Vice-Chairman, Royal College of General Practitioners, London, and Visiting Professor of General Practice, University of Lincoln and Associate Director of Postgraduate General Practice Education, Trent Multiprofessional Deanery, UK
Received date: 23 September 2014; Accepted date: 11 February 2015; Published date: 21 March 2015
There has been a demand over the last few years to increase the workforce in both primary and secondary care to meet the requirements of The NHS Plan 2000.1 The NHS Plan stated that staffing constraints, rather than lack of funding, posed the greatest threat to NHS modernisation.
There has been a demand over the last few years to increase the workforce in both primary and secondary care to meet the requirements of The NHS Plan 2000. The NHS Plan stated that staffing constraints, rather than lack of Funding, posed the greatest threat to NHS modernisation. As a result there has been the development of new and extended roles. This has often been a localised response to address a particular need. The titles of these new posts vary, leading to confusion and lack of clarity of roles and responsibilities. This is a very unsatisfactory situation with unregulated practitioners providing care for patients, with varying degrees of supervision. These roles may also lack the potential for transferability and sustainability in the NHS.
There is a need to define the standards of education and training for these emerging roles. To help address these problems, the Royal College of General Practitioners and the Royal College of Physicians have worked with the National Practitioner Programme to develop a competence and curriculum framework for medical care practitioners. This role developed from the physician assistant model in the United States.
Physician assistants were developed in the United States in the 1960s to ‘relieve a nationwide shortage of doctors in primary care and to increase access to health care for people in under-served areas’. Physician assistants undergo two years of training after a first degree and pass a national certifying examination. They also have to complete 100 hours of continuing education every two years and pass a recertification examination every 6 years.
The medical care practitioner is defined as ‘a new healthcare professional who, while not a doctor,works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision’.
In primary care, the medical care practitioner role will provide an opportunity to improve and develop the skill mix in healthcare teams, whilst emphasising the unique skills and knowledge of general practitioners (GPs) and other healthcare professionals.
The competence and curriculum framework for medical care practitioners outlines the standards, education and assessment of these practitioners, providing the basis for a qualification from a UK higher education institution. It outlines the knowledge, skills and core competences expected at qualification. It is anticipated that a fully trained medical care practitioner will deliver care and treatment at the level of a doctor in their second foundation year.
A medical care practitioner will be able to perform many tasks that are currently carried out by doctors, enabling doctors to concentrate on the complex problems which require the particular skills and knowledge of a GP or hospital consultant.
The medical care practitioner will be able to:
•take a detailed history, perform a physical examination and develop a differential diagnosis within the limits of their competence
•develop a patient management plan taking account of the particular circumstances of the patient
•perform some diagnostic tests, therapeutic procedures and prescribe (subject to legislative changes)
•request and interpret some diagnostic tests and undertake patient education, counselling and health promotion.
The training programme is 90 weeks with 3150 hours of teaching, of which 1600 hours is designated as clinical learning. This is broadly equivalent to a threeyear degree programme. Entrants to the course will be recruited mainly from science graduates, but it is also open to existing health professionals. This is a new profession and it is important that standards and the level of competence are clearly defined, which will enable criteria to be developed for statutory regulation.
Medical care practitioners will always work under the supervision of a doctor and will only delegate tasks which they are competent to perform in accordance with guidance set out in the General Medical Council’s document, Good Medical Practice.
The recognition of clinical conditions beyond the expertise of a medical care practitioner is a vital competence. Medical care practitioners will be trained to work to the medical model so that they will be able to apply their knowledge and skills to the needs of the individual patient, rather than working to predetermined protocols. The document includes a model for categorising clinical conditions on the basis of required competence. Competences are elements performed to a predetermined standard, which combine to create professional capability in a defined role. Using this model there are conditions which a medical care practitioner will be able to diagnose and treat; those conditions which when already diagnosed can then be managed by a medical care practitioner; those situations when referral to the supervising doctor is required, and those conditions which a medical care practitioner can monitor when this has been diagnosed and a management plan developed by the supervising doctor.
The Changing Workforce Programme (now the National Practitioner Programme) began piloting the medical care practitioner role in South West London and North East London in 2004.
In 2002, Tipton and Rowley Regis Primary Care Trust in the Black Country recruited physician assistants from the United States in response to problems of recruitment of GPs. These physician assistants are currently unregulated, and responsibility for their actions is taken by the supervising doctor. Birmingham University Health Services Management Centre has evaluated this initiative. The report emphasised the need to retain the dependent practitioner status as this was recognised as essential for patient-centred care. Stewart and Catanzaro reviewed the experience of 12 US physician assistants working in Sandwell, West Midlands. They concluded that the physician assistant model worked well in the UK. They suggested ‘this group of practitioners can provide a high standard of care to patients as well as help to support the medical multidisciplinary team’.
The development of the medical care practitioner role should benefit both patients and other health professionals. It will provide an opportunity to further enhance the skill mix within the healthcare team. This will allow doctors to be able to spend more time with patients with multiple complex problems. It will give patients more choice of healthcare professional and, by having a national curriculum and competence framework, medical care practitioners will achieve a level of competence to agreed national standards helping to ensure that patients receive high-quality patient-centred care.