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Songs of Innocence and Experience

September 2, 2014

Last month’s news that the government plans to more than double the number of training places for physicians associates passed almost without comment from the nursing community. Maybe they feel that at 225 places a year, numbers are still too minuscule to make much difference. Doctors’ leaders meanwhile gave a guarded welcome to the expansion of this relatively new occupational group whose duties include (according the NHS Careers website) ‘taking medical histories, performing examinations and diagnosing illnesses’. BMA Council Chair Dr Mark Porter said physicians associates ‘could be a valued part of the NHS’ but also warned that ‘only doctors can provide certain types of care’.

You might wonder at the ambivalence. Surely doctors should jump at the chance to offload some of their work? Family doctors in particular routinely complain of being chronically overstretched; and compared with other professions, medicine has spawned very few ‘helper’ occupations. Teachers, by contrast, have classroom assistants; the police have community support officers; social workers have social work assistants and even nurses have health care support workers. And what do doctors have? Well…nurses of course – which probably explains why the physicians associate role has been so late in developing.

The BMA’s reservations seem to be based on a number of factors – some noble, some less so. First off is the understandable concern, shared by many patients’ groups, that in these economically-straitened times, physicians associates are just a way of getting ‘medicine on the cheap’. Speaking to The Times, Katherine Murphy, chief executive of the Patients Association, expressed anxiety that ‘as physician assistants are cheaper to recruit and pay, hospital managers may become reliant upon them to bring up staff numbers on their wards’ with obvious detrimental effects for patients who are seen and treated by these ‘less qualified’ personnel.

But the BMA also undoubtedly has an agenda of protecting what you might call the ‘mystique of medicine’: it’s a hard career, it takes seven years training and because anyone who’s any good at it has to be practically super-human, they’re entitled to the biggest financial rewards and the highest standing in society. It’s a position that’s somewhat undermined by the possibility that a decent science grad might be able to master a good part of it in just two years.

Nurses, who have in the past been the major victims of medical elitism and professional exclusionism, might feel themselves entitled to raise a wry smile at the BMA’s difficulties. Except that thanks to the growth of advanced practitioners and clinical specialists, there are now plenty of nurses who feel entitled to worry that their roles might be under threat from the advent of physicians associates. Much of the discussion in the comments section beneath The Guardian‘s article on the subject turned on the importance of relevant experience. In a well-received intervention, a retired (?) nurse called Ephemerid rallied the troops with the cry that ‘rather than have a 2-year course for someone to be a quasi-junior doctor, it would make more sense to train nurses’.

It’s a question that goes to the heart of nursing. Should nurses aspire to being ‘quasi-junior doctors’ (even when years of experience should preclude them from being quasi-junior anything) or should they place themselves at a remove from the medical model, in order to offer different skills and a different approach to healthcare? It hasn’t happened yet of course, but the en-masse appearance of physicians associates into the healthcare landscape might, just might, be the kick up the backside that nursing needs to force it to confront this dilemma.

One thing has to be clear from the outset though: nursing must not allow medicine (or managers for that matter) to dictate where the boundaries between the different occupational groups will be drawn. It has to be a partnership and a discussion between equals, and that’s why it’s so important that – in contrast to what seems to have happened so far – nursing acknowledges these new developments and engages with them. If we don’t, what’s the betting that we’ll find that our roles and our priorities are decided for us by other professional groups in line with agendas that may not be ours. We’ve seen how we’ve been co-opted into the administration of targets and ‘bed management’ on managers’ behalf and we don’t want to find that if we’re no longer needed to hold together medical provision, we’re summarily deskilled and tossed aside like discarded wrapping paper.

Nursing should be cautiously optimistic about the arrival of physicians associates. It’s an opportunity – not least because implicit within it is the recognition that medicine and nursing are distinct roles with distinct contributions to make to patient welfare. It’s also an opportunity for medicine to show that it can hold a grown-up conversation with nursing, without treating us as just the junior partner.

Nurses are not simply doctors’ handmaidens, doctors-in-miniature or the default collectors of the jobs doctors no longer have time to do. If the physicians associate role took off, it could do us the enormous favour of creating space for nursing to think about how it conceptualises itself and what it offers to society as a whole.

Grumbling Appendix will not be writing a blog next week. If anyone would like to submit a guest blog, please get in touch.

For the British Medical Association’s response the announcement of increased numbers of training places for physicians associates, see:

For The Guardian‘s article on the subject, see:

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