Bad Medicine: Advanced practitioners versus doctors

Des Spence

doi:10.3399/bjgp19X702041

We don’t have enough doctors. This is odd because we have plenty of applicants, good universities, and the money spent on training is a fraction of the cost incurred by a limited supply. For example, locum costs in primary care are £500 a day and, incredibly, some consultants are being paid £375 000 a year.¹ Scarcity is highly profitable.

Is this scarcity by intent? An attempt over generations by doctors to maintain high pay and the status of the profession with no care for the negative impact on patients? Consider also if the NHS had more doctors and shorter waits, would anyone pay to go private? The profits made in private practice are eye-watering. But scarcity is causing care to break down across the country and patients are suffering. Doctors maintain an air of superiority and entitlement, and the profession isn’t going to change as it is steeped in its own vested interests. The public deserve better from the NHS and our profession.

But becoming a doctor has little to do with ability and everything to do with opportunity and class, with 80% of doctors coming from 20% of schools, and 50% of secondary schools having no applicants for medicine in a 5-year period. A 6-year undergraduate course is simply not an option to the many and is reserved for the privileged few.² Talent wasted. Something must change and that change is coming. The other professions — nursing, pharmacy, physiotherapy, and our paramedics — are stepping up with the rise of the advanced practitioners (APs). These professions are stuffed with able and motivated people, many of whom were denied the opportunity to study medicine.

So can APs do all the tasks of doctors? Spare me the pseudoscience research base. From my extensive personal experience, and with the right training, they absolutely can.

Doctors are deeply conflicted by the rise of APs, seeing it not only as helping to improve access but also as a threat to their status. The genie in the bottle is prescribing rights, allowing truly independent practice for the first time. Doctors have always wielded all the power in health care, always had the ear of the politicians and the media, and been a brake on real reform. But now there are unstoppable economic pressures blurring the professional barriers between doctors and the other professions. Breaking doctors’ monopoly position will have profound effects on health care and lead to improvement in care and access.

There is a need for APs to organise and assert themselves. These are new roles and need resources and support — the costs are a fraction of those squandered on locums. And, as undergraduate medicine training is only accessible to the privileged few, then allowing new paths to a medical degree through developing AP roles seems an obvious way forward.

It is time to break the outdated mould of medical training, and time to deliver much more equity in status and pay between the professions. Change is the best medicine.