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Opinion Acute Perspective

David Oliver: The fractious debate over physician associates in the NHS

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2449 (Published 25 October 2023) Cite this as: BMJ 2023;383:p2449

Rapid Response:

Task-shifting, polarised perspectives and the reality in-between

Dear Editor

One of the proposed solutions in the NHS Long Term Workforce Plan [1] (LTWFP) that has generated much debate in recent months is task-shifting through scale up of Physician Associates, Advanced Nurse Practitioners (ANPs) and Anaesthetist Associates (AA) [1]. Task-shifting through substitution is when one group of health professionals enhance their skills and takeover the roles previously undertaken by another [2,3]. MPs, the BMA and doctors have raised concerns around patient safety and expectations including the level of clinical expertise, public misconceptions around the role, wider impact on medical training and absence of regulation [4,5,6,7]. In a media landscape where opinions are plentiful and easily shared, legitimate debate is increasingly polarised and potentially toxic. Perceived conflict between health professionals, framed within the widespread dissatisfaction over increasing workload and patient safety [6], the negative impact of existing challenges on physical and mental health and the effect of moral injury, on all cadres of the workforce mustn’t be underestimated [8].

Under these circumstances, doctors may want to consider the evidence for, and intended benefits of task shifting. Furthermore, careful consideration is needed on how best to raise legitimate questions around the unintended consequences of task-shifting with the general public, leaders and policy makers that doesn’t feed public mistrust, stigmatise our health professional colleagues and exacerbate moral injury.

The European Commission Expert panel recommended that European health systems should embrace flexibility in professional roles if they are to respond effectively to the myriad of challenges facing health systems [2]. In addition to the workforce crisis, the NHS is facing backlogs in care exacerbated by the pandemic and industrial action across the workforce, worsening health inequalities and health outcomes [9]. Alongside the anticipated increase in the number of people with multi-morbidity, frailty and complex care needs; health systems should be moving towards a new paradigm of population health, prevention and integrated care with a sharp focus on community based care [1].

Task-shifting between healthcare professionals is a key part of the LTWP to effectively address those challenges and will play an increasingly important role in the evolution of health and care. Task-shifting has already moved beyond enhanced practitioner roles and substitution between health professionals; the LTWP highlights the expanding roles of patients, carers and volunteers in healthcare [1] and task-shifting through innovative technology and artificial intelligence is an explicit policy priority [1].

Given the proposed scale of change and potential unintended consequences, doctors’ are within their rights to challenge their leaders. Leaders have a responsibility to clearly explain the rationale and evidence behind task-shifting in any given context [2]. Where the evidence is weak or conflicting, there should be a duty of candour to health professionals, patients and the public as to the potential wider impact on the health system including quality of care. Furthermore, there should be investment in research and evaluation to better understand the contextual factors that determines what works, when and where [2].

There are legitimate concerns around regulatory frameworks, training and acquisition of expertise and the longer-term impact on organisational models, existing hierarchies and professional development across professions. Whilst we must continue to hold leaders to account, doctors must remember there is truth on both sides of the task-shifting debate with evidence supporting the role of task-shifting in addressing acute system and human resource pressures and contributing the strength of diversity within teams. Divisive rhetoric at a time of unprecedented pressure only exacerbates moral injury, feeds public mistrust and risks stigmatising fellow health professionals. Only by, engaging in constructive discourse, working collaboratively can we hope to provide high quality healthcare, effectively advocate for our patients and meet the myriad of challenges facing our NHS.

References

1. NHS Long term Workforce Plan. (2023, June). NHS England

2. Task Shifting and Health System Design. Report of the Expert Panel on effective ways of investing in Health (EXPH). (2019). European Union.

3. van Schalkwyk, M. C., Bourek, A., Kringos, D. S., Siciliani, L., Barry, M. M., De Maeseneer, J., & McKee, M. (2020). The best person (or machine) for the job: Rethinking task shifting in healthcare. Health Policy, 124(12), 1379–1386

4. Stacey, Alison. (2023, August 17th). Nurses for medical consultant rota: NHS trust’s job ad U-turn. Nursing Standard. RCN Vol. 38 issue. https://rcni.com/nursing-standard/newsroom/news/nurses-for-medical-consu...

5. Dean, E. (2023, August, 2nd). Physician associates in the media spotlight: what’s the latest on the role? BMJ 2023;382:p1731

6. Keely, B. Physician associates. Hansard HC. 6 July 2023:735:col 1025. https://hansard.parliament.uk/commons/2023-07-06/debates/D98F2ABE-7B33-4...

7. https://anaesthetistsunited.com

8. Time to change. Sustaining the UK’s Clinical Workforce. (2023, May). Deloitte

9. Health Equity in England: The Marmot Review 10 Years On. (2020). The Health Foundation. https://www.health.org.uk/publications/reports/the-marmot-review-10-year...

Competing interests: No competing interests

21 February 2024
Ahmed Seedat
Consultant Respiratory Medicine
London, UK