every four-to-six months until they reach consultant level. Rotations usually require recent med-school graduates to move around the country and switch specialty. PAs, on the other hand, theoretically remain on the team permanently. If a consultant trains a PA to perform a lumbar puncture, or chest drain, or even to be their assistant during a hip replacement, then they will personally benefit from the time they put into training that person. Crucially, they probably won’t have to retrain someone else in a couple of months’ time.
As a result, it’s now not uncommon to find junior doctors doing admin on the ward while PAs are in out-patient clinics or surgical theatres with the consultant. The result, perversely, is PAs getting all the experience that junior doctors need.
The government claims that PAs are merely filling rota gaps because we just don’t have enough doctors. But though it is planning to increase the number PAs, it is doing little to address the bottleneck in opportunities for much better-qualified medical professionals. The NHS’s long-term plan is for consultant anaesthetists to each supervise three Anaesthetic Associates — the equivalent of a PA — simultaneously. Meanwhile, there are nearly 3.5 doctors applying for every anaesthetic training post — a necessary path to consultancy. This bottleneck exists across almost every specialty.
Given these stark facts, how can the NHS — as the chief executive of the General Medical Council has urged it to do — tackle the perception that PAs are replacing doctors? Indeed, how can it deny that replacement was the plan, when official minutes obtained via an FOI state that “there is an ambition to increase PA numbers in the UK and to make sure that maximum value is derived from them as medical role substitutes”?
And how can they explain why some NHS trusts are actually including PAs on senior doctor rotas? I’ve heard reports of PAs being given responsibility for the stroke bleep — the pager that a consultant doctor specialising in strokes is supposed to hold at all times, so that other doctors can contact them urgently when they need advice. This could lead to the absurd scenario of an emergency department consultant being forced to go to a PA for advice.
Then, at the end of last year, the government announced plans for the GMC to regulate PAs. Billed as a “patient safety boost”, this move has criticised for potentially “blurring the lines” between doctors and PAs. Because what patient will be able to tell the difference between Mr John Smith, GMC number 12345 (an orthopaedic surgeon) and Mr John Smith, GMC 23456 (a PA)?
When challenged, it’s common to hear NHS managers justify PAs as bringing “diversity” and “a different perspective” to medical teams. But patients don’t want a different perspective. They want the right treatment. And diversity is only valuable when everyone has received training that qualifies them to undertake the tasks they’re expected to perform.
The evidence that PAs risk harming patients is mounting. A recent FOI request of Leeds Teaching Hospitals has revealed that PAs have ordered over 1,000 treatments that expose patients to ionising radiation, such as X-rays and CT scans, which can only legally be ordered by doctors. And new data from Scotland implicates PAs in a number of “never events”. These are, as the name implies, “wholly preventable” events that should never happen: performing a procedure on the wrong body part, maternal deaths from haemorrhage, incorrectly placing a nasogastric tube.
A price can’t be put on the lives that could potentially be lost if the PA to doctor ratio continues to tip. But the cost of compensation is measurable. Where doctors must pay for their own medical indemnity insurance, which compensates patients harmed by medical negligence, PAs do not; when they make mistakes, it is the NHS itself that pays. Last year, the service spent £2.6 billion compensating victims of negligence; how much more could it have to pay if it succeeds in adding 6,000 PAs to the workforce?
It’s a sign of how desperate the NHS is that it is allowing itself to increasingly depend on physician associates. Doctors are burning out at record rates: we need help. But instead, less qualified members of NHS staff are taking on more and more of our responsibilities, because hiring them is easier than tackling the root causes of the service’s malady. To give patients the care they need, sweeping reform is necessary: of administrative systems, of junior doctors’ rotations, of career ladders. Instead, what we have are physician associates — at best a sticking plaster, and at worst a danger to the NHS.
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Subscribe“I say this not out of resentment” Is the most telling sentence in the whole article. The headline as well “Why is the NHS hiring fake doctors? ‘Physician associates’ are increasingly a risk” fake doctors seems nearly malicious.
I have no idea if physician associates are a solution but there has been a steady drumbeat of doctors speaking out against the role for several years. Usually because of patient safety which surely could be compared against (checks wikipedia 16 other countries usage of the role) or physician associate negligence compared to doctor negligence maybe.
The writer mentions the three-year undergraduate the health/science-related degree has been dropped but provides no link as evidence which would be good to see.
Surely there must be a comparison between training, patient safety and other factors between other countries something that would actually produce a baseline of understanding of what might be wrong with the role compared to how they are used outside the UK?
They are I believe called physician assistants in the USA, the name was changed in the UK to attract people to the career because it had little take up at first I think.
UnHerd contributors don’t write the titles, which are clickbait focused.
I know the title the is usually an editorial decision but I have noticed them become click-bait in style for awhile. I recorded the headline because I have seen headline’s change as a day has moved on.
I just felt that the headline reinforced a biases article. It was listed as an opinion overnight and then dispatch in the morning.
The author is describing the gradual unravelling of a medical system no longer suited to modern needs. Her solution is to train more highly qualified physicians who are, by the nature of their training, expensive.
I would suggest another way of looking at this problem (and I’m pretty sure it won’t be popular). The starting point is that every medical professional should be competent in their assigned role. I’m sure there’s no disagreement on that point. But, if we put the history of the modern medical profession aside, and a desire by its most highly educated practitioners to maintain their grip on high salaries, we can surely ask if it’s necessary to train more MDs, or whether people with less extensive training could fill most roles?
In America, medicine is a post-graduate degree and only the top undergraduate students are accepted into medical school. From my perspective, there is no reason to require a medical student to possess an undergraduate degree–most other countries have no such requirement. Further, although medical professionals require a certain level of intelligence, they don’t have to be academically gifted. The very high admission standards are simply a way of dealing with too many applicants for too few places.
Why can’t a nurse become a specialist, such as a specialist surgeon, after appropriate training? Is a medical degree really necessary to become a specialist who practices in a narrow area of medicine? I would suggest not. Of course, the notion of someone with a nursing degree, or some other (perhaps yet to be created) general medical qualification less than an MD, becoming a surgeon is currently unthinkable, even scandalous. But out-of-the-box thinking is what’s needed to deal with the current crisis in healthcare.
Ironically, in the future, primary care physicians (or nurses who’ve received additional training, such as nurse practitioners here in the US) may be more highly valued than specialists. The general practitioner needs a broader knowledge base than someone who spends most days fixing slipped discs.
As an aside, I have a neighbor who is a senior nurse and she tells me the academic standards to get onto the Registered Nurse degree program are now almost as high as for medical school. Prospective medics can earn a significant salary as a nurse and carry only a fraction of the malpractice potential as an MD. The market will eventually sort out this problem, but the process could be much quicker if only the relevant leaders were willing to think outside the box and act decisively.
Your nurse neighbor is exaggerating the entrance qualifications for nursing training in the US. It is not nearly as rigorous or competitive as Medical School. Apples and oranges. Baccalaureate nursing degrees are undergraduate degrees, meaning most applicants are applying with High School transcripts, no pre-requisite STEM requirements beyond minimum HS requirements and SAT or ACT scores taken as teenagers. Medical schools are graduate programs and applicants are applying with college transcripts, specific collegiate-level STEM requirements, and MCAT scores (a grad school caliber exam) taken usually in the Junior or Senior year of college. There is no way to say that the “academic standards” for those two processes is equivalent. Tellingly, the University of Pennsylvania Nursing School, for example, has to admit nursing students via a separate admissions process from its general University freshman applicants; not because the nursing applicants are more qualified than other applicants to Penn but because the opposite. Penn would not be able to fill its nursing school if it applied the same rigor to nursing applicants that it applies to general undergraduates so the prospective nurses are admitted under relaxed requirements.
Additionally, the number of programs in the US that train nurses is exponentially larger than the number of medical schools. Consequently, talent is concentrated in medical schools and diluted in nursing schools. Anyone who says otherwise is merely attempting to artfully inflate the prestige of the nursing profession. Nurses are invaluable to healthcare and serve a unique, honorable, and esteemed role; but to start down the road of professing equivalence with physicians is dishonest and only makes nurses look like wannabe posers.
In the crazy-quilt we have for a health system in the US, PA’s have been around for over 40 years and nurse anesthetists for a century. Obamacare doubled down on the idea of what we euphemistically call midlevel providers that now include all sorts of non-MD’s including nurse practitioners who have prescriptive authority and in some cases complete autonomy. Even though our system differs greatly from your NHS, it comes down to the same thing: money. In both countries government-run programs seek to mitigate budget constraints.
In the US, however, there additionally exists the mammoth private Health Industrial Complex that has in the recent years bought out almost all American private hospitals, clinics and physician practices. These companies love PA’s because they are another way to enhance their profit. Doctors here now work mostly as salaried employees of these large multi-billion dollar companies. They have become fungible assets and increasingly so, not only vis a vis other physicians but also in the pool with midlevel providers as well. They are given work quotas and salaries contingent on production. Many spend their days at computer terminals reviewing electronic medical records generated by PA’s on patients the MD will never personally see. It is like a scene from Fritz Lang’s Metropolis.
The few MDs who defend this system are in one way or another “on the take” having secured one of a handful of niche positions that profit from this very cynical situation. The average doctor here despises what practicing medicine has morphed into and most would change occupations were it not for the vast investment they made to become a physician and the limited potential for alternative career options for MDs. They can’t all switch to biotech companies. Ironically, while some patients here bridle at being shunted to a PA instead of an MD, many profess to prefer the PA’s who they find friendlier, which means less inclined to sternly remind the patient that his/her bad habits (smoking, overeating, sedentary living) are the root of their problems. I practiced medicine for 42 years. The first twenty years were a privilege, the rest was hell. Sadly, I would not today encourage a bright altruistic young person to embark on a career in medicine
‘many profess to prefer the PA’s who they find friendlier, which means less inclined to sternly remind the patient that his/her bad habits (smoking, overeating, sedentary living) are the root of their problems.’
Indeed. Doctors are supposed to tell patients what they need to hear and not what they want to hear. I well remember a doctor at my local surgery – she was a real old school doctor, and had no hesitation in putting it to you straight on the line. Have you given up smoking yet? Why not? She was like a dog with a bone, and never gave up trying to make her patients see sense and do something about it. She was a sad loss to the profession when she retired. But nowadays it seems that most people are engaged in their own private vanity fair, and any criticism – however tactfully delivered – is against their human rights and will be ‘triggering.’ [that hated over-used word].
PA assistents we don’t use that in Denmark. I’m under recovery from treatment of a simple lung cancer, they didn’t spend more than a few minutes mention my smoking habits a couple of packs a week.Why waste their costly time on this, they know and I know it isn’t healthy. Instead we have have a very efficient treatment system based on a clearly structured planning with open journals and use of emails. We also use private hospitals for many simple procedures, financed by the state. Often in fact it’s just State hospitals doctors and nurses working overtime.
I’m not sure that’s fair. I am very happy for a doctor to tell me the risks involved with whatever I am doing. I am happy for them to inquire about things when I visit them, after all, they can’t say what’s wrong if they don’t have that information. But if they think it is their role to tell me what choices to make about my lifestyle, they can b****r right off. It’s nothing to do with being triggered, it’s about over-stepping.
In the USA, hospitals pay a very steep price for mistakes through malpractice lawsuits, so they work harder to avoid mistakes.
How are they working harder to avoid mistakes if they are using more and more PAs instead of fully qualified Drs?..
Because they train the shiit out of them and define very clearly the boundaries of their practice.
Exactly – the Prof who did my aortic dissection in the US had a PA who had been with him for 10 years and had far more experience and knowledge than a registrar here in that specific speciality.
My son-in-law is in medical school in New Jersey. Only 6% of applicants to US med schools are accepted. He is studying for Boards for 6 months and couldn’t even take a day off for the holidays. It’s still apparently a very desirable profession for many.
That is a truly frightening revelation!!
I would say a reassuring revelation.
Seems to me there is some value in having PAs, to free up time and bring in more medical staff. It’s the implementation that has been buggered up.
I think you have bots working for you Jim, that post wasn’t worth upticks let alone 50? Just sayin’
Medical students (and junior doctors) hate PAs. These kinds of articles written by them have been a thing for years. I was in the first cohort of PA students in Australia, at University of Queensland back in 2009. The Australian Government was looking to fill gaps in areas such as rural and military with mid-level practitioners. Everyone accepted into our Masters PA degree had health degree registered backgrounds – I was a military nurse, there were also military medics, paramedics other specialty nurses and a pharmacist, all with at minimum a few years of healthcare experience.
The private sector was also very interested, as Specialist Doctors liked the idea they could have a dedicated PA they could employ and work closely with to help free them up from routine tasks and at a great price.
But inevitably, there was too much opposition, primarily from medical students who were concerned about PAs potentially filling training positions, and also upset that PAs would start out a higher initial income on graduation (though that would quickly level out and the doctors would naturally go on to make a lot more money). Strong opposition was also from Nurse Practitioners, who felt very territorial and thought PAs would take some of their positions.
After several cohorts of PA graduates, the university stopped offering the course, as despite initial excitement about the idea by the government and some sectors, the legislation didn’t follow, so there were no jobs to be had.
I’m genuinely not bitter at all, for me I enjoyed the study and I’ve since become a very happy stay at home mum, and am glad I didn’t end up taking on the additional stress. But there were some great students with many years of healthcare experience on my course, who really would have been an asset to the doctors or communities they would of helped served.
The NHS is a planned economy – except for years the Treasury refused to allow a long term manpower plan. The practical results are all too clear – if the bitterness is exacerbated by sniping between competing professional tribes.
IKR – Shaman on shaman violence – you gotta laugh
The solution is simple: scrap every university course with ‘Studies’ in the title and divert the money saved to training real doctors and nurses.
Just one word for doctors: Harold Shipman.
What is that supposed to mean??
That’s two words. DOH.
They’ll be the ‘real’ ones who spent the last 3+years injecting all those older than six months with stuff about which no long-term effects were known?
Another ‘simple solution’: No more ‘migrants’ who can’t pay for their medical needs
Another ‘simple solution’ would be to stop excessive population growth and especially prevent ‘migrants’ who can’t pay for their medical needs from entering Britain.
Hmmm , does that include the 20% of non UK medical professionals who are keeping the NHS afloat?
As far as I can discern from this article, the reasoning for the PA role is sound. They could offer a useful support to more qualified clinical staff. Putting aside complaints about relative pay (but they earn more than me! frankly is childish), the fundamental patient safety concerns evidenced in the article arise from how doctors as a profession use the PAs. If it is routine for consultants to be taking PAs on the rounds and leaving the junior doctors doing admin, this is a damning indictment of the professionalism of doctors, not PAs. If anything, the article inadvertently suggests there are deep seated issues with the way doctors manage themselves and others.
Yes. The article is long on emotional anecdotal instances of PAs getting it wrong but short on serious analysis.
For example if you click through to the link in connection with a Scottish survey of PA “never events” it turns out to be a general submission recorded in Hansard that among other things highlighted that the Chesterton case referred to in the article should not have occurred if the PA had followed the practice protocol that provided that a patient should not see a PA twice for the same condition.
The data relating to “never events” is not provided so we don’t know what the comparable figure for qualified doctors.
There is a clear shortage of qualified physicians and the PA is a solution but as we know there are no solutions merely trade offs.
I worked in a claims handling office where the claims were handled by qualified lawyers but when we were under pressure the decision was made to retrain a couple of the experienced secretaries who know the business to give advice and handle simpler cases. They probably referred cases out at an earlier stage than the qualified staff but the extra costs became externalities that could be recovered from the client by adjusting their premiums.
Bureaucracies seek to shift costs onto someone else’s budget if they can.
It makes no sense for the most highly qualified to see every case being presented just in case someone less qualified might miss something. What is needed are protocols that will effectively triage cases to the right level of expertise and to stick to those rather than allow naturally occurring overconfidence to subvert the system.
Of course a physician is going to make use of an asset that will remain with him rather than train one that will depart and effective protocols are needed to counter this in the interest of the system as a whole.
I came back here to see if my comment had made it through moderation as I had been slightly surprised that fairly uncontroversial comments had disappeared into moderation in the first place.
I am also surprised that my comments have already attracted two downvotes but without and actual critical comment. I am entirely relaxed at disagreement but it would be nice to know which of my various comments were disagreed with.
Downvotes by Jane Smith and Jane Smith’s mammy perhaps because there’s little you’ve written that I can imagine anyone might dispute. And as you write, the data isn’t there to substantiate the claim Jane made and what she then implies, which is poor for any writer but for a degree-qualified STEM professional trading on that professional qualification to support her arguments is simply unforgiveable.
Bravo!
Probably more than 2 down votes, as up and down cancel each other. It might have been 100 down votes, but 98 up. You’ll never know….
There are huge differences between handling claims and diagnosing and treating people.
My point was to indicate there were trade offs in any attempt to substitute a less skilled human resource for a more skilled one but that bureaucracies and individuals working in them seek to shift costs away where they can.
However, a lawyer has to take a history in order to try to diagnose whether there is in fact a legal problem that is capable a legal solution so the diagnostic process is not entirely dissimilar. A lawyer should be better at obtaining the relevant information in the fact finding process and seeing the potential legal solution if there is one than a Secretary- even one with some experience, common sense and some narrow training.
My mother-in-law had bruised her big toe and her GP dismissed it as something minor but referred her to hospital for another complaint. As soon as the consultant saw her in hospital and saw her toe he told her she needed to receive further treatment in hospital since as a diabetic she could potentially lose her leg if it was not promptly treated. Had the GP in fact been a PA no doubt his failure to act appropriately would have been ascribed to his limited qualification.
People make mistakes and are overconfident of their abilities. Systems need to be in place to reduce the risk of error at every level of training.
The medical analogues to the experienced secretaries you mention are experienced nurses — the ones who have been around the block enough times to know what the medics would do in the circumstances (it’s well worth remembering that by no means all nurses ever reach this stage). The analogue is not the fresh-from-their-2-year-course PA.
The issue of pay is not childish given the problem of retention of medically qualified personnel. Pay differentials that favour the less experienced and knowledgeable hardly seem justifiable in this context.
As for how the profession uses PAs — this might hold water if doctors had autonomy in this regard. The days are long gone when hospitals were run by doctors – hospitals are run by management with an eye on the bottom line. (I have to say that I don’t think it is a very good eye, because PAs will almost certainly turn out to have been a false economy.)
It’s just another Tory scam
Brought in 2003, from memory thats 7 years before Labout lost power, and a few more years before the Lib Dems relinquished their say in the NHS
This is worth 50 upvotes! (Jim)
I need to read this article in detail. But a first reaction is this – why should we assume that the current structure of the medical profession where we essentially have only doctors and nurses is the only or best one ?
Given the absurd historical restrictions on the number of doctors being trained (partly a result of BMA pressure to limit doctor numbers to maintain standards/safety and/or increase wages) and the increased cost of nurse training (degrees now being deemed essential), the obvious question is “why not have more tiers of medical staff ?”. After all, in a resource-limited environment, the last thing you need is over-trained, expensive staff doing tasks that can be done equally well but at far lower cost.
In a two-tier (doctor, nurse) system, it seems likely that there are inefficiencies. So any way we can find to make this more efficient should be explored. Whether that’s new tiers of medical professionals, better medical diagnostic tools and technologies (augmenting/replacing staff), improved medical training, reducing the absurdly long (and surely dangerous) junior doctors hours, etc.
I am not convinced that we are trying hard enough to improve the efficiency of health services. Nor that we are prepared to challenge the vested interests that will resist change.
Fair points. I think AI might be a significantly transformative technology in the medical world (although I wouldn’t guarantee for the best:) but I expect significant push back in the area.
Also, and I freely admit to being a cynical individual, I suspect a lot of the resistance to change is due to status preservation.
Status is EXTREMELY important in the Human Psyche. People need STATUS more than food,drink and comfort.
Yes, because behind that is basic survival instinct. High-status people fare better than low-status.
Speaking as a former nurse, I see healthcare assistants who comand much lower salaries performing more and more roles that nurses used to do, including cannulation, catheterisation, wound assessments etc. When people talk about nurses salaries, they forget about the poor exploited nurse assistants who do the majority of nursing these days in the NHS.
This is surely what we want more of – provided the nurse assistants are not underpaid.
But are you also hinting that the staff we used to know as nurses are now really “nursing administrators” ? In which case I’d say, call a spade a spade and make the “nursing assistants” the nurses.
The ever-increasing credentialism of everything is just pushing up costs for everyone without actually improving services. In fact, over-training staff ultimately means you have less front line staff and worse services.
That couldn’t possibly be why the NHS is always short of doctors and nurses, could it ? i.e. because they have deliberately chosen a staffing structure that makes it so.
There is also a huge salary gap between teaching assistants and teachers. I struggle to understand why that is too.
Time was when the term “professional” meant fully-qualified solicitors, accountants and the like (and sometimes even us engineers). Now it means almost anything – “health professional” seems to mean almost anything. “Professional” also used to mean demonstrating professional ethics. But we know from the world of professional sport that the exact opposite can be the case (“professional” there being a euphemism for cheating).
Yes. ALL the actual nursing is done by HCAs, the nurses have SO MUCH paperwork to keep up with they don’t have time to actually nurse and it takes a big chunk of time organizing the medication distribution every day and we all know how serious it can be to get this.wrong even by accident – for the patient and the unfortunate nurse.
Excuse the dumb question, but why can’t this paperwork (or is it entering data into computerised systems ?) be wholly or mainly automated ?
Because not everything can be automated. You still need a human to enter information into a computer system. I face the same problem with teaching. Would love to have to have a system that can grade papers for me, but as far as I know there is no suitable software out there.
That’s true.
I’m a consultant anaesthetist/pain management Dr in the South of England. The hospital has given me a speech to type dictaphone & got rid of half the secretarial team. I now treat fewer patients because the intelligent dictaphone isn’t & I spend longer correcting its spelling. But hey, the secretarial budget has been reduced, which is good.
The whole PA thing is a story of unintended consequences/mission creep if you don’t/can’t define the endpoint.
PAs started life as Physician’s Assistants & are morphing into Physician’s Associates, with proposed GMC regulation.
The good old days of widely educated, experienced diagnosticians is over, as there’s an MRI/PA App For That.
Hope you haven’t got anything that doesn’t come in the first few chapters of the PA’s glossy college folder, or you might not Do Well.
I’m not disputing the general thrust of this article, i.e. that PA’s should not be performing clinical tasks in which they do not have the required training/competence or for which a qualified doctor is required by rule.
However, tragic as they are, the examples given of patients who died as a consequence of mis-diagnosis by a PA don’t actually prove this point. Trained doctors also make mistakes and are implicated in never events, as a consequence of which people die or suffer significant negative outcomes.
There will always be some mistakes. The test is surely whether PAs are making these mistakes at a higher rate than trained doctors. This may well be the case but the article above doesn’t demonstrate it with any data I can see.
There will always be mistakes, and there will always be ‘exceptions’ where even in retrospect doing the right thing can have a bad outcome. But the mistakes PAs are making are off the scale, both qualitatively and quantitavely.
The examples in the text would stand the hairs up on the neck of any doctor. They are so aggregiously bad that any doctor who offered that level of response in an exam would be immediately failed. There is no subtlety or plausible frustration in these case, the author should have highlighted to the non-medical reader how awful these decisions are to any doctor / experienced nurse.
Still, there are some doctors who manage to slip through the net and be equally crappy, especially as we ask fewer and fewer questions about overseas medical schools. I’ve experienced one such doctor who has now luckily been stripped of his license. But the number of PA’s is vastly smaller than the number of doctors presently, yet the number of critical errors is massively over-represented in the PA workforce
“But the mistakes PAs are making are off the scale, both qualitatively and quantitavely.”
If the number is off the scale then it should be an easy matter to cite the relevant data.
Again, I’m not saying it isn’t true. I’m just asking where the data is which demonstrates it is true.
“The examples in the text would stand the hairs up on the neck of any doctor. They are so aggregiously bad that any doctor who offered that level of response in an exam would be immediately failed.”
I can’t speak to tests but I did know a guy at uni who was told by a GP he had a bad migraine then went home and died from a brain haemorrhage a few hours later.
I’m not suggesting the GP did anything wrong. For all I know he followed the correct diagnostic procedure to the letter and came to an apparently sound conclusion. But it was clearly a mistaken diagnosis.
Which just circles us back to my original question. Is there data which supports the case that PAs make more of these mistakes than GPs?
There almost certainly is data or at least the raw statistics from which the data can be compiled. It is though held by the people who made the decision to increase the number of PAs.
I could not agree more. I had started writing a comment about all the fail diagnose made by fully qualified doctors. I deleted it but will try again.
I would not be alive anymore if, on more than one occasions, I had not doubted the tale the spun me by the specific doctor and asked for a second opinion. The failed diagnoses started many years ago with an inadequate medical assessment after a miscarriage. Luckily I had to go to my native German soon after and in no time found myself on the operating table. My German doctor insisted on writing a stiff letter to my GP.
Then the doctor in A&E, where I had sought help from severe cramping and rectal bleeding, wanted to send home with a pack Paracetemol. Again, I insisted on a second opinion and was soon after operated because of large growth in my colon/rectum which, because of its size, was expected to be cancerous. It was not. During each of the follow up appointments the surgeon beamed at me and exclaimed: ” You were so lucky”. I was, but not because of the doctor’s vigilance who examined first
I come from a family where everybody(father, mother, brother) , , had suffered strokes and heart attacks before they were 60. I also had high blood pressure for many years. but when I presented with severe heart symptoms to my GP she dismissed them, she did not even do an ECG.
As this was at the time of the first lockdown. I could not escape to Germany but eventually wen to A&E. I was sent home again, but the examining doctor arranged a telephone consultation with a cardiologist. Again the same story. Since I did not suffer from breathlessness I was unlikely to have angina. Still the doctor promised to arrange a 24 hr ECG. When the date for this arrived, I was lying in hospital because of an emergency triple bypass operation after a heart attack.
When that happened I took myself to A&E, but this time I was not let out again.
Btw. the scans showed that I did have minor heart attack before, when I first saw my GP about it.
These are only the most dramatic incidents in my life in which real doctors misdiagnosed me. There are quite a few more.
Surely, I cannot be the only one who had such a string of bad experiences. I dare say they do reflect badly on the quality of medical provision in the NHS on all levels of service. It’s not just the poor PAs who pull it down.
I
Junior Drs are doing paperwork, she says. I beg to differ, in my experience they spend more time on strike! They prioritise pay over patients!
Asked my mate who is a doctor (but doesn’t go out on strike all the time) and he said that it is a matter of management. The PAs are under the direction of doctors and have to follow instructions from them. If the instructions are too lax (or the doctors a bit lazy) then of course there will be mission creep as if a job is given once then it will likely continue. The author focusses on the PAs problems but who else does she think will do the jobs described if doctors are “overworking”?
A second claim is that £2.6billion is spent on medical negligence. What would have been useful is the proportion of this which is incurred by PAs (as opposed to nurses/doctors). That this figure isn’t given leads me to suspect that it doesn’t back her case. A proper journalist could find this out, unfortunately the author is not. If they claim to be a journalist writing under pseudonymity then the error is even more eggregious.
Finally, the lines “all the notes on your patients — which should be kept around their beds, but tend to be scattered around the ward. Finding them can also take 30 minutes.” is chilling. Does the author not realise it is their job to keep these in order? Even if they are delegating (read: abdicating) responsibility for this does this seem like something that would happen at a professional company or a private practice?
Unherd – we need a riposte from a PA.
Here speaks someone who has never worked on a ward which I have as a nurse. Lots of health professionals have access to the notes not just doctors. Why should it be the doctors job to make sure the notes are always filled away?
In other workplaces you put something back where you found it. Why would a hospital be held to lower standards?
Because a hospital ward is a place of constant movement and upheaval. Best carry on watching Bargain Hunt in the armchair.
Okay, so if not doctors’ job, then whose it is? Because it should be someone’s, no? Since you’ve worked in a ward, I have to believe you would agree with that.
In the old days it would have been Matrons job. Hattie brooked no nonsense. It’s ironic that back then women were not “equal” but respected. Now women are “equal’ (me excluded) but seen as and treated as Silly Girlies. We need more old style fearsome dragons,the closest we have now is Anne Hegerty on The Chase. Maybe she could run training courses.
It doesn’t have to be the doctor’s job to make sure the notes are properly filed away but it has to be the job of whoever is in charge of the ward that the medical notes are always properly filed away surely. That a doctor should spend 30 minutes searching for notes on a sufficiently regular basis to mention it suggests an utterly dysfunctional system is in place. Of course it should be drummed into everyone needing access to the notes that they are returned as a matter of course to their proper place. Indeed the whole paragraph where she describes the start of the ward doctor’s day highlights a dysfunctional system wasting the NHS’s human resources through a lack of proper organisation.
First of all, by far the largest part of the £2.6Bn paid out for clinical negligence is incurred by Maternity Services. It represents the lifetime costs of babies brain damaged at birth by shortage of oxygen in a prolonged second stage of labour. A major feature of this morbidity is that it occurs when there are staff shortages and the midwives do not call in medical assistance at the right time.
Next the practice of medicine is roughly 80% predictable from a history, examination, relevant testing and investigations, leading to diagnosis followed by a treatment plan. In essence the diagnosis relies on pattern recognition. The other 20% arises when information arising from the history, examination and investigations fails to match either a putative diagnosis, or anything else that may be closely related to it in the differential diagnosis of related conditions. That is where experience and highly specialist knowledge come into play in order that the patient is managed safely. In short it is what consultants are for. Junior doctors (a horribly discriminatory term for highly trained people) move from being highly trained generalists towards highly specialised consultants during higher medical training. They are trained not to exceed their limits.
PA’s on the other hand have two years “supervised clinical “experience” on top of a previously acquired STEM degree. That is compared to five years of clinical training followed by two years of Foundation Training to produce a fully registered (but as yet fully trained for independent practice) doctor.
The problem this disparity leads to is the fact that PA’s (and this applies equally to some nurse practitioners) adhere strictly to protocols, and tend to regard clinical guidelines as inviable rules in the face of clinical signs and symptoms that suggest that what they are doing is inappropriate. In short they may lack the knowledge to be aware of those situations where a different approach is required. Also they may not be sufficiently aware of their limitations.
These people, as of today are not regulated. The Royal College of Physicians created a Faculty to oversee what they are taught, but this does not amount to proper regulation. To my mind the Government, The NHS, The GMC and the relevant Royal Colleges have colluded to foist upon the public a new (often hidden) class of “practitioner” which is professionally unaccountable and unregulated. That is a crime of monstrous proportions, and all concerned should hang their heads in shame. The public deserves better than this.
For the record, I hold Medical and Higher Medical qualifications and was for 30 years a board level Director in the NHS at both District and Regional levels. I was also the national Chair of an organisation that provided professional support to staff dealing with alleged Clinical Negligence in the NHS, now part of the Patient Safety Section of the Royal Society of Medicine. Over my career I have worked at every level in the NHS from a Ward Orderly to a consultant.
Interesting on the maternity point – i think there was an article on here a few months ago about maternity units being run as a midwives’ fiefdom and the friction caused by unaccredited staff (midwives) thinking that they are above doctors in the pecking order. Once again decisions being made by people who shouldn’t really have that authority. Did you have any idea of the figure for PA negligence as opposed to doctor/nurse/midwife?
It wasn’t clear in your reply whether there is any “assistant” role assigned to PAs. Can a doctor not just assign them to tasks which the doctor finds time consuming, such as administration, which the article says the PA should be used for. In the real world this would be placed squarely on the shoulders of the overseers giving incorrect instruction and not on the PA who is following orders.
They probably can’t read and write,or only Ukranian
Is not the far bigger issue those imported medics of any rank who do not possess the requisite command of English nor meet the standards of the UK medical schools??? And the deliberate choking of domestic supply? When will any govt take on the ghastly bullying BMA and triple the numbers of home grown medical students?? A cap of 1000 dentists for a population soaring toward 75m??
Thus demonstrating how even white collar unions have minimal regard for their professions or the public at the sharp end of their activities. They’re more like medieval guilds, but without the critical step of being remotely responsive to their users.
Why are the NHS hiring PAs – answer for the same reason the NHS is hiring Diversity Officers. Same poor over rewarded “management” making wrong decisions about resources.
The best way to encourage ‘management’ to make the right decisions…? To make sure they are facing facing competition in the marketplace.
Or to face meaningful consequences for their decisions (good and bad). Or increase the accountability to their actual patients, rather than their senior managers and SCSs.
Shocking stuff that we have come to expect from an NHS stuff full of managers who would prefer to be in the privat sector.
No organisation employing 1.5m people providing personal; services can function without good modern IT .
The NHS management is not competent to commission and purchase IT systems- so they dont.
I saw a consultant recently. He was perfectly fine- but then things fell apart. He dictated (yes dictated in 2023) a letter which then was sent as a tape (remember them ?) to a typing pool (a 1960s item those) who then spent a week getting to his “tape” . He then reviewed the letter and posted it (remember posted letters ?.) Heaven only knows what all this cost. For me and my GP to get a letter a month after consultation. But then another slightly different letter came – and then a third- clearly the system didnt realise it was duplicating.
The consultant could have dictated an e mail onto his iPhone in ten minutes and sent it to me and the GP. That would taken ten minutes. No need for dictating machines, no tapes, no typing pools , no posting -no scanning hard copy letters into the GP system etc.
This is an example of why the NHS is so costly- its management are over promoted out of date rubbish.
I can offer a fairly deep insight into the process you find so antiquated.
Dictation is how consultants want to work, when dictating letters they spend most of their time thinking. The consultant will be reviewing medical notes, scrutinizing medical images, while this happens the stop/start button on the dictation machine is clicked up and down.
Dictation will typically be direct to a central digital computer system. At this point AI software will do a fairly good job at automatic conversion to a standard letter text format and patient details will be dropped in by the software.
Medical admins will then cross check the machine transcription with the audio. The greatest problem at this stage is the extremely poor english language skills of so many consultants employed in the NHS. The medical admins will also catch the medical errors made by junior docs dictating letters because medical secretaries working in the cardiac department will instinctively know the recommendation for the surgical amputation of the patient’s big toe is unlikely to help treat a wonky heart valve.
Finally letters go back to the consultant for final review because that is where the buck stops.
I assume you are happy with the pilots of a commercial aircraft running through a check-list before take off?
Can it really be wise (and safe) to employ “so many consultants … with extremely poor english language skills” (your words – I assume based on some facts) ?
Isn’t that a far bigger problem than the wasted resources involved in dictation ?
In so many areas of life, we rely on fast, accurate communication. I assume that must be true for medical operations where ambiguity and misunderstandings must have a real cost.
The ability to communicate fast and accurately with correct information is really one of the hallmarks out the true professional in any field. Along with technical competence, professional ethics and knowing one’s limitations.
I’m also rather uneasy about a system which – you claim – relies on “medical admins” correcting the “errors of junior doctors” !!! That sounds rather like hoping the cabin crew can pick up and correct pilot errors (to use your example).
I am very familiar with the workings of a provincial hospital department in a general NHS hospital covering a mainstream medical specialty.
The department has not employed a British trained consultant for 5 years, the established foreign permanent consultants are now at say 95% the language ability expected from a native English speaker in the same role and medically speaking they seem first class.
The problem is with the rotating population of locum and trainee docs. Sometimes the medical secretaries have to circulate problematic dictations around the team and use their collective medical knowledge to comprehend the intent. Heavens knows what patients understand.
The NHS will always be compromised because we invented English and British trained docs can choose where to work world-wide. Who would choose Bognor Regis over Bondi Beach?
It causes intermittent frustrations but no more than a 10% drag of administrative performance. I don’t know how the effect on patient diagnosis can be measured. So much medicine is preordained by prescribed treatment pathways, test result numbers and scans, I am not sure what patients say is significant. It is all a numbers game of waiting list management, cancer alert performance targets and responding to official complaints. The biggest avoidable consumer of time is dealing with angry patients and GPs on the phone demanding some action.
The main point I wanted to raise is that it would be ridiculous to expect a consultant to spend 10 minutes writing up a full letter to a GP when the consultant can spend 5 minutes dictating the same to the internal admin team, in the case of an experienced medical secretary the dictation can be abbreviated to 3 minutes using inhouse lingo.
With 20 people scheduled to attend an outpatient clinic a consultant is working in production line mode, even Henry Ford would know that writing a letter between each consultation is dumb. Consultants do note dictations towards the end of the day in batch mode, the event also allows them to cross check their thinking from when the patient was in the room.
Britain is full of wannabe Gerry Robinsons who know how to fix the NHS. If they want to fix the NHS they should do 4 rigorous 4 mile walks a week.
Thanks, that’s very helpful. I am, of course, one of those wannabe Gerry Robinsons. And I do need more exercise.
> professional ethics
There is no time for ethics in the NHS, it is just a bloody battle ground.
The consultants hate the management, the junior docs feel abused and let down by the consultants, there is a continual turf war between the docs and nurses. Everyone views patients as a potential official complaint on two legs.
Hospital admins are engaged in continual sniping warfare with GP Surgeries.
Medical treatment is just an incidental byproduct of the whole shambles.
This should be the least of your concerns. Either the consultant would have spotted the error or the recipient GP who knows that amputation of a big toe will not fix a heart valve. The main priority of the department is to avoid a snarky complaint letter from a GP.
Dictation mistakes by junior docs just provide some much needed hilarity during the working day.
The visitors to the patient,usually family are the worst. They break all the hygiene rules,they disrupt the ward. They demand,they threaten,they are often rude to the nurses and HCAs. They demand Special Treatment for their relative.
They often threaten to bring legal action against the hospital or even individually members of staff. They complain at the treatment and medication their relative is getting that is the correct course and try to insist their relative should have a different course of treatment that would not actually be suitable.
Yes, the attitude of patients/families can be awful. But the NHS has no sanction. They cannot refuse rude and troublesome customers. Nor can they prefer valued, well-behaved customers. It’s an inherent weakness of such a system.
Also people don’t value something as much if they get it for free (or rather, think they get it for free – at around 10% of GDP healthcare certainly is not “free”).
There is an additional subtlety that needs to be mentioned here. Some middle class people who would be the model propriety in face to face interactions can be as disruptive as the relative who shouts at a nurse on the ward.These middle class thugs attack the NHS using different techniques, they wage a protracted bureaucratic war via telephone and letter.
You are correct, patient relatives are the driver of complaints, I would amend my post above but the edit button has gone.
The complaint procedure can deliver benefits such identifying a minor failure that nursing staff are too busy to notice. The problem is there is nothing to counter the incentive to raise a complaint, maybe a £25 charge refundable if the complaint is upheld is needed.
People want and expect everything Instant these days.
The darks days for NHS IT were 20 years ago following the crash of the £18 billion project that was meant to digitize and unify everything. Outsiders want to fix the NHS in 2024 based on some TV documentary they saw 15 years ago.
I was surprised how well the NHS responded in the first months of the pandemic. Home working requires virtual desktops and virtual desktops consume a lot of computer server capacity. Home working increased by 100s of percent at the time, yet the NHS IT teams kept the show on the road.
I am puzzled by the consultation/dictation experience quoted above.
The NHS is just a feudal system comprised of clinical commissioning groups and regional hospital trusts that function as local middle sized businesses. It is possible the complainer was unlucky and his hospital is run by a trust behind the IT curve.
The complainers experience would also be consistent with someone buying a private consultation, was the consultant disconnected from everyday IT systems hence the tape based dictation. Hospital admin staff take exception when consultants try to slipstream private admin work into their NHS workload, maybe the letter was placed at the bottom of the in-tray as a protest. If consultants fired off GP letters direct from their iPhone that would cause chaos downstream, consultations need to be indexed with the patient’s main medical record and related events tied together such as tests, scans, treatment pathways and follow ups. Then there is the formality of discharge.
It seems to me that we don’t have enough doctors, and PA’s are seen as a solution to this. The question is, why don’t we train enough doctors? There are plenty of bright young people desperate to enter medical school but the places are limited, and even then a lot are sold off to foreign students.
So either the government, the medical schools or the Royal Colleges need to sort this out. But perhaps they don’t want to, or at least the second 2 don’t want to. Scarcity creates demand.
The irony is that with standards now so high to get into medical school I doubt we even end up with best overall doctors. Instead we as like end up with a cohort of swots with limited life experience and personality, as all they’ve done is study. Not always for the best when dealing with your fellow human beings is a big part of your job.
Isn’t this all just part of that hallowed British tradition of being just too damned stingy to pay for the real thing?
Eg: Special Constables, Community Support Officers, Territorial Army etc etc.
People don’t want to pay taxes Charles and governments act like it is their money! Look at Sunak spending 400 billion of our money without even a by your leave, it was not his money, a referendum should have been called for such a crippling misuse of money!
I will be asking everyone for their actual medical title & role from now on.thank you.
The underlying issue is that westerners are indolent and we are destroying our bodies faster than medical science can invent more efficient techniques to treat the diseases we willfully ferment in our bodies.
The blurring of the traditional distinction between doctor and nurse is the only pragmatic option available to cope with the tidal wave of disease we throw at the NHS.
It is interesting to read about the rise of the PA in the NHS, I had no idea of the scale of their adoption.
However PAs are just an element of a broader trend in the NHS. We don’t hear complaints about Nurse Practitioners or Advanced Prescribing Nurse Practitioners presumably because our experiences with them are positive. Most of us would prefer to see anyone at our GP practice rather than wait 2 weeks with earache to see a proper doctor.
The same trends are prevalent in hospital medicine. It is now routine for advanced nurses to run a whole out patient clinic with no doctor. Such nurses are graded and paid at the level of a junior nursing matron, they examine, diagnose and dictate the discharge letters that our GP will read and trust.
The problem is that most people still think NHS medicine functions as depicted in a 1960s film like Carry-On-Doctor with a god-like consultant diagnosing and issuing commands to fawning nurses with little brains.
As to anesthetists, they are a separate issue. Anesthetists are only called doctors due an historical grading accident, most of them function as theatre technicians. Sure we still need full consultant grade anesthetists but most of their work can be done by a software algorithm.
Have a really good think about what an anaesthetist does.
The medical establishment already has. Anesthesiology is recognised as an easy specialty that offers a fast-path to a consultants wage 5 years ahead of a surgeon.
The existence of nurse anesthetists confirms my point.
It is time to accept that the grading landscape in medicine is evolving and becoming fragmented. Technology will also shake things up and blur traditional professional demarcations.
We should focus on identifying the unintended consequences that occur as things change such as consultants being motivated to give more training time to a PA than a specialty registrar.
In the US, anesthesiology residency is a minimum of 4 years post-MD. Internal Medicine and Pediatrics residency 3 years, General Surgery 4 or 5 years depending on the optional year of research. I’m stunned that anesthetists have so meager training in the UK compared with other consultants and such low esteem as well! My goodness, bring on the software program that will save us from these bottom feeders!!
We are not comparing like with like. The British equivalent of a Resident Doctor is a Specialty Registrar, even an anesthetist registrar will have up to 8 years of training but usually a few years less.
It is a fact that trainee anesthetists get to consultant years before a surgeon. The standardized pay scales of the NHS do not reflect the relative training effort of doctors in different branches of medicine, in fact between the ages of 35 and 45 a surgeon will be at a financial disadvantage.
Just curious. You seem particularly judgmental about anesthetists. Do you have some professional experience with them or something personal? Do you have particular knowledge of the speciality? In other words, upon what objective criteria do you base your unequivocal condemnation?
In a discussion about the expanding role of mid ranking advanced practitioners in modern medicine, anesthesiology is a prime example where technology plus changing practice should be expected.
We can imagine a future where a single consultant anesthetist would sit in an anesthesiology mission control monitoring 10 concurrent operations in a hospital, with anesthetist nurses next to the operating tables.
Consultant anesthetists will still be needed in theatre for complicated cases, many patients on an operating table have comorbidities and their sedation is a complex chemical balancing act.
Modern medicine is not working in both our countries for different reasons, in the UK access to treatment is regulated by unacceptable waiting times and in the US access is regulated by cost. Fresh thinking is needed.
Not what I said but I do think it is an area of medicine that warrants critical review in order to save money and so expand the delivery of treatment capacity.
Medicine is constantly evolving. We still refer to surgeons as Mr. because 150 years ago surgeons were considered too lowly for the more respected Dr. title. 2024 might be the year when it is time to reconsider if sedation according to very well calibrated algorithms is always a doctor calibre function.
100 years from now the highest paid medics might be Paramedics, ER Teams and Surgeons because AI trained neural nets and bedside Bots will oversea the rest of medicine.
“anesthetists are only called doctors due [to] an historical grading accident, most of them function as theatre technicians.” That is a patently insulting condescension and one betraying an obvious personal agenda you nurture against them. Are you a surgeon? Are you a nurse? You do not seem willing to reveal how you have arrived at such sweeping dismissal of people who serve an important function in the care of patients. Tell us what you are that we might better weigh the veracity of your assertions. And you needn’t natter on about “imagining a future with nurse anesthetists… ” The Anesthesia Team Care model has been the dominant model in the US for about a century now. It is no groundbreaking innovation and your posing it as some brave new alternative to which health systems should aspire only demonstrates that you are ill-informed.
The hospital where I spent my career staffed its forty operating rooms using the both physician anesthesiologists and nurse anesthetists supervised by them. The former had a variety of responsibilities in addition to supervision. They staffed a pre-operative evaluation clinic where patients underwent interviews, physical examinations, reviews of past records, and the ordering of new lab, EKGs, X-rays, consultations as indicated. During these visits patients were counseled as to options for anesthesia (regional vs general, e.g.) and given an outline of what to expect relating to the preoperative experience including the wide variation in options for post-op pain control such as epidurals or other in-dwelling regional techniques such as supraclavicular blocks (placed by anesthesiologists). As a tertiary-care facility the patient population tended to be quite unhealthy. Often new medical problems were first diagnosed by the anesthesiologists in the pre-op clinic and quite frequently patients had non-optimized conditions requiring adjustment of therapy pre-op. It was also the venue to meet with parturients prenatally to discuss alternatives for anesthesia in labor or C-Section. The clinic was rigorous and required every skill a physician learns for the proper recognition and assessment of disease.
We also provided separate physician anesthesiology staff to oversee the Post-operative Care Units (pediatric and adult) where a host of not-uncommon and often life-threatening complications arose. Post-op bleeding, MI, stroke, CHF, pulmonary decompensation, and airway problems were the coin of the realm. No software algorithm exists to substitute for the examination and intervention of a capable physician at the patient’s bedside.
About half of the surgical anesthetics in our institution were personally administered by physician anesthesiologists (26 in number) and tended to comprise the sickest patients, the most challenging surgeries, and the very young. Our department included 4 anesthesiologists who had done pediatric anesthesia fellowships post residency. The duties of supervising the nurses anesthetists required a separate subset of 4 anesthesiologists set aside for that purpose. They did not sit idly off somewhere looking at screens but were in constant motion attending to the legions of problems that are ubiquitous in operating rooms where fragile patients are undergoing aggressive procedures. It was also a rigorous task.
I could write a book about how challenging it is to practice the specialty of anesthesiology. Whatever conception you may have about it is grossly incorrect, whichever side of the Atlantic. You don’t know what you speak of and should be ashamed to discredit a profession that you obviously resent for personal reasons.
You say you spent your professional life working in a hospital with 40 operating rooms. This must be one of the largest hospitals in the US? Examples of the large hospitals in the UK are Manchester and Cambridge, these have 22 and 37 operating theatres each.
https://careers.cuh.nhs.uk/where-could-i-work/nursing-and-midwifery/theatres-and-recovery/
Maybe the terminology is different and we are not comparing like with like.
I am a little puzzled why a big cheese in American anesthesiology would get drawn into an extended debate with a bloke on the internet, it would be like Big Gates expending hours on an internet forum arguing with someone who claims that Windows 3.1 was the worse operating system ever.
I must have touched a nerve, is there a similar debate underway in professional US medical circles about the relative ranking of anesthesiology?
Surgeons have coped with an historical grading accident for 150 years, anesthetists need to toughen up and not overreact to a suggestion of a downgrade. Over reaction might trigger a no smoke without fire type curiosity.
A few years ago I visited the National Rail Exhibition in York in the UK. This is where the stream engine that pulls the Harry Potter Hogwarts express is based when not out huffing and puffing. There is a fascinating feature in the museum showing a cutaway slice through a stream engine, the sophistication of the design and fabrication skill at the end of the steam age was remarkable. Yet within 20 years all that human achievement over 200 years lost its commercial value to society.
I do believe anesthesiology will be one of the first medical specialisms that will be shrunk into an AI neural net and a black box sitting in the operating theatre will in future pull the sedation strings.
If this is barking mad then your professional body needs to spend more time promoting your trade with fly-on-the-documentaries like other branches of medicine. From the outside it does look like a numbers watching job.
At the end of the day modern medicine is failing in the UK and US, a 50 year old African living somewhere in that continent had a better chance of surviving the covid pandemic than a Briton or American. Questions need to be asked about what is going on in your profession.
I believe it is time to start measuring the value of a national health system based on the prevalence of good health and not on the volume of ill health treated.
There are many hospitals un the US with much larger surgical departments than mine. This is America remember; everything’s larger here. I am not and have not suggested that I am a “big cheese” (another example of your confusing ad hominum and cogency). You have managed to continue to elide the issue of what qualifies you to make the pronouncements that you so belligerently aver. Why not put on your big-boy pants and admit what it is you do? Most likely because it will betray your motives. The demand for anesthesia resources continues to grow and if you think that you will see its demise in your lifetime you should slip your VR goggles back on and retreat to your little happy place. Trashing other people’s occupation is shabby. Grow up. Quod erat demonstrandum. And yes, you are correct, I am wasting my time with you.
I think the answer to the question is quite simple. It is because the U.K. NHS ( across all regions) is broken and the leadership which is required to mend and fix it for the future is entirely lacking or simply not brave or skilful enough to even try. It a huge slow motion train crash happening before our eyes. The result will be a wreck of a “system” for the less well off to pick their way through, an increasing privatisation of services for the better off and those in the middle being continuously squeezed from either side. That’s not good. It’s not at all good.
It’s being done on purpose and they are now using a divide and conquer policy after suitably weakening the structure with years of inadequate funding.
Jane I think you give them too much credit. They ( politicians and medicos) are not competent planners either. It’s a shambles not a conspiracy.
Man-made “viruses”, gene-altering “vaccines”, illegal alien invasion, farming will cause famine, 15-minute cities, now “doctors” who aren’t . . . why, you’d think there’s some sort of sinister world body trying to kill us.
Don’t think about it and it’ll go away!
I guess the PA is similar to the MO in the military? Probably better than nowt in an emergency BUT not trained in “truth diagram” type diagnostics or the “cautionary principle” either. Sadly for the doctors (many of whom are simply shills for big pharma) they have brought this on themselves. Many seem contemptuous of empirical methods needed to gain knowledge based on evidence, they often hold to the “one true truth” regardless of evidence and many seem to openly belittle the Mertonian norms of science needed to remain open to errors and new paradigms. I realise this malaise doesn’t affect all medical doctors but due to their rarified Shaman status in society it does tend to afflict a lot of them. As William Burroughs opined “you need a good bedside manner with doctors or you will get nowhere”
Is this a shocking whistle blower piece or is this just a lament about the UK health system and people just accept this?
UK Doctors make 44000 a year..? What an I missing? That’s less than a teacher. I know doctors here in the US that make that in a month!
Almost everything.
UK doctors earn between £32k and £180k.
Here is a table for you by age:
23 = £32k
35 = £60k
40 = £95k
50 = £125k
55 = £170k (with some private work on the side)
55 = £200k (with privs plus some special ability recognition topup awards)
60 = £1700 per day after you have resigned because you despise the hospital management and went on a world cruise with the wife. Six months later your department has plunged into an operational crisis and the hospital wants you back on any terms.
In the US, they’re called physicians’ assistants, and there is a cadre of nurse practitioners who are skilled beyond the basic level. Neither is a doctor but both reflect the changing face of medicine and the administrative world behind it. Also, medical error remains among the leading causes of death, but no one is blaming PAs and NPs for some reason. Maybe we’re doing it wrong.
Here’s the thing: you can have medical that is high-quality, accessible, and affordable. Pick two. There is no perfect system. There are some good systems and some good practitioners. And as the Covid episode exposed, there is no shortage of not-so-good practitioners.
My 25yr old grandson is now in dialysis for stage 4 kidney failure. His consultant told him very recently that his GP had test results showing he needed urgent referral to hospital – 3yrs ago!
He was very ill and kept being told nothing was wrong. They looked at the bladder but not the kidneys… and totally ignored serious test results.
*His GP was African who actually said his high Blood Pressure was due to him having large upper arms!*
This woman cannot be a bonafide qualified qualified MD.
I am utterly distraught at the suffering of my grandson.
They only ‘qualify” as “doctors ” to escape poverty (not a bad reason in itself),get out of Africa and make lots of money. They don’t care a fig about people,I don’t either but I’m not a doctor with people’s life in my hands. I once was at a place where this black guy from Africa was training to be a doctor or retraining to get English qualifications that would let him work here. People would say to him teasingly,arent you gong back to Africa to save the lives of your countrymen. And he would reply I am going to go into private practice and earn lots of money so i.can buy a big car.
You sound like you have a case of bigotry, go and see a doctor.
Africa???
Good Lord! I am so sorry to read that. That GP sounds like an utter quack. I hope your grandson recovers.
“Junior doctors regularly work around 48, for a starting salary of £32,000”
This is mind-blowing… Is there any better evidence to the citizens of Britain that nothing in life is free, most especially free health care? Who would want to be treated by a doctor getting paid less than a sales clerk? The NHS should be scrapped.
To be replaced by what? Well, the only way for goods and services to be allocated efficiently and justly is for people that receive benefits to also incur the expense of those benefits. Any system that tries to break this bond will inevitably fail to allocate those goods and services to the people that want them the most. This doesn’t mean no insurance; it means insurance systems that maintain the role of the market in the distribution of goods and services.
“But what about the poor?” some will scream. But no one is or should be entitled to indefinite life. If we evaluated medical interventions on the basis of ‘days of good health purchased’ we could quickly see that some tax-funded medical interventions are basically the old and sick robbing from the young and healthy.
It’s a tragedy when you die at 25 instead of 85. It’s not a tragedy when you die at 80 instead of 85. You are going to die, and you are probably going to die sooner than you want to. This is a theological problem, not a medical one.
You might not be aware this is a political slogan used by activists.
A 23 year old fresh out of medical school gets £32k. The salary increments quickly and by their mid 30’s the junior will be on £+60k and soon thereafter £90k going on £122k as a consultant.
Thanks, that is helpful. A 23 year old in the US system would still be in medical school, earning $0.
£32k for their first F1 year out of medical school, when they can’t be trusted to make the tea, let alone be left alone with a patient.
That’s why all NHS users should beware Black Wednesday.
And don’t forget all the extra shift payments and “ash cash”. No junior doctor is actually on £32k.
I know so well as an immigrant from Eastern Europe that GP’s in UK mostly will prescribe ibuprofen or paracetamol (or do a pregnancy test for a women) rather than conducting a thorough examination.
Opposed to back home in Romania where most doctors are eager to feed you whatever pharma brands are lobbying with them. Two extremes, no middle ground!
UK GPs get lobbied by big pharma. The staff at a GP practice look forward to the scheduled pharma presentation lunch each month because by 2pm the surplus free donuts and pastries will be distributed.
In my experience In the U.S. the only tasks a physicians assistant does is blood pressure, weight, pulse, paperwork, and when trained an EKG or similar.
I’ve always had excellent care, maybe even more assiduous than the doctor, with a Nurse Practitioner. Never had a problem in over thirty years, many friends say the same.
Perhaps I’m just lucky, or perhaps in the U.S. you’re more likely to get sued if you screw up. Litigiousness has its advantages and disadvantages, more of a safety net for the patient, but it leads to much higher costs for care due to insurance.
All medical systems are flawed because it’s dealing with health, which entails dealing with people, solving highly complex problems involving life or death, costing vast sums of money and then add in soaring emotions. Not a good mix.
I know, it’s terrible isn’t it? The real ones are incompetent enough, especially the GPs. God knows why we need more incompetents. It must be a cost thing. Can’t more nurses be trained, or does “physician associate” sound more acceptable to an English graduate who wants to cross-train?
It’s easy to cherry pick bad cases to advance a dubious claim; it’s one of the foundations of modern journalism. My experience and that of my wife is that physician assistants (formerly called straight-up nurses before HR got its hands on things) are more savvy than a lot of doctors and certainly spend more time getting to the root of things than does the average hurried physician on his way out the door to the next patient.
Thanks to 14 years of incompetent Tory government Britain has become a third world country and can no longer afford qualified doctors.
I think you mean 9 years of incompetent Tory government proceeded by 5 years of incompetent Tory/LiDem government proceeded by quite a few years of incompetent Labour government leaving that note about there being no money left. Sadly competence and government are like oil and water they don’t mix easily.
The people who are guilty of the state of our country now are all the people who voted Tory in the last 45 years. It’s your fault.
I blame the Boomers who are aptly named, they are a generation of medical timebombs typically 2 to 4 stone overweight.
We are a nation that cannot build a 3rd London airport, or a highspeed trainline or a working military aircraft carrier. Why do we expect excellence from the NHS when this rotten nation state blunders at everything else?
This is a shoddy article based on the ‘hasty generalisation’ logical fallacy.
Pick three anecdotes and use them to ‘prove’ the whole idea of PAs is dangerous and should be scrapped.
How many patients do they see in a year? 3 million?How many more would have died if there was no PA to see them?Where is the control-group for comparison?
I was twice duped into seeing a physician’s associate who I believed to be a doctor. Both times the PA had to leave the room to consult with a real doctor, so not much time was saved. Recently I was offered an appointment with yet another PA, and said “no, thank you; I want to see a real doctor”. I have more than one rare condition that even GPs may not be familiar with.
On the other hand, I was hugely impressed by the expanded health care assistant role in hospital. They are highly skilled at limited, specific tasks such as siting a cannula or recording a 12 lead ECG (the doctor then interprets it). This is much more cost effective and safe than having a PA assess and diagnose patients who could have any of a huge number of different conditions.
And we really must stop assuming physical symptoms are caused by anxiety. At the very least, patients should be advised to come back if their symptoms don’t improve or get worse.
The Health Care Assistants do an incredibly good job under very stressful and difficult conditions.
Without necessarily endorsing PAs, what’s missing from this article is an acknowledgement that doctors too make mistakes and some statistics comparing error rates of doctors and PAs.
The Chesterton example was interesting, as Mrs U once presented herself to her GP on a Friday with two swollen, painful legs that she could hardly walk on and severe tiredness. After being reprimanded for coming in with more than one complaint per appointment, the GP arranged a blood test, chest X-ray and ECG for the Monday.
But by Monday she had been admitted via A&E with acute leukaemia and started on chemotherapy. The swollen legs turned out to be DVTs.
So yes, all grades of medical staff can make life-threatening mistakes.
The fundamental problem with PAs is a really simple one: a little knowledge is dangerous. That’s why simple but life critical diagnoses are easily missed by PAs but would be picked up off the bat by both medical students and 1st year residents.
It appears the NHS needs a major overhaul. I have practiced in the US for over 40 years, many in the emergency and urgent care setting. During the latter I trained and supervised several PAs.
First , one should note that in any profession, there are varying individual levels of skill based on experience, dedication and intelligence. Not surprisingly, my experience with PAs was that experience was key. When I hired a newly trained PA, they did indeed “slow me down”. I would have been more productive without taking the time to teach and mentor. Rightfully, they deserved the on-the-job training. The benefit to me would be that once trained, they would be largely autonomous and the practice as a whole was more efficient. If however, they “moved on”, I personally did not benefit, but the health care system did. I told these PAs when they had evaluated over 5,000 patients and practiced for 3 years, they could consider themselves competent.
PAs typically have a 4 year degree, of which 2 is spent in clinical training. A physician will have 4 years of undergraduate training followed by 4 more years of medical school. Over half of medical school involves clinical training, much of it rigorous. From the start, a new physician has a greater knowledge base than a PA. Subsequently a physician will spend a minimum of 3 years in a specialty residency program before employment in a general practice. Surgical specialities are much longer.
After graduating from medical school, I thought I “knew it all”. Turns out after my residency, I realized I knew “nothing”. The difference was the thousands of patients I treated during my training that allowed me to have the “pattern recognition” and clinical intuition essential to diagnosis and treatment. One cannot gain this from a book or computer. The analagy is that PAs need this experience as well, and it is not required to practice.
My opinion is that a PA can be a valuable resource when properly trained and integrated appropriately with well-defined parameters. PAs must be under physician supervision, with the trend that it can be done remotely. I am not a fan of this for inexperienced providers. It appears the NHS as a system problem, not a PA problem. I am confident the PAs I worked with would have diagnosed the examples given in the article, with possibly the exception of a 25y/o with aortic dissection. It would have taken exceptional acumen and intuition in this case(did he have Marfan’s?)
“The government claims that PAs are merely filling rota gaps because we just don’t have enough doctors.”
[Aircraft assembler:] Me and the boys routinely fill the last few holes with paperclips when attaching wings to the fuselage, because we just don’t have enough rivets.
[Government:] Your reasoning makes perfect sense to us.
Somewhere along the line, this will all have to do with ‘diversity’.
I was seen in my Bristol GP’s surgery by a nurse practitioner. I was not happy – I wanted a doctor for my painful, deep cough. She listened to my chest, said there was no infection, just congestion, and sent me home to rest. 36 hours later I was in hospital fighting for my life – double pneumonia complicated by sepsis. My kidneys and liver packed up and I came within a hair’s breadth of dying. But at least I knew she was a NP. I should have demanded to see a doctor. How much worse to be seen by someone basically pretending to be a doctor?
There is another elephant in room about why they are using these people. It helps with “diversity” targets, because not enough off some minorities manage to qualify as full doctors.
When challenged, it’s common to hear NHS managers justify PAs as bringing “diversity” and “a different perspective” to medical teams.”
Ah yes the beloved diversity DIE trick – the ruination of meritocracy – and the substitution of BLMocracy.
Paperwork? Seriously? In 2024?
Here in the US I don’t think I’ve seen a doctor or nurse holding pen or paper since about 1999.
If you want to see a patient’s “paperwork” go into his online profile in the hospital’s or clinic’s system. Twenty seconds of mouse clicks and everything you need to know about anything is in front of you.
Jeez. Or is this paperwork dystopia the state of the “envy of the world” NHS ????