The scope, supervision and regulation of physician associates need to be urgently established to promote patient safety and professional identity

In  the evolving landscape of the National Health Service (NHS), the role of physician associates has come under scrutiny, revealing intricate connections with broader policy shifts. There is a complex interplay between NHS policies, physician associates, and the implications for patient care. There is, unfortunately, quite a torrential amount of hysterical click-bait misinformation about physician associates spread by people on both sides of the debate, and the Government has set out its case in a blog and other channels.

The journey begins with the significant impact of the Health and Social Care Act (2013), a turning point in the privatisation of the NHS under the Tory government since 2010. The act, catalyzed by the disastrous Lansley reforms, laid the groundwork for integrated care systems, quietly passing legislation in 2022.  Lord Simon Stevens’ influence, rooted in his training with United Health in the U.S., is evident in the blueprint for integrated care systems in the UK provided through the NHS Long Term Plan. The shift towards accountable health systems mirrors the intentions of transforming the NHS into a U.S.-style insurance system.

A critical examination of the policy drivers reveals a multifaceted approach. The push to increase the number of physician associates is seen as a strategy to dilute the influence of doctors and reduce collective bargaining power. This move is economically motivated, as doctors are perceived as more expensive than alternative non-medical professionals.

Health Education England’s complicity in decreasing senior doctors’ numbers, coupled with tougher competition ratios, exacerbates the recruitment and retention crisis. Local funding policies lead to the substitution of sessional GPs with Advanced Nurse Practitioners (ARRS), raising concerns about patient safety. It is already clear that perverse incentives in the NHS workforce market have had a detrimental effect on GP workforce numbers and morale. 

The training of physician associates is brief compared to doctors. At the moment, there is a voluntary register, but the intention is for them to be under statutory regulation from the General Medical Council. This convergence of regulator has emphasised further a need for their identity as “non-doctors”, despite a medical approach (although some argue that the term “non-doctors” is unnecessarily pejorative).

As they are trained on fewer prototypes and exemplars, the number of differential diagnoses physician associates can come to is restricted, meaning that the scope for diagnostic errors is increased compared to registered doctors.  A/Prof Nicola Cooper is one of the country’s leading physicians, and an expert in clinical reasoning:

The central role of GPs in the 8 am ‘scramble’ highlights their unique competence across various medical domains. The shift towards a non-medical workforce, while dealing with complexity differently, raises questions about the nature of healthcare delivery. While acknowledging the potential role of physician associates, the article questions their suitability in acute medicine. The lack of comprehensive medical training and potential very serious diagnostic errors pose challenges, particularly in emergency medicine, general practice, and anaesthetics. There is ambiguity surrounding physician associates’ participation in management plans, citing concerns about the limited supervision role doctors may have. The inclusion of prescribing powers further blurs the lines between medical and non-medical roles. It is e important to recognise that medics are not the sole managers of complex cases. A call for effective multi-disciplinary teamwork is crucial to meet outcomes that truly matter to patients.

As physician associates become a focal point in the evolving NHS, this article underscores the intricate web of policies, political motivations, and implications for patient care. Navigating this complex landscape requires a careful examination of the forces shaping the future of healthcare delivery in the UK.

The Faculty of Physician Associates resides within the Royal College of Physicians of London. An extraordinary general meeting will be held on 13 March 2024 to discuss further the College’s position on physician associates.

According to published information, a college spokesperson said, “We host the Faculty of PAs and believe there is a valuable role for physician associates within the multidisciplinary healthcare team, but they are no replacement for doctors, and their employment in NHS trusts should definitely not be to the detriment of doctors in training or growth in doctor numbers.”

A position statement from the Edinburgh College has been previously published.

Why a sensible debate about ‘physician associates’ matters urgently

As a carer in the final year of mum’s life, what mattered to me regarding the NHS was obvious.

I wanted to be able to see a GP when I wanted to, urgently if need be. I am a registered doctor, but I was meticulous about never taking mum’s medicine management into my own hands.

I would face the ‘8 am scramble’. The performance of the NHS noticeably deteriorated within the last year. For the first time ever, towards the end of mum’s life, I would be held in a queue on the telephone on 999. That had never happened before.

I don’t underestimate the pressure that friends and colleagues had to work under in the coronavirus pandemic. There were a huge amount of pressure. There were some successes, like the vaccine roll-out and development, but there was also a fair share of problems, such as ineffective PPE procurement and staff sickness.

The problems in the NHS workforce have pre-existed the pandemic, however. The NHS has had problems recruiting and retaining staff. Practitioner health has been an ever prominent issue, with burnout being a tragedy affecting many. There has only latterly been a workforce plan, but the return-to-practise programmes are suboptimal, and the NHS prefers to pay for locum staff. It has imposed tight bottlenecks in career progression, at a time when we are clearly not as a service leading on matching patient demand.

Doctors in England have a legitimate pay concern, where their pay has not kept up with the cost of living. It is not unreasonable for doctors to afford to pay mortgage repayments, University fees debt repayments, or child care costs; or the cost of professional registration, or the cost of postgraduate exams.

As a registrant for the General Medical Council (GMC), I feel that the regulator is living on borrowed time. It has improved markedly from a low baseline about fifteen years, when there was an obvious problem with suicide rates of doctors facing fitness to practise. I don’t know of any other corporate entity where membership is life-threatening. We know that there is a problem with a culture of racism in the entire NHS, and the referral rates to the regulators of BAME professionals remain striking. The GMC is supposed to maintain patient safety on behalf of the whole public, and yet the whole public doesn’t pay for it; only registered doctors. Democratic accountability is now a massive problem, where many doctors feel that the GMC is unresponsive to their concerns about participation. The issue about physician associates is another tragic development.

The GMC claims to have completed a consultation with its members about physician associoates. This workforce does contain individuals working as hard as they can, in a struggling NHS. But it is obvious that they run the risk of being poorly regulated, and working out of scope. Clinical patient safety errors exist across various workforce groups in the NHS, so it is unfair to single out the physician associates potentially. But every avoidable death is a tragedy. The deaths caused by physician associates for misdiagnosis of a blood clot or an infection not treated in the urinary system are gobsmacking for a number of reasons, not least they involve very basic medicine.

There has been an unpleasant meme that the NHS want people to working ‘at the top of the license’, but it is obvious that due to cultural pressures in the NHS some physician associates are being inadequately supervised and working independently basically where they should not be.

The problem is entirely the making of politicians to have refused to match funding with demands. The stubborn ideological drive of politicians to introduce a market into the NHS through white papers such as ‘Equity and excellence: liberating the NHS’ (2010) have introduced new ideas.

The approach has been to portray Doctors like me as ‘luddites’ and overly protective about the medical profession. This is simply ridiculous as I saw how members of the multidisciplinary team, including podiatrists, physiotherapists, occupational therapists and dieticians, were invaluable in my mum’s care. As it happened, I came top of my year in my Master of Business Administration in innovation management.

As a member of the Royal College of Physicians, without personal, I have more to say on this matter than a Hereditary peer with experience in the Ministry of Sound perhaps. Physician associates, robustly regulated and working in scope, have the potential to contribute to the NHS in a remarkable way. That many appear to be paid more than exhausted junior doctors with staggering financial pressures themselves is causing unnecessary resentment. Also causing resentment are spokespersons from the Executive talking about how they wish to introduce non-Doctors to break up the medical workforce. The implication is that their collective bargaining power is less. This is purely an ideologically-driven antagonism towards doctors. Doctors feel that senior leaders in the NHS are not on their side, and this is problematic if the leaders are to ‘govern’ by mutual consent.

I am not surprised that the Royal College of Anaesthetists and the Royal College of Emergency Medicine have already made cautious moves. These are not coming from a place of being hostile and obstructive. It’s simply that all associates need to feel welcomed, valued and safe, in rôles they feel comfortable with. And the rest of the workforce needs to feel safe in working with them. They certainly do need to feel ‘threatened’ by other team members. There is of course scope for misinformation about this, but it is also documented robustly that some NHS Trusts are not taking safety concerns seriously enough, and that some associates are being recruited as replacements as doctors (for example sessional GPs). The leadership and direction of the Royal College of General Practitioners are somewhat in need of marked improvement for members to feel comfortable. Patients likewise don’t want to go to see their GP or be put under for an operation to find at some later date that they were never seen by a registered accountable doctor. This is terrifying for the general public, and unacceptable in equal measure.

Physician associates can work well, and many enjoy working well with other staff members, patients and carers. Surgical associates have been popular, freeing up time by doing admin work or basic procedures, admittedly freeing up time so that NHS consultants can spend more time doing their private work. I have been surprised how little we have heard from medical education specialists, however. If you have a markedly shortened training, exposed to much fewer prototypes and exemplars of case presentations and their medical management, it is inevitable that the scope for fundamental diagnostic error is much larger Some of these errors will be tragic, and needless avoidable.

Admittedly, there is only a finite amount of money to go round. But we then have to ask what is the point of this? If it is to introduce a yet further cost into the system, and yet another workforce which needs to have its work double-checked all the time, why is it worth it compared to training and retaining the medical workforce? Or is it simply that both Labour and the Tories have totally given up on the NHS workforce, expecting to import staff from India, Bangladesh or the Philippines?

Natalie Bennett, in the House of Lords, from the Green Party, will bring forward a ‘fatal motion’ to allow these issues to be properly debated, to give priorities to patient safety and democratic oversight. These issues are basically impossible to disagree with, even accounting for ideologically-held positions. It is unclear quite what Labour’s position on this might be (unhelpful as the next government will have to inherit these problems). It is really not on that such an important policy development has been ‘nodded through’ on the mere whim of a statutory instrument, without being given the parliamentary scrutiny it so clearly deserves. What then happened to ‘taking back control’?

This is a mess.

The discussion needs to be sincere, honest, respectful and complete. There is a danger by introducing too much noise, and snuffing out the light, the discussion becomes toxic. But even a pause over a workforce which is supposed to be supernumerary will be extremely useful for avoiding tragedies from happening and for sincere seniors to think about how they wish to shape the professional role, syllabus and curriculum. It’s not too late. Yet.

The issue whether physician associates are an opportunity or a threat to junior doctors is an important one to be resolved

In all the promotional YouTube videos I’ve seen, physician associates are likeable, hard-working members of the team, willing to learn and to put the patient first. The caricature of a ‘power grab’ is demeaning to the professional dignity of the physician associates, and teamwork is supposed to be a central plank of the medical profession. There is, however, a discussion to be had over whether physician associates are a help or a hindrance overall, and what could be done to improve the situation if desired.

Since I started blogging on NHS policy and politics around 2012, I have seen various variations on a few themes. One is the increasing ‘demand’ of NHS services, which invariably has been blamed on people living longer. The same neoliberal solutions have been offered by the Conservatives or Labour, for example the improved use of technology. Fast forward to 2024, and that means artificial intelligence (AI). The adaptations to the workforce have been a factor too. When the Conservatives were taking the Health and Social Care Act through parliament in 2013, the emphasis was on market fixes, notably s.75 which was based on the bogus assumption that improved competition in markets would inevitably result in higher quality. At that time, there was a ‘pause’ and the illusion of a consultation – and then the legislation happened anyway.

I don’t know what to believe any more. Maybe it’s because I’ve been watching too many films like ‘The Truman Show’ or ‘North by Northwest’. The ‘advert’ for physician associates, as currently envisaged by NHS careers, is here. Physician associates are conceptualised to work under supervision, rather than being independent practitioners. Even looking at this brief description, it is hard to see how physician associates can form appropriate management plans without a much more than basic knowledge of medicine. Even FY1/2 are considered to have a fundamental knowledge of medicine compared to senior specialist registrars such as ST5 or 6. Poatgraduate diplomas, extremely costly that they are, are supposed to add an extra layer of sophistication to doctors’ practise of medicine. It’s totally unclear what continuous professional education physician associates are supposed to do, and what their career progression entails.

It is inevitable that, with increasing case complexity, physician associates will practise unrealistic medicine, in other words over investigate patients for clinical scenarios even as ‘simple’ as a nose bleed. Likewise, it is equally possible that the wrong investigations will be requested, or someone is underestimated according to the actual clinical problem,. The relevant question is whether the systems in place for performance management by peers are robust enough. In the worst case scenario, one would expect an underperforming physician associate to face a fitness to practise proceeding, but it is not clear how standards for competence can be set safely.

The medical regulator, the General Medical Council, has found itself regulating physician associates, which is odd because it appears intentionally to blur the boundaries between doctors and physician associates. As physician associates, last time I looked, are not doctors, it would make much more intuitive sense for the physician associates to be regulated by the Health and Care Professions Council (HCPC) and not the GMC. The last thing, one assumes, that the public wants is not knowing whether they’ve been seen by a graduate who’s been six years at least through medical school or whether they’ve been seen by a postgraduate of two years in physician associates school.

The horse has bolted. The consultation is happening after the policy has begun to be driven through. So what’s the point of that? The medical regulator boasted today of its interaction with National Voices, but this behind closed doors consultation, nor the conversation with the Doctors Association yesterday, will do little to allay the fears of junior doctors. Junior doctors are already being pilloried by various client journalists in the media. Longstanding patient safety issues due to a demoralised, overstretched workforce have been largely ignored, while NHS leadership seems to be at war with the juniors. All of this can be doing nothing for morale. Physician associates, or anaesthetic associates, or surgical care practitioners, potentially can improve morale in the workforce of junior doctors, if it is genuinely felt that they are relieving the pressure off junior doctors. We know that the workforce, compared to demand, has been shrinking. The return to practise schemes for unanticipated leavers are non-existent, for example.

But this solution, of ‘substitutes’, may be not exactly what junior doctors asked for. Physician associates are not the answer to their question of: can their pay be restored? can there be more doctors in the workforce? The retention of junior doctors is a longstanding shambles, with bottlenecks in training post numbers. We are left with the ludicrous position that there are one or two candidates for consultant posts in geriatric medicine if that in London, and even then some posts remain unfilled. This is all while presumably the numbers of people with frailty syndromes, including dementia and physical frailty, are going up. The numbers of people with chronic disability are going up. The pressure on hospitals is going up. And so on. Many of us can’t understand why the Government can’t make more of an effort to recruit and retain their skilled medical doctors.

There is as such a workforce plan for doctors in the NHS. We train a limited number of doctors, and some are exported now to Australia or New Zealand, and we no longer can import as many from the European Union due to Brexit meaning that we have to foster a good relationship with India or Bangladesh. A crazy situation is that junior doctors often graduate with substantial debt, like ‘home grown nurses’, while physician associates can have a salary paid for them during training. International medical graduates are more likely to have an encounter with the medical regulator, but it is uncertain whether this is due to rampant racism in pockets of the NHS.

The critical question for me is whether physician associates, whether in hospital or in GP land, replace or supplement doctors. A close eye needs to be kept on HR to check that they are not replacing doctors with ‘substitutes’, when employment contracts come to and end. The current Government has often whinged about the unionisation of ‘junior doctors’, and nothing would give them greater pleasure than to see this workforce stripped of their collective bargaining rights. The irony of a plan to introduce a two tier-system where the “free at the point of use” NHS is manned by physician associates and allied health professionals is that some of the staff will be unconsciously incompetent, in other words not even aware that they are missing diagnoses. This is clearly, at worst, a potential threat to patient safety. And to see a doctor may involve paying a fee. And this is the last thing the private sector itself wants to do, with complex, multi morbid patients with polypharmacy. A time will come when the British Geriatrics Society will have to deal with the ‘difficult’ elderly care being taken out of scope of the ‘basic NHS’. This, with the rocketing numbers of people with dementia with ineffective drugs to slow down progression, will be an unmitigated disaster.

It seems that Labour doesn’t want to scare the horses. Both Labour and the Conservatives are fully signed up to the policy, There is no discussion between many of the junior doctors individually themselves and anyone, including notably the Royal Colleges. For all I know, physician associates are an opportunity not a threat. But this challenges my view of how diagnoses and management plans are made with increasing expertise, which I’ve studied in my own Masters in medical education at Nottingham. We’ve all seen the phenomenon where doctors of different training grades can seem to get a totally different ‘history’ off the same patient. This is partly because, as you gather more expertise (different potentially from more experience), you know what to ‘look for’. You know more medicine, and you know what the various possibilities are. If you’re taking history as a robot, there’s no guarantee that you will take an ‘effective’ history for the purposes of producing a realistic or efficacious management plan.

The clock is ticking. All of this has unfortunately come about at the end of a protracted period of austerity, with still some element of crisis. But we could be going out of the frying pan into the fire with this one. The question of whether an inferior history and examination, taken by a physician associate compared to a registered doctor, is ‘worth it’. This is a question of patient safety, but it is equally a question about the nature of medical expertise in the specialist field of medical education. What the medical profession must do at all costs is to avoid the perception, even if unintended, of one profession picking on another. The medical profession inevitably has substantial power, and it is critical that it does not abuse that. There is, however, an important discussion to be had. What do you think?

Wes Streeting proved today that he has no political nous over the NHS. This could be quite a big problem.

This year, Vogue was one of many to report that American dictionary Merriam-Webster has just made “gaslighting” its word of the year, “after searches rose by 1,740 per cent in the last 12 months, and it was looked up multiple times, every single day.”

“The dictionary broadly defines gaslighting as “the act or practice of grossly misleading someone, especially for one’s own advantage”.”

Wes Streeting MP clearly has his eyes on the top job in politics – if he can make leader of the Labour Party, he has a chance one day to become Prime Minister. Today, however, Streeting’s performance in the TV circuit interviews was appalling. I’ve been a seasoned viewer of the politics of the NHS and social care since about 2011. I used to blog regularly on the political machinations which were leading to the enactment of the Tory Health and Social Care Act. I remember those times quite well. Here are some of my blogposts on ‘Our NHS‘.

There is no doubt that there is rock bottom morale in the NHS at the moment. The impact on practitioner health has been gobsmacking to me. Family doctors are being pushed out of the profession due to burnout, an inevitability as a result of the hostile environment towards doctors from the media. Nurses, professionally regulated depending on their vocation for their livelihood, are contemplating striking in desperation as a last resort. The political mismanagement of the NHS by the only political party to have been in government (apart from the Liberal Democrats in coalition in 2010 – 5) is to blame. They were in charge of the purse strings. They set the policy. They for years had no workforce plan – until one was announced this year. Jeremy Hunt, to add insult to injury, conducted an inquiry into low morale in 2016, and then did not act on it. Jeremy Hunt comes across as a vicar you might be proud of, but his actual track record as the longest serving SoS for health is nothing to write home about.

That the political establishment might be at loggerheads with a major stakeholder in the NHS, the doctors, is nothing new. It is alleged that, in 1948, Aneurin Bevan boasted that he was able to accomplish his goal “by stuffing the doctors’ mouths with gold.” What he meant by his famous and oft quoted statement is that he allowed some British doctors or consultants as they were called, to continue seeing private paying patients if they accepted NHS patients. What happened this morning was truly abhorrent, however. Streeting, not even provoked, claimed, “Whenever I point out the appalling state of access to primary care, where currently a record two million people are waiting more than a month to see a GP, I am treated like some sort of heretic by the BMA – who seem to think any criticism of patient access to primary care is somehow an attack on GPs.” This directly feeds into the No. 1 complaint from the NHS privatisation pioneers – that the NHS is viewed as some sort of national religion. As David Nicholson, previous chief of the NHS previously is alleged to have said, the NHS was probably so large it could be viewed from Outer Space.

Explaining Mr Streeting’s behaviour is easy. Streeting and Starmer are unable to talk about Brexit, in the same way that you might not talk about a verruca on your penis. It is well recognised from all the major medical think tanks that Brexit has had a catastrophic effect on the workforce of the NHS and social care. Add to this, the major decline in economic performance due to Brexit, and various other factors, the NHS has never been in such a terrible state. Even in 2010, prior to the peak ravishes of the pandemic, it had been reported that the Red Wall areas were suffering major problems in NHS access. I was once told that it is not only the ‘content’ of what you say it is the ‘style’. When asked about this fracture in relations this morning, Sir Keir Starmer MP rather implied that it is the BMA who are being obstructive. Nick Abbot on LBC drew attention that the criticism that ‘nurses should put patient care first’ from Streeter rather came out as an affront – as if nurses are not putting patient care first. This would be hostile, nasty and divisive.

Listening to Mr Streeting was like travelling back in time, but he sounded like all the Tory ministers from that time – not at all like Andy Burnham MP who valiantly opposed it as the shadow Secretary of State for health with Ed Miliband MP as leader in the run up to the 2015 election. Burnham around that time had had an epiphany that the outsourcing of NHS services had been too much. One of the biggest myths about NHS privatisation is that it is a ‘Big Bang’ affair in the City like an initial public offering. All privatisation means the transfer of resources from the public sector to the private sector. That’s it. It is well recognised that the privatisation exacerbated by the Lansley ‘reforms’ of 2012 accelerated health disparities.

What was telling to me was how Streeting trotted out the same Tory memes which had been so popularised in 2012. I remember hearing the same mantra being repeated by health journalists in events such as at the RSA more than ten years ago. Streeting almost verbatim repeated the slogan from the Blairite era, popularised as “I don’t care who provides the care, all I want is good quality care.” There was a fierce push on ideas such that competition in economic markets could and should drive up quality in the NHS – such as in this blogpost – much of which has been debunked or discredited. Famously, as Mark Britnell, a former director of Department of Health Commissioning (who later became Head of Health for at accountancy giant KPMG but was not appointed as head of NHS England)  told potential investors in 2010, “In future, the NHS will be a state insurance provider, not a state deliverer”.  The technology trope is longstanding – that people should not hold the Government to ransom, when corporate-endorsed technology, e.g. automation, is much cheaper.

These are longstanding tropes of the privatisation movement of the NHS. The blueprint for the privatisation of the NHS has been the country’s worst kept secret. It is a document by Oliver Letwin MP and John Redwood MP for the Centre for Policy Studies entitled, ‘Britain’s biggest enterprise, ideas for radical reform of the NHS‘. The mood music that Streeting would want to go to ‘war’ with the BMA is intentional red meat to members of the public who are exasperated at ringing up at 8 am to secure a GP appointment. In 2010, it was reported that then-health secretary Matt Hancock MP, subsequently of ‘junglewashing’ fame, said all GP consultations should be carried out remotely, unless there’s a ‘compelling’ reason not to. Streeting’s move is to encourage members of the public, especially ‘anti-woke Red wall’ voters, to side with him in blaming the doctors for the struggling service of the NHS. This is simply cruel to the struggling workforce of the NHS, who themselves are fed up. Such a move is likely to worsen the retention of GPs, already at breaking point.

Streeting’s appearance, even if unwitting, of Union bashing is strange. As Sangita Myska pointed out on LBC, he used anti-Union rhetoric while appearing to say that demands of some Unions were ‘reasonable’. They are reasonable as the evidence for the nurses’ relative pay freeze is irrefutable. The NHS prides itself on inclusivity and collaborative working – so the ‘war on the unions’ is at odds with what NHS staff want.

anti union bashing

But it is possible that Mr. Streeting can hold on until Sunak introduces his draconian anti-Union laws in the new year. It might be that, it is at this point, Streeting can claim victory over the Unions on behalf of Tory sympathetic voices. In response to Mr Streeting this morning on the local radio station for London, LBC, Andrew Castle enthusiastically opined that these words ‘could have been said by Iain Duncan Smith’, and ‘are likely to go down extremely well’. I was seeing however a rather different outcome on my Twitter feed, especially from supporters of the Labour Party prior to and including 2019, who remember warnings from Jeremy Corbyn that the NHS was being privatised, but which were rubbished by the client journalists cabal. It is noteworthy that the UK Labour Party has thus far refused to rule out supporting the proposed draconian legislation. Take back control, and all that?

Even Peter Mandelson, whom many blame for the drastic internal changes within Labour, appears to have given up. John Rentoul, a spokesman for the Blair movement in past times, tweeted some of his most recent predictions.

It seems odd, rather dangerous, for Streeting and Starmer to park their tanks on this particular lawn. But the rest, as they say, might be history.

Is the NHS really like Blockbuster, or do we merely have a Betamax Health and Care Secretary?

Tories for as long as I can remember have feigned outrage that anyone could think Tories don’t care about the NHS or social care, and repeatedly emphasised that the ‘NHS will be free at the point of use’.

They have managed to keep up this myth by wanting to charge for more bits of it and restricting access to more bits of it; or get people in the private sector to run it for profit. Ultimately, deep down, there is a refusal to see the NHS and social care as parts of the national infrastructure, just an acceptable ‘waste of money’.

So the vaccine “roll out” is framed as nothing to do with the NHS, rather a success of Pharma. In a weird world, it’s as if Tories are not consumers, nor ever get ill in the NHS acutely. This is patently untrue.

The pandemic is really weird. We’re no longer ‘a nation of shopkeepers’, but a ‘nation of courier riders with zero hour contracts and no employment rights’. Bring it on?

I suppose it is possible that Tories don’t watch or listen to the BBC, and like flag shagging instead or like binge watching series of Ricky Gervais. I don’t think so though.

I find it absolutely astonishing that Boris Johnson counts as one of his ‘big wins’ the reconfiguration of the NHS and (social) care. This is reminiscent of the precedence fellow Eton toff established that by saying something has happened you convince yourself it has happened.

I actually feel a bit sorry for Red Wall Man (and Red Wall Woman). Unlike Far Right News, I don’t wish to go down the rabbit hole of how do you know she’s a woman. I am more worried about the idiocracy we currently are enduring, and possibly putting up with well after the next general election.

The Blockbuster label for the NHS I suppose refers to a business model which no longer becomes fit for purpose, and needs to be replaced by Netflix. This comparison with Netflix is a direct parallel with the Conservative Party trying to devalue the BBC or C4, not because of their output (although they disagree with that, in keeping with contemporary theories of free speech). It is entirely to do with the longstanding campaign against the private sector.

I am not old enough to remember when the late Tony Benn, who shares the fact he is a graduate of New College with some Twitter followers of mine, was ‘minister of technology’. He was also involved with the nuclear power station debate, and was an arch Brexiteer.

What goes around, or plus ça change. But even Red Wall Person must have felt a bit ill when ‘man of the people’ Nigel Farage, a longstanding Tory of sorts, declared that he was vehemently opposed to strike action. This is of course not the sort of levelling up corrupt capitalists want.

Making the NHS like ‘Netflix’ speaks to the feeling that you should only pay into temporarily what you get out of something. In other words, you save money by never paying for any insurance on your health, in much the same way you take the risk of your house burning down (if you’re one of the lucky ones to be on the ‘property ladder’).

And paying for Netflix allows for tiers of subscribers. This is exactly what people have warned about for ages – that you can access ‘gold NHS’ if you pay the higher the rate of subscriptions (and sod everyone else)

The NHS being Blockbuster in a Netflix speaks to the idea that the NHS is continuously using outdated technology (like bleeps and fax machines). Apple has redefined technology as fashion items, e.g. MP4 players as iPods, and put the emphasis less on the physical means of access (e.g. Wifi rather than a TV cathode ray tube or satellite dish). This makes the derision given to Labour for suggesting a national infrastructure for internet absolutely unintelligible, for media debate to be replaced by far right presenters from Far Right TV News on BBC Question Time.

Build hospitals and people will come. This Tory government has tapped into the anger that some people perceive that they can’t get a GP appointment, despite putting the policy in place for this at the start of the pandemic. The NHS has almost become like a TV channel that is in denial over its number of viewers. Of course, the advantage of this is that you have to do no planning for resources – or in the case of the NHS, ‘workforce planning’.

Blockbuster went extinct, so did the Sinclair C5 and Betamax. For far too long, the Tories have been incapable of hiding their enthusiasm about making the NHS extinct. With little effective political opposition to the current political mess, arguably, however, it has never been a worse time to be a supporter of the BBC or NHS.

Even I didn’t know I had burnout at the time

This is emotionally difficult for me, as I have never told my story.  It’s deeply personal to me, and my life pivots around the burnout I experienced within the NHS. It’s self-reflection for me, and I hope this never happens to you.

 

So here it goes.

 

The health and wellbeing of NHS staff affects patient safety (1). Burnout is a psychological syndrome due to the prolonged response to chronic interpersonal stressors at work. Key symptoms are overwhelming exhaustion, feelings of cynicism, and detachment from the job as well as a sense of ineffectiveness and lack of accomplishment (2). Definitions vary, however, and formal psychiatric classifications are lacking.

 

When I qualified in 2001, I didn’t really know what burnout was. I thought it was something which happened to other people. In 2002, with high hopes, I moved to London from Cambridge to do my ‘SHO jobs’, as they were called then. I looked forward to a change of pace from the rarefied world of academia. I was optimistic. I believed that I had the aptitude to master neurology one day.

 

I was prepared to go “beyond the call of duty” to look after my patients. I had moved to a new flat in a new city. But I had no idea that my new future could mean working ridiculous hours in prestigious teaching hospitals, where many seemed too busy to care about my emotional wellbeing.

 

Neurobiologically, the human brain needs rewards to learn (4), but almost no one gave me positive feedback. I had no friends in London. After my commute home, I’d feel exhausted and alone. These were supposed to be “the best years of my life”. I started having a drink on my own to unwind.

 

I was terrified of making a mistake at work. There was no “learn not blame” culture then, as such. I felt so insecure, with infrequent educational supervision but a constant feeling that I had to be perfect (5). The culture seemed almost to demand a ‘superhuman ability’, but you were not supposed only to admit fallibility, vulnerability, or fatiguability. I felt I had to exude confidence, chutzpah, and bravura (6).

 

In reality, I also had compassion fatigue (a reduced ability to feel sympathy and empathy, exhaustion, anger, and irritability) (7). I remember feeling totally exasperated by the number of patients I had to clerk, to the point of being obsessed by the clock. I may not have actually cared much about the emotionality of people’s life stories. I just wanted the work to be done as fast as possible. I would have preferred colleagues not to have noticed that I had burnout. I felt I had no-one to turn to, in case my underperformance would become ‘official’.

 

I am in no way surprised that depression and burnout are similar phenomenologically and biologically (8): at the time, my mood plummeted. After my fourth SHO job, I didn’t want to apply for another clinical job. I felt hostile, and excluded; I felt that I didn’t want to belong in the “medical club.”

 

Long after finishing my jobs, I started receiving letters from the GMC containing witness statements from colleagues about my poor health and performance. I was even identified in a statement to be a problem drinker, but I had never been advised to see occupational health at that particular time. I waited a few years for a GMC hearing, which eventually came quite publicly in 2006.

 

The GMC erased me from their register, absolutely correctly, but my drinking went through the roof, with no job, no social network, and no future. Even then I refused to admit I was an alcoholic. In 2007, I had a cardiac arrest and was in a coma for a month, and I became physically disabled.

 

When I left hospital, with my new physical disability, I finally admitted defeat, I luckily found a consultant psychiatrist, and I was fortunate to commence sobriety. I retrained to postgraduate level in law and business, and the GMC restored me to the register in 2014. I have been in continuous recovery ever since, and in the care of a GP and psychiatrist I have never looked back. Only this weekend, I was invited to ‘share’ in a Alcoholics Anonymous (AA) group I’ve been a member of. I feel honoured to do so, and I hope it goes ok. I have now not drunk alcohol ever in the last thirteen years.

 

 

Reflections

 

I didn’t actually recognise burnout in myself, so I don’t especially blame senior colleagues for not recognising it either. I realised only recently, after reading Clare Gerada’s columns in The BMJ. My ignorance still shocks me to this day, but it was a great relief that the diagnosis of burnout, in actual fact, explained the enormous, distressing, previously inexplicable symptoms I’d had all these years.

 

Doctors are somewhat expected to portray a healthy image. Combined with unease about adopting the role of patient, this can lead us to take responsibility for our own care even when we are patently unwell. This is extremely dangerous to patients at large, and might result from a genuine lack of insight.

 

Many doctors drink alcohol to cope with the chronic stress from working in demanding  environments (9). Some doctors may not have registered with a GP, for fear that the GMC might learn of health problems such as alcoholism. Such maladaptive coping has significant implications for patient care, individual wellbeing, and the functioning of whole organisations.

 

The GMC’s Duties of a Doctor makes clear, however, that doctors should have their own GP (regulation 30, page 12). It also calls, rightly, for immediate protection of patient safety, which might require disclosure to the regulator about unsafe practice.

 

Burnout inevitably leads to dysfunctional teams. The GMC’s Duties of a Doctor includes a domain on working together. The 2019 GMC report on wellbeing, “Caring for doctors, caring for patients,” argued that central to doctors’ sense of “belonging” is the quality of team working, and the culture and leadership in their teams and organisations (11).

 

While reflecting on burnout, I have found – to my surprise – that I am not actually alone. The statistics are eye watering: one estimate indicates that one in 15 UK doctors may have alcohol or other drug dependency. (Sick Doctors Trust)

 

The US palliative care doctor Adam Hill has written in the New England Journal of Medicine about his own burnout, alcoholism, and recovery: “When mental health conditions come too close to us, we tend to look away — or to look with pity, exclusion, or shame.“ (10)

 

 

Suggestions

 

Happier doctors who support each other are safer doctors (12). In my case, rare supervisions with consultants never touched on my personal wellbeing. Educational supervisors could be trained to recognise symptoms of burnout. Senior doctors are under huge pressure, but still they must find time to care for junior doctors who are struggling, especially if they can find time to write to the GMC.

 

Professionals with burnout should not be “othered” as “problem doctors”, nor indeed “difficult doctors”. A lack of mentoring, coupled with a “blame culture,” often contributes to our difficulties.

 

I do not wish to absolve myself from the recognition that I contributed to my own problems, though. I deeply regret not recognising the symptoms of burnout in myself. If I had known I was in such trouble earlier, I might have been motivated to seek help. It might be a really good idea if, even with a packed medical curriculum, students learn how to seek help, take care of themselves and others, and be kind.

 

Approaching burnout has remarkable similarities to approaching problem drinking. The only person who can help you is yourself – but you can’t do it alone. Ask for help as soon as you can.

 

Things have changed: today the BMA, Health Education England, and the royal colleges are vigorously promoting wellbeing. And I really admire the GMC. It runs programmes on wellbeing and acknowledges head-on that professional behaviour and patient safety are closely linked.

 

But things are far from perfect. Ethnic minority doctors have a higher referral rate to the GMC (14). And radical reform is needed so that regulation complements the wellbeing of doctors working under pressure. This has indeed lobbied for by the BMA.  Regulators such as the GMC and the CQC need better to consider the links between individual problems and dysfunctional or toxic organisations and culture.

 

I really appreciate you listening to me.

 

 

 

References

(1) Wilkinson E. UK NHS staff: stressed, exhausted, burnt out. The Lancet 2015;385:841–2.

(2) Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016 Jun;15(2):103-11.

(3) Browning L, Ryan CS, Greenberg MS, Rolniak S. Effects of cognitive adaptation on the expectation-burnout  relationship among nurses. J Behav Med. 2006 Apr;29(2):139-50. Epub 2006 Mar 10.

(4) Morita K, Kawaguchi Y. A Dual Role Hypothesis of the Cortico-Basal-Ganglia Pathways: Opponency and Temporal Difference Through Dopamine and Adenosine. Front Neural Circuits. 2019 Jan 7;12:111.

(5) Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg  Med. 2018 Apr;54(4):402-409. doi: 10.1016/j.jemermed.2017.12.001.

(6) Taylor TS, Raynard AL, Lingard L. Perseverance, faith and stoicism: a qualitative study of medical student perspectives on managing fatigue. Med Educ. 2019 Dec;53(12):1221-1229.

(7) Powell SK. Compassion Fatigue. Prof Case Manag. 2020 Mar/Apr;25(2):53-55.

(10) Bianchi R, Schonfeld IS, Laurent E. Burnout-depression overlap: a review. Clin Psychol Rev. 2015 Mar;36:28-41

(8) Montgomery A, Panagopoulou E, Kehoe I, Valkanos E. Connecting organisational culture and quality of care in the hospital: is job burnout the missing link? J Health Organ Manag. 2011;25(1):108-23.

(9) Hill AB. Breaking the Stigma – A Physician’s Perspective on Self-Care and Recovery. N Engl J Med. 2017 Mar 23;376(12):1103-1105.

(11) https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf

(12) Rao S, Ferris TG, Hidrue MK, et al. Physician Burnout, Engagement and Career Satisfaction in a Large Academic Medical Practice. Clin Med Res. 2020;18(1):3-10.

(13) https://www.gmc-uk.org/about/how-we-work/corporate-strategy-plans-and-impact/supporting-a-profession-under-pressure/improving-support-for-doctors-to-raise-and-act-on-concerns/professional-behaviours-and-patient-safety-programme

(14) https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/fair-to-refer

 

 

Dr Shibley Rahman

@dr_shibley

Racism in the NHS – a personal viewpoint

I really don’t know how one can make sense of all the various viewpoints on ‘racism’ in medical education or training, given variations in the type of race or ethnicity; or the culture of the receiving organisations; or personal characteristics of people you work with.

The purpose of me writing this personal opinion piece is essentially an abreaction to not being asked for my opinion. This of course is quite commonplace, as nobody has ever sought my opinions about living with recovery, being a carer of a mum with dementia, living with disability, or medical regulation.

I don’t think any one person’s opinion or ‘lived experience’ is more meritorious or valid than another’s. I too often feel there is a competition about who has had the worst lived experience, for example a lthe worst case of belittlement or worst case of bullying. Recounting these personal stories is difficult as we all make attribution errors, i.e. we get who to blame wrong.

Taking things chronologically, I was a junior doctor a long time ago, and I was propelled into highly competitive hothouse “ivory towers” jobs early on in my career. My career was then ended. I developed an alcohol dependence syndrome. For the last 12 years, I haven’t touched a drop of alcohol. So my memories of the NHS can be best described as ‘historic’ at best. They also coincided with a bad time in my life – i.e. I had recently moved to London, I had no social network, I was exhausted through the on-calls, and on the whole I didn’t enjoy the job.

So therein lies the difficulty, not victim blaming, but the possibility exists that I was actually not great to work with. It is easy to blame poor relations with seniors as ‘racism’, on account of me being British Asian. And indeed there still remains the possibility that they really wanted to tell me about my performance, but couldn’t because of hurting of my feelings.

Years after I left the job, though, I was able to read in great detail how I had a health problem (for which nothing was done) through witness statements provided by consultants to the GMC, without any discussion with me. This was of course looking at the horse after it had bolted.

I retrained in English law and business at postgraduate level in 2007-2014 after I became disabled in 2007, after contracting meningitis. I was erased in 2007 but returned to the GMC Register in 2014. But learning English law helped me understand the rights I had for my own disability, and the meaning of discrimination under the Equality Act (2010).

I can’t blame any of the bad treatment I had on my ethnicity. In the same way, when I go for assessments now, I can’t explain the feeling I have from white older examiners in vivas of being inadequate, being Asian and disabled, before I’ve even said a word. I no longer wish to ‘fake confidence’.

Talk is cheap, and it’s easy to talk of diversity and equality, and workforce shortages, but I don’t think anyone frankly gives a monkeys whether I return to the NHS as a doctor now or not.

I will never be able to tell the impact racism has made on my career. But it is a statistical fact that many more BAME doctors are wrenched in front of the regulator.

And following the judgment in Bawa Garba some BAME doctors don’t feel very safe in a ‘hostile environment’.

I’ll leave it there.

Thank you for listening.

 

@dr_shibley