Last Friday I had a small procedure to remove a BCC (Basal Cell Carcinoma) from the top of my head. All went well, until it didn’t. I had been reassured by the doctor doing the procedure that it was a quick, simple operation, utterly routine and nothing to worry about. And honestly, I wasn’t that bothered. I have a family history via my mother and brother of malignant skin cancer. I know that melanoma is serious and potentially life-threatening, whereas BCCs are neither. I have also had three other BCCs removed, one from my arm, another from my leg and one from the hairline of my forehead. All those procedures were (relatively) uneventful. But this one wasn’t.
I had been in the chair for about an hour when the atmosphere suddenly changed from relaxed to tense. For the next half an hour the doctor tried and failed to close the wound and the blood kept flowing.
As neither the nurse or doctor was talking to me, I asked “Are you worried?” To which I received no reply. I was desperate to spend a penny, so asked if that was possible. The doctor told me I would have to wait for 10-15 minutes and after that time they bandaged up my head and the doctor disappeared, not to be seen again. After the loo, the nurse asked me to wait in a side room, happily with my daughter, who, whilst in reception, had heard the doctor tell a waiting patient that she had been dealing with a medical emergency! Fortunately, just ten minutes later, a plastic surgeon arrived and took me back into the treatment room. He was immensely reassuring, quickly assessed the problem and equally quickly fixed it with some expert stitching. Since then I have gradually recovered and the oozing and swelling from and around the site have both subsided.
The reason I am writing about this is because something snagged my attention this week when I was listening to a podcast. It was a section called ‘under the radar’, which is about things that have received little publicity but which are important. This item was about the BMA (the British Medical Association) and their call for an immediate pause in the recruitment of Physician Assistants, which you may or may not be familiar with. Before I tell you more, I must underline the fact that my treatment was carried out by two fully qualified doctors supported by a trained nurse. The reason I am linking the two is about us as patients, our vulnerability in certain situations, and how we have the right to ask questions of the health professionals that we encounter.
Physician Assistants have been in the NHS since 2003 and there are just over 3000 of them, some working in hospitals and some within GP practices. To train as a PA you have to hold an undergraduate degree, usually in a biomedical, health or life sciences field and have some prior health or social care experience. You then enrol on a course lasting 90 weeks, which, quoting from the Department of Health’s fact sheet: “consists of theoretical learning in medical sciences, pharmacology and clinical reasoning, as well as a clinical placement experience in a wide variety of settings”.
After training, a Physician Assistant is deemed qualified to work alongside doctors and offer support to do various routine tasks in order to “deliver aspects of patient care, increasing the capacity of clinical teams and reducing the workload of other clinicians, including doctors, which increases the capacity of the medical team to deliver care to patients. PAs are trained to do clinical duties such as taking medical histories, carrying out physical examinations, and developing and delivering treatment and management plans”.
Sounds great doesn’t it? The NHS is chronically understaffed, many posts cannot be filled, so being able to train, say, a speech and language therapist (one example of suitable prior training), in just under 2 years to supplement a clinical team would seem to be eminently sensible. So, why is the BMA ringing alarm bells, with a call for an immediate halt to recruiting further PAs?
I am going to quote extensively from their report, published on 16th November 2023*:
“Doctors from across the UK who make up the BMA’s UK Council have passed a Motion which calls for the moratorium (on recruiting more PAs) on the grounds of patient safety. They want the pause (in recruitment) to last until the government and NHS put guarantees in place to make sure that MAPs (Medical Associate Professionals) are properly regulated and supervised. The move follows a number of recent cases in which patients have not always known they were being treated by a physician associate and tragically have come to harm.
Professor Phil Banfield, BMA chair of council, said:
“Doctors across the UK are getting more and more worried about the relentless expansion of the medical associate professions, brought into sharp focus by terrible cases of patients suffering serious harm after getting the wrong care from MAPs. Now is the time for the Government to listen before it is too late. We are clear: until there is clarity and material assurances about the role of MAPs, they should not be recruited in the NHS”.
“We have always been clear that MAPs can play an important part in NHS teams, and doctors will continue to value, respect and support individual staff they work with. But MAP roles and responsibilities are not clearly defined. We are seeing increased instances of MAPs encroaching on the role of doctors; they are not doctors, do not have a medical degree and do not have the extensive training and depth of knowledge that doctors do. As doctors, we are worried that patients and the public do not understand what this could mean in respect to the level of experience and expertise in care they receive.”
Often we encounter health care professionals when we are at our most vulnerable. Nobody likes hospitals or having to undergo procedures whether minor or major. However, the last thing on our minds should be whether the person treating us is properly qualified to carry out that treatment. One of the recommendations in an earlier BMA report from July 2023, is that; “PAs ‘must only be appointed to work under a named responsible registered medical practitioner… who is immediately available, appropriately indemnified and specifically consents in writing to supervise a physician assistant’ and that PAs ‘must take personal responsibility for their professional actions’.”
I am sure that many of you will have stories of the outstanding and amazing care that you or your nearest and dearest have received at the hands of the NHS. My own special granddaughter is testament to the incredible medical care she has had for the past 11 years. I decided to raise this subject because that small procedure reminded me of the level of trust which is needed whenever we encounter a healthcare professional. Doctors themselves are rightly up in arms about: “the most massive passing off in history, of physician associates as some kind of doctor through a confusion of titles and grading structures. The solution has been designed to deliberately confuse the public by appearing to be staffing the NHS at a record level of capacity and competence not borne out in reality.”
In my case all’s well that ends well. My medical procedure was eventually happily resolved. Although there was no discussion with me, I am assuming that when the doctor who removed the BCC realised that she was unable to deal with what had become (in her words) a ‘medical emergency’, she was able to call in a more experienced person to resolve the situation. This is exactly what the BMA is calling for in its proposals to regulate the role of Physician Assistants - that they work under a named, responsible, registered medical practitioner who is immediately available, appropriately indemnified and specifically consents in writing to supervise a physician assistant’.
After nearly a week I am gradually recovering from my procedure. My head has been too sore to wash my hair for a few days and there has been swelling in my forehead. One eye has had a dark ring underneath it and is also puffy and swollen. The whole experience has made me realise how vulnerable we are in medical situations. We put our health and wellbeing in the hands of people whom we trust to take the very best care of us. I accept that sometimes things may not go according to plan, but we have the right to expect that under such circumstances, there will be back-up in the form of a reliable Plan B.
And I have also learnt lessons for the future. I intend to be less passive, more assertive and less trusting. How? By asking lots more questions including the level of experience and expertise of the person who will be treating me.
*You can read the BMA report from 16th November 2023 here: https://www.bma.org.uk/bma-media-centre/bma-calls-for-immediate-pause-on-recruitment-of-physician-associates
And another BMA report from 6th July 2023 here: https://www.bma.org.uk/news-and-opinion/call-for-alternative-regulator-of-and-to-rename-physician-associates
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