Cheap medicine
The NHS’s growing use of non-doctors risks creating a two-tier health service, argues Jatinder Hayre
After Aneurin Bevan created the National Health Service in 1948, the principle of universality became firmly embedded in the popular consciousness: illness would no longer divide the British people according to wealth, and the quality of care received in sickness would not depend upon the depth of one’s pockets. Bevan articulated another principle which receives rather less attention today: that the state might finance medicine, but it should not command medical judgement. Doctors needed sufficient professional independence to practise according to the needs of their patients rather than the administrative or financial convenience of the state. Both principles are now being tested – and in some cases, rewritten.
Across the NHS, work historically undertaken by doctors has increasingly been transferred to physician associates (PAs), advanced clinical practitioners (ACPs) and an expanding constellation of other roles. I use “Noctor” as an umbrella term for the phenomenon whereby non-doctors cease to complement doctors and begin to serve as a substitute for them.
The language surrounding this transformation is revealingly anaesthetic: “skill mix”, “workforce transformation”, “new models of care”. These phrases make a profound political choice sound like an administrative rearrangement. Beneath them sits a simple idea: medicine can be dismantled into tasks, those tasks redistributed amongst more rapidly trained practitioners, and the whole reconstructed without meaningful loss.
Yet medicine has never simply been the possession of competencies. It is the cultivation of judgement: knowing what does not fit; recognising what others have missed; understanding when the reassuring result should not reassure us; perceiving catastrophe before it announces itself. Medical education is lengthy precisely because illness is uncertain. Once medicine is reduced to a checklist of tasks, however, substitution becomes seductively easy to justify.
The public were never meaningfully asked whether they supported this process. It has been inflicted upon them – one rota, one job description and one blurred professional boundary at a time.
The evidence in favour of this shift is far from convincing. Greenhalgh and McKee’s rapid systematic review of UK research concerning PAs and anaesthetic associates identified 52 relevant studies from approximately 5,000 records; critically, they found no study directly examining patient safety, and warned against interpreting an absence of reported incidents as evidence of safety. The subsequent Leng Review acknowledged considerable confusion surrounding PA roles and recommended clearer boundaries, including renaming the role “physician assistant”, with an explicitly supportive rather than substitutive function. My own international review of the literature painted a further, more troubling picture. Direct comparator studies have associated non-physician practitioners with lower diagnostic efficiency, poorer-quality referrals, greater use of diagnostic imaging and specialist services, higher rates of antibiotic and opioid prescribing, and lower productivity; diagnostic error is also the predominant allegation within a large series of paid nurse practitioner malpractice claims.
For the left, there is a deeper problem. Tudor Hart’s inverse care law teaches us that the availability of good medical care tends to vary inversely with the need of the population served. We already have emerging evidence that non-doctor roles proliferate and are distributed in low-socioeconomic areas with populations who have lower health literacy and greater comorbidity at earlier ages.
The affluent already possess an ‘escape hatch’: they can purchase a private GP appointment and get a second opinion. The poorer patient can only take what’s offered. This should trouble every progressive. A two-tier NHS does not necessarily imply a cashier at the hospital entrance: it merely requires one class of patient to retain reliable access to doctors while another is reassured that a cheaper “skill mix” is good enough.
Nor is the economics as clever as its proponents imagine. The elementary mistake is to confuse cheaper labour with cheaper healthcare. A lower salary does not establish cost-effectiveness. If a doctor must provide supervision, that doctor’s time has a cost. If differences in clinical decision-making generate additional investigations, referrals or prescribing, those have costs. If assessments are duplicated, the duplication has a cost. If medical training opportunities are displaced while qualified doctors struggle to progress through bottlenecks in postgraduate training, the long-term opportunity cost may be greater still. International comparative evidence raises questions concerning differences in diagnostic testing, referrals, prescribing and productivity between physicians and non-physician practitioners. There is clearly something perverse about spending enormous public sums to educate doctors while simultaneously restricting their opportunities to continue postgraduate training and constructing alternative workforces to perform key parts of their jobs. Then, of course, we require doctors to supervise these workforces while insisting that doctor shortages make substitution unavoidable. This is hardly ingenious workforce planning.
I did not arrive at this argument from political theory; Noctor began at the bedside. As a doctor working in the NHS, I encountered the consequences of workforce substitution during clinical practice, including seriously unwell patients whose diagnoses or deterioration I believed had been inadequately recognised before they came under my care. I reported those concerns. The experience which followed, including professional isolation and the loss of work, forced me to ask a larger question: why had scrutiny of this radical workforce experiment become so uncomfortable?
Following that question backwards led inevitably to Bevan. The book became an attempt to understand how a health service founded upon universality and professional independence came increasingly to understand medicine through the grammar of management: productivity, throughput, competencies and interchangeable units of labour. Once expertise has been reduced to discrete tasks, the cheapest person to perform those tasks becomes the obvious choice.
The NHS need not introduce charges at the hospital door to become two-tier. It need only reach the point where wealth determines reliable access to medical expertise while those with nowhere else to go are offered something cheaper and told that it is equivalent. Therein lies the question we should be asking before this experiment proceeds any further: if a doctor remains what you would want for yourself and your family when serious illness arrives, why should somebody poorer be expected to settle for less?
