There are no quick fixes for the workforce crisis

After almost a year of industrial action by doctors in England, with several walkouts over recent months, there are signs that progress is being made towards avoiding further strikes. The government has agreed to hold talks with specialist, associate specialist, and specialty (SAS) doctors, junior doctors, and consultants (doi:10.1136/bmj.p2464 doi:10.1136/bmj.p2420).12

But another dispute is also causing debate among doctors. Two extraordinary meetings taking place this month in the UK consider the role and scope of physician associates and anaesthesia associates in the NHS. The Royal College of Physicians was due to hold a council meeting this week to discuss growing concern among members and fellows (doi:10.1136/bmj.p2375).3 And the strength and depth of disquiet among doctors was shown at a general meeting of the Royal College of Anaesthetists on 17 October (doi:10.1136/bmj.p2460).4 Members voted to pass six resolutions, on a high turnout and with a large majority for each vote. These included enforcing nationally set levels of supervision at the local level, ensuring patients understand when they are being treated by an anaesthesia associate, and pausing recruitment of anaesthesia associates until the effect on doctors in training has been fully assessed.

Richard Marks, a consultant anaesthetist and committee member of the campaign group Anaesthetists United, explains why he is part of this grassroots group calling for a wider debate on the issue (doi:10.1136/bmj.p2369).5 He asks, “Is it sensible to be training a newly expanded workforce, when we could be using the money and resources to relieve bottlenecks in specialty training and create more anaesthetists?” This view is echoed by David Oliver, a consultant in geriatrics and acute general medicine, who writes that, because some trainees are unable to progress into higher specialty training, “it can seem as though the most highly trained group with the longest postgraduate training is being replaced with a cheaper group, thereby undermining rather than supporting medicine” (doi:10.1136/bmj.p2449).6

Physician associates are a growing part of the workforce worldwide (doi:10.1136/bmj.p1926).7 In the US they first began training in the 1960s. Recent research found that between 2013 to 2019 the proportion of Medicare visits delivered by physician assistants and nurse practitioners increased from 14% to 25.6% (doi:10.1136/bmj-2022-073933).8 The question of how to maintain quality and trust in this increasingly common part of the workforce is relevant to many parts of the world.

One aim of increasing the numbers of physician and anaesthesia associates is to help plug workforce shortages and ease workload pressures. But because they cannot prescribe and need careful supervision it isn’t clear how much their availability helps. “There is a safety aspect, and it takes a lot of doctor time to supervise them properly,” says our GP columnist Helen Salisbury (doi:10.1136/bmj.p2460).4

Blame doesn’t lie with the associates themselves. “It is not their fault that they chose to take the postgraduate course at a time when doctors were increasingly unhappy with their own terms and conditions,” says Oliver, who points out that the hostile and fractious debate is harming interprofessional solidarity and team working (doi:10.1136/bmj.p2449).6

In addition to pay, the consultant cardiologist Kiran Patel and consultant endocrinologist Tim Robbins suggest other ways to make doctors feel more valued (doi:10.1136/bmj.p2439).9 These range from practical steps that could be achieved relatively quickly, such as better IT, office spaces, and car parking, to tackling longer term issues such as equality of training opportunities, clarity in roles and responsibilities, and culture change. Better workforce planning and appropriate staffing are also vital. Kamila Hawthorne, chair of the Royal College of General Practitioners, calls on politicians to “control GPs’ workload” and increase numbers of doctors (doi:10.1136/bmj.p2444).10

None of these calls are new and will take more than a quick fix to change.