Sunday, 18 March 2007

Physicians Assistants- DoH’s weak response

The DoH has replied as regards questions on PAs via the freedom of information act.

When asked about the lack of evidence for PAs, the reply was:

‘All Department of Health publications are subject to the necessary level of scrutiny and reflect the necessary levels of consultation. They are not usually academic/scientific papers that need a peer-review process – the scrutiny to which they are subject is in different terms.

Department of Health documents on New Ways of Working are written in collaboration with the NHS and tested with key stakeholders (e.g. Royal Colleges, regulatory bodies). The information is easily accessible on the Department of Health website and is open to public scrutiny. ‘

What is meant by necessary level of scrutiny? This is simply justification for the DoH not using any proper scientific evidence to back up its lame duck ideology. Their idea of public scrutiny seems to be merely putting up information on a well hidden part of their website.

The evidence of the efficiency of PAs comes from the ‘There is substantial evidence from the US of Physician Assistants increasing productivity in healthcare settings. Please see the AAPA website ‘. Another completely biased source, of this is all the DoH can offer than I really do fear for our healthcare system.

Again when asked on the evidence, the only piece is this vague bit that has not been published! “

I then responded to this weak piece of evidence:
'I am not convinced by this rather long winded piece of writing. It has not published in a journal and has not been peer-reviewed. Do you not have any evidence other than this? And by evidence I mean something that has been published in a reputable peer-reviewed journal.

Birmingham University Health Services Management Centre is a renowned research centre. It is their decision as to whether and where they publish their research.”

To which they replied:

‘As the role is new to this country, there is no other evidence apart from testimonials from a number of Consultants and General Practitioners who have worked with PAs.’

My lord. There is no evidence at all behind their PA scheme. Unbelievable.

When the DoH are asked as to how can they justify thousands of unemployed skilled junior doctors:

‘There will always be inefficiencies in a macro workforce planning system based upon the fluctuating needs of employers, the amount of funding available and the global migration of healthcare workers. Whilst it can be seen as wasteful to train too many it is also unwise to train too few as the NHS experienced this problem in the late 1990s. The history of the NHS has proven that there is not an ideal system or formula that accurately defines the future workforce needs across health and social care. ‘

What a pathetic answer. There will always inefficiencies! Well if idiots in the DoH actually employed junior doctors rather than spending millions training these quacks then things would be significantly more efficient.

The BMA has backed the scheme:

Will doctors be able to apply for the PA posts? (Surely they are adequately trained) and if not, why not?

‘No. The reason is that although they are doctors, their training allows them to work within the scope of practice of a doctor - not as a PA. The danger is that they may work outside the scope of practice of a PA because they have the skills and knowledge of a doctor. If they worked outside their scope of practice as a PA and something went wrong, the GMC would not be able to adjudicate. At present, if they are employed as a PA, the supervising doctor (as PAs are not regulated yet) takes some responsibility as set out in the GMC Code of Good Medical Practice.’

This is absolutely nonsensical. It is expected, as if by magic, then PAs will miraculously know their exact range of competency and hence know when they are outside this range. This is hogwash. PAs will not know when they are outside their area of ‘competency’ as they are under trained and undereducated for their role. Oh and they aren’t regulated yet, why the hell not?

How can they be bringing forward PAs but they haven’t come up with a regulation system as yet? This is simply dangerous and reckless in the extreme.

It seems all reform in the NHS today. I wonder if you have any evidence that nurse practitioners or physicians assistants are more cost effective that doctors? (as surely what is the point in changing the system if they are the same cost- the measures to put changes in place will make the overall process more expensive)

‘The development of new roles should not be based on cost alone (either the cost of training or employment). Health and social care employers need to ensure that there are career pathways for the diverse range of school leavers and graduates from further and higher education programmes. There has to be a range of skills available to meet the range of patient care needs and a range of career options to ensure employers can attract the most appropriate recruits to the care environment. As an example of this it is unfortunate that not all male school leavers have the ability to become doctors and most don't want to be nurses so we need to attract them into front line healthcare with alternative career pathways’

Another lame reply. So rather than provide a good cost effective service, it seems the DoH wants to provide jobs for everyone leaving school! This is a bizarre and flawed argument.

‘In recent years, as nurse practitioners have become more numerous, there is a much wider appreciation of what can be expected of a health professional, calling themselves by this name. It has become evident that their practice is characterized by higher levels of decision-making, independent action and the ability to make complex judgments. In addition, there is a growing body of research showing where nurses with these advanced level skills are taking on roles previously the preserve of doctors, the outcomes they achieve are at least as good, and patients as satisfied or more satisfied with their care

Though we are aware of the contribution nurse practitioners are making, and continue to support their development, it is vital that local organisations are able to make investment decisions based on local conditions. We trust our front-line doctors and nurses to know what is best for their patients, which is why we have introduced practice-based commissioning, so that their decisions can be put into effect, within the strategic intent of the PCT. ‘

Absolute rot again. The DoH seems very happy to make baseless statements backed up by hot air and no evidence. Where is the ‘research’ they point to?

Given that the DoH keeps going on about their policy being open to public scrutiny:

I quote the DoH "The information is easily accessible on the Department of Health website ( and is open to public scrutiny." How is the information open to public scrutiny other than by being accessible via the website? Why not introduce some kind of on lone voting process whereby members of the public can agree or disagree with policies?

‘You then asked how what other ways other than the website is information open
to public scrutiny. Department of Health publications may also be ordered via the Parliamentary hotline (0845 702 3474). However, the Department of Health website is an excellent vehicle for publicising DH policy and is very widely used having 875,897 unique users in November 2006, 618,055 in December 2006 and 830,614 in January 2007. With regard to your suggestion on lone voting, the Department is always looking to update and improve its website. Your suggestion has been passed to the Department of Health website management board for consideration in future website updates.

Additionally, if you have concerns regarding Government health policy, you may wish to consider contacting your local member of Parliament, who, as your elected representative, is best placed to take up your concerns on a national level.’

Overall Physicians Assistants are another in a long line of poorly thought out policy that is based on no credible evidence, and this is not an efficient use of tax payer’s money. The biggest concern is that the DoH’s logic circuit is wired incorrectly.

It appears that the DoH can create and justify any quack practitioner as long as they have a defined competency area. They then make the assumption that because they have a defined area of competency, the particular quack will automatically know when they are practicing outside their specific area of competence. Unfortunately this assumption is flawed as instinctively knowing when one is working outside ones area of competence is only something that comes with extensive experience and training. Many of these quacks, such as PAs, will not be safe to practice unsupervised after such short periods of training and supervision. They will frequently not realise when they are outside their ‘area of competence’. They are accidents waiting to happen and the patients will be the ones to suffer.

It is also exceedingly worrying that this regime will use rather inconsistent and illogical arguments to justify its pursuit of policy based on ideology. They care not for evidence and efficiency, they are simply pursuing a predetermined ideological path at any cost. This is negligent and it is a danger to us all.


The Angry Medic said...

Have I ever told you how you have the best pictures accompanying your blog posts? :)

Brilliantly written, as usual.

Red Rabbit said...

" is unfortunate that not all male school leavers have the ability to become doctors and most don't want to be nurses so we need to attract them into front line healthcare with alternative career pathways..."

Have you ever heard such self-serving sexist circular brain-rot? Why should MALE school-leavers who are not clever and/or dedicated enough to become doctors or nurses in particular need to be attracted to front-line healthcare?

I'm waiting for your response, oh dear bureaucratic boneheads of the DoH.

Great post.