Wes Streeting kept his word. One of the first phone calls he made the day after Labour won its landslide victory in July was to the doctors’ union, the British Medical Association (BMA). Within a few weeks he had negotiated a deal that looks likely to end the long-running junior doctors’ dispute in England. On 1 August GPs began their own work-to-rule industrial action, in which doctors are reducing some services or capping the number of patients seen each day. Despite apparently constructive talks with Dr Katie Bramall-Stainer, chair of the BMA’s GP committee, a resolution to this dispute seems further off. Streeting will argue that he does not have the resources immediately available to reverse a decade of underfunding and neglect of primary care. But he is strongly signalling his desire to “reset” the relationship between government and the medical profession to one of collaboration rather than conflict.
To achieve this reset, the Health Secretary will have to confront the fundamental crisis engulfing the medical world – a crisis that won’t be fixed by upping pay or magicking measures to render workloads manageable again, and about which he has been largely silent to date. The drums of discontent have been sounding with escalating tempo and volume for the past year, and a state of war has ostensibly now broken out between grassroots doctors and the medico-political establishment.
There have been casualties already. Several medical royal colleges – august institutions that have traditionally safeguarded and promoted the highest standards of practice in their particular branch of medicine – have faced revolts from their rank-and-file members. Members of the Royal College of Physicians of London’s senior leadership team have resigned and its president has been defenestrated. The medical regulator, the General Medical Council (GMC), is facing two lawsuits, one on the part of the BMA, the other a crowded-funded action by a group of anaesthetists called Anaesthetists United.
The conflict has erupted over the introduction of a new role into the health service, the medical associate professional (MAP). There are various types, but MAPs are usually degree holders who have undergone a two-year condensed and abridged programme of clinical studies, equipping them with a basic understanding of the commonest aspects of medical practice.
The first MAPs started working in the NHS 20 years ago. They were originally envisaged as assistants, relieving doctors of routine and administrative tasks, something that would have been uncontroversial and helpful. But over the past ten years, the role has transmogrified into something very different, with health service leaders looking to MAPs to take on what might be deemed medically “simple” cases, escalating only the more challenging patients to their supervising doctors.
There are currently over 4,000 MAPs in the NHS: 3,500 physician associates (PAs), assessing and treating patients in various settings; around 150 anaesthesia associates (AAs), administering anaesthetics to lower-risk cases; and approximately 600 surgical care practitioners (SCPs), undertaking low-risk surgical procedures. The NHS Long Term Workforce Plan, published in June 2023, revealed explicitly for the first time the ambition for the role, aiming to increase these numbers to 10,000 PAs and 2,000 AAs by 2036-37. The theory goes that the more MAPs there are taking on the “simple” workload, the fewer doctors will be required in the future system overall.
At one level the controversy over the introduction of MAPs can be construed as a turf war: members of an established profession resisting incursion on to their traditional territory. This is certainly how proponents of the MAP project, such as the former health secretary Steve Barclay and erstwhile health minister James Bethell, have attempted to frame the dispute. But that is a political obfuscation designed to minimise sincere misgivings on the part of many doctors.
In order to understand the issues, it can be helpful to envisage the NHS as a complex ecosystem, populated by various species of healthcare professional – doctors, nurses, physiotherapists, pharmacists, paramedics, radiographers and so on – working in concert in the cause of patient care. Each profession has its own area of expertise, new entrants must satisfy the training and qualification requirements of their chosen field, and all practitioners are accountable to a regulator for the quality and safety of their work.
The NHS ecosystem today looks very different to how it did 30 years ago. The professional titles might be the same, but responsibilities have evolved beyond all recognition. Many nurses, for example, now undertake advanced training to be able to perform tasks that would have been the preserve of doctors a generation ago. There have been several drivers behind this process, but the two most important are productivity gains – in general, professions that have taken on new responsibilities are less expensive to train and employ – and career development: an experienced casualty nurse, for example, will become intimately familiar with the management of typical cases and might relish the opportunity to put extended skills into practice. The ecosystem has adapted over time to deliver its end goal with ever greater cost-efficiency.
The MAP project – fundamentally about achieving further productivity gains – has been different and can best be understood as the abrupt, external introduction into the ecosystem of an entirely new species. For it to succeed and thrive, this new species must carve out a niche for itself. In the case of MAPs this would be undertaking those “simple” cases alluded to earlier.
Had MAPs been introduced as doctors’ assistants as originally intended, the role may well have evolved organically in the way many others have. But the Tory government was in a hurry. Wages account for roughly 45 per cent of the total NHS budget and after top managers, senior doctors are the health service’s highest-paid employees. The rapid introduction of new, less-expensive personnel was seen as an urgent necessity to help mitigate the projected inexorable rise in health service spending.
A programme of wholesale role substitution like this might be expected to attract scrutiny. Is it safe? Does it actually reduce costs? Is the quality of care maintained? What limits are there to what MAPs can reasonably do? How much supervision is required and how can it be funded and resourced? What is the impact on the next generation of doctors who will be expected to provide that supervision? Such questions would take time to research thoroughly, and there is always the risk that the answers might not be as hoped. Far easier to do what the Conservative government did: create the conditions under which hospital departments and general practices would seize upon these new pairs of hands and develop the roles away from public or indeed regulatory gaze.
The prerequisite was an ecosystem starved of the very species MAPs are intended partially to replace. We are constantly told that the NHS is short of doctors: long waiting lists for hospital care and difficulties getting GP appointments are adduced in evidence. Yet paradoxically there is no shortage of medical manpower. Rather, the opportunities available for doctors to progress their careers have been inexorably squeezed. Postgraduate training places and substantive posts have been curtailed in anticipation of proportionately fewer specialists and GPs being required in the future. Funding has been diverted to the training and employment of MAPs instead.
This has resulted in demoralising bottlenecks at every stage of medical careers, with many doctors left languishing in “holding” posts or facing the need to find alternative work outside of medicine. According to the BMA, there are at least 1,500 fully trained GPs in England struggling to find work, while patients are crying out for access. Practices, subject to years of real-terms cuts, can no longer afford to employ them. But there is a special fund known as ARRS (additional roles reimbursement scheme), ring-fenced by the previous government, that enables surgeries to recruit MAPs at no cost to individual practices. The only string attached is that the practices must deploy them to do what GPs have always done, assessing undifferentiated patients – the great swathes that come to general practice each day with every type of problem from the trivial to the deadly serious.
In July 2023, a coroner’s report was published on the tragic case of Emily Chesterton, a 30-year-old actress who died from a blood clot on the lung (a pulmonary embolism). Chesterton had attended her local surgery twice, complaining of calf pain and breathlessness. She had been told that she had strained a leg muscle and was anxious. Shortly after the second consultation, she collapsed and died.
Although Chesterton believed she’d seen a GP, her appointments had in fact been with an MAP: in this case a physician associate, or PA. The conjunction of leg pain and breathing difficulty should make any doctor instantly think of a pulmonary embolism, an eminently treatable condition. The coroner ruled that had Chesterton seen someone medically qualified it is likely she would have lived. The needless death of a young woman was shocking enough, but what it implied about the level of PA training and competence, and the mismatch with the degree of autonomy some were being given, caused collective disbelief.
The Chesterton case could have proved to be a tragic one-off, but it was not. Front-line doctors in both general practice and hospital medicine began circulating on social media other examples of PAs allegedly mismanaging patients with conditions as diverse as cancer, heart failure and stroke. Numerous instances of PAs replacing doctors on hospital rotas were disclosed; likewise, examples emerged of usually inner-city general practices where PAs conduct almost all the clinical work. Patients were frequently unaware of the qualifications of the practitioners treating them.
MAPs, with their very basic training, are supposed always to be supervised by experienced senior doctors, yet this was simply not happening in services stretched beyond their limits and seizing on any way of plugging gaps. Earlier this year, Joanne Kearsley, senior coroner for Manchester North, issued an official alert following the inquest into the death of 77-year-old Susan Pollitt in 2023 after a PA mismanaged an invasive procedure at Royal Oldham Hospital. Kearsley’s report echoes the concerns being repeatedly raised by the medical profession: “There is no national framework as to how physician associates should be trained, supervised and deemed competent. This is placing both patients, physician associates and their employers at risk.” She goes on to say: “There remains limited understanding and awareness of the role of a physician associate both amongst medical colleagues, patients and their families… The title ‘physician’ gives rise to confusion as to whether the practitioner is a doctor.”
Beyond the patient safety concerns, the impact of the MAP project on medical training has also become plain. Social media has reverberated with examples of MAPs being prioritised for educational opportunities, while doctors-in-training are missing out. Competition to study medicine is intense, and students typically incur £100,000 of debt by the time they graduate. At every stage of their postgraduate careers they must pass exacting examinations and continuous workplace assessments in order to progress. To see unregulated MAPs with far less rigorous and comprehensive training being fast-tracked for advancement with no standardised assessments of competence, and whose pay eclipses that of younger junior doctors, is having a devastating impact on medical morale.
Then there is the question of ultimate responsibility. Traditionally, this has rested with doctors. The GMC holds medically qualified practitioners accountable for the decisions made and the care afforded to their patients. If aspects of that care are delegated to other professionals, then the doctor retains responsibility for ensuring the safety and appropriateness of the delegation.
In 2017 the first case to test the relationship between MAPs and their supervising doctors came before the GMC. A medical registrar, Dr Steven Zaw, was criticised by the tribunal for not having repeated the assessment of a patient with suspected meningitis that had been carried out by a PA in his department – part of a verdict that led to his suspension from the medical register for 12 months. MAPs have been let loose in the NHS without regulation and with no definition of the scope or limitations of their practice – a situation that has been described by medics as the “Wild West”. When things go wrong, it is patients who suffer, and doctors who ultimately carry the can.
Neither NHS leadership, nor the GMC, nor the several medical royal colleges that have been revealed as having cooperated with the MAP project are prepared to define the boundaries within which MAPs should work, insisting instead that this is a local matter for their employers – this despite overwhelming evidence that those employers frequently deploy MAPs in unsafe and inappropriate ways. The BMA has stepped in to fill the vacuum, publishing guidance to protect doctors who are required to supervise MAPs. The BMA stipulations curtail many of the activities MAPs have until now been carrying out, such as attempting to diagnose undifferentiated patients like Emily Chesterton.
The battle lines have been drawn. Anecdotal indications are that doctors are heeding the advice of their union, and the potentially dangerous ways in which some MAPs have been practising to date are being halted piecemeal. The medical royal colleges that the government had involved with the project are following suit.
The MAP project has descended into farce, with NHS England and the GMC insisting it was never about replacing doctors, despite a plethora of documentary evidence to the contrary dating as far back as 2015. Caught up in the chaos are several thousand well-intentioned MAPs who have trained in this new type of healthcare-practitioner role; an unknown number of patients whose care may have been affected; a generation of doctors who feel their rigorous training – involving considerable personal and financial sacrifice – is viewed as essentially irrelevant by those leading the NHS.
The MAP project is just the latest instance of the marginalisation of medical expertise in the NHS. Doctors are deemed by health service leaders to be too expensive to be doing anything other than dealing with complex cases. We have seen this unfold in the GP out-of-hours setting over the past 15-20 years. A service that used to be fully staffed by GPs and triage nurses has been gradually eroded by the advent of 111, in which call handlers without clinical training use algorithmic software to assess patients.
The core problem – whether in general practice, hospital medicine or the administration of anaesthesia – lies in the concept of the “simple” case. Which cases are simple can only be determined after the fact. Most chest pain is trivial, but some instances herald major heart or lung pathology. Most headaches are migraine or tension, but some can reflect serious disease of the brain. Leg pain and breathlessness might indeed be due to muscular injury and anxiety, but some will be due to pulmonary embolism.
To reduce the chance of a “simple” case proving to be anything but, the 111 algorithms are designed to be highly risk averse. Huge numbers of patients are pushed into the ambulance service and A&E departments, the majority of whom would have been safely and effectively managed in the community were GP capacity to have been maintained. The system may look cheaper on paper – doctors are more expensive than call handlers and computers – but the escalation in overall costs has been ruinous, and the quality of patient care and experience has been dramatically degraded.
The same is now happening with daytime primary care, with MAPs and other allied health professionals replacing GPs, and with integrated care boards in various areas experimenting with impersonal “hubs” to replace traditional doctors’ surgeries. Alongside the patient-safety incidents and impacts on doctors’ training, a third concern about MAP practice has come from consultants whose departments have been swamped by requests from PAs for investigations or opinions that GPs would ordinarily have managed without referral. Healthcare needs that aren’t met in primary care will inevitably turn up in the hospital sector, hugely amplifying system costs.
This is the crisis that Wes Streeting inherits, and which he will have to resolve if he is to rebuild a health service fit for the future. His key mission is to rebalance the NHS away from expensive hospital and specialist activity in favour of more care being delivered more cost-effectively in the community. To achieve this, he will need around 8,000 more GPs in England to bring numbers of patients per doctor back down to the levels last seen in 2015.
The devaluation of medical expertise in the NHS is creating a brain drain. UK-trained doctors are internationally sought-after, and countries such as Australia, New Zealand, Canada and Ireland are energetically recruiting from the demoralised ranks. John Burn-Murdoch, chief data reporter at the Financial Times, has written that an estimated 18,000 UK-trained doctors are now working abroad – an increase of 50 per cent on 2008. That represents one in seven of the home-grown workforce and is almost three times the rate among peer countries.
The trend is continuing. In April, the General Medical Council published independent research that suggested 30 per cent of remaining UK medics are contemplating moving overseas to practise in the next year, 16 per cent of them already taking what the GMC terms “hard steps” towards emigrating. Applications for certificates of good standing (CGS), which doctors must obtain from the GMC if they are to work abroad, on average number 5,000-6,000 per year (not all CGSs convert to departures), but 8,600 were requested in 2023.
Charlie Massey, the GMC’s chief executive, was at pains to point out that the numbers leaving have yet to show a comparable uptick. But he was sufficiently concerned to go public and to urge those in power to act as a matter of “urgency”, to stem what he clearly believes may be an imminent exodus. (The GMC has been intimately involved in creating the crisis. Under Massey’s leadership it agreed to take on the eventual regulation of MAPs, and has proposed lumping them together with doctors under the umbrella term of “medical professionals”, blurring the boundaries between the two groups sufficiently that most patients wouldn’t be able to tell the difference. This is an irony that has seemingly passed Massey by.)
Shortly after Massey’s disclosure, the BMA published an analysis of the costs of this attrition in the medical workforce – up to £2.4bn to replace the doctors who left the NHS prematurely last year alone. Not all went abroad: early retirement or quitting medicine altogether for alternative careers were also part of the picture. But whatever the off-ramp, the underlying causes are the same.
Streeting appears to understand the gravity of the crisis. He recently relaxed the rules so that ARRS funds can be used to employ GPs instead of PAs, an “emergency measure” pending a wholesale review of the GP contract in 2025. And as well as pledging to help resolve the junior doctors’ pay dispute, he has acknowledged the dispiriting degradation of medical training that has destroyed morale among the next generation.
Turning around the situation will require significant political strength. There have been so many health secretaries over the past six years it is inconceivable that the MAP project – and the wider trend towards marginalising the role of doctors in the NHS – can be considered the project of one politician. Instead, it speaks of a groupthink pervading the upper echelons of the Department of Health and Social Care and the leadership of NHS England.
Wes Streeting signalled his intentions for change on his first day in office, declaring that the NHS is broken. In parallel, he should announce an end to external interference in the health service’s ecosystem: the safe and appropriate evolution of roles must be returned to the professions involved. And he needs to make clear the irreplaceable value of fully qualified doctors to high-quality care for all NHS patients, and to the sustainability of the service he aspires to restore and transform.
[See also: Labour’s first policy should be to break up the NHS]
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This article appears in the 28 Aug 2024 issue of the New Statesman, Trump in turmoil