The quick retort is, of course, that they are actually treated worse — at least worse than some factory workers. The heading is from an article in BMJ careers. Jane Dacre is quoted as saying we need more juniors, and ‘more boots on the ground’. By contrast, Catherine Calderwood, Scotland’s CMO didn’t agree that an any increase in junior doctors was necessary:
“I’m not sure that more is definitely better. We’ve had a 38% increase in consultants in Scotland in the past eight years, and almost a doubling of our emergency medicine consultants, and I’m not sure if I walked into an emergency department they would tell me it’s half as much work as it was eight years ago.”
She went on to spread the kool-aid a little more:
“I think sometimes doctors have not embraced others doing some tasks, and I would like us to be much more like a conductor for the orchestra. So (only) the really difficult stuff, the really responsible stuff, and the really clever stuff is what comes to the doctor as the senior leader.”
I think some of what they both say is correct, but I also fear some of what they both say is politics. The UK — including Scotland — is desperately short of doctors. Appointment times are too brief, waiting times out of control, clinical expertise increasingly patchy, and doubts about the adequacy of training, widespread. Demand is rising, and wants and needs increasingly confused. From where I stand, clinical service in some areas is getting worse. Scotland’s NHS is, in some parts, second world standard, as a colleague from mainland Europe once reminded me.
The issue about paramedical staff is important, but we have been here before. I may be misquoting the figures a little — and they are for the US— but around 1900 one in three health care workers was a doctor. Now the figure is around 1 in 14. This trend in the ratio will and should continue. The discussions about physician assistants and the like have been going on for over half a century, with little evidence of action. The key issue is that if you want to encourage people to move into new roles, you have to create a certification system that rewards and encourages people to do these jobs. That is why we have radiographers, pharmacists and the like. But successive UK government officials hate the idea of certification, and prefer that ‘nurses’ moves into roles that they have little formal training for, and instead, end up existing free of any meaningful regulation. Governments cannot face up to the fact that these ‘health care workers’ (apologies: an awful bloody phrase) will need more than subsistence wages, and setting the system up will require upfront funding. I used to laugh at the image of a doctor’s office with all the certificates on the wall behind the desk, but now I advise patients always to ask whether the person providing diagnostic or therapeutic activities has a recognised medical qualification. How many melanomas do you diagnose a year?; how many times have you performed this procedure?; what exams did you have to pass etc.
If you ask whether you can train graduates to become physician assistants in dermatology, dermatological surgery and the like, the answer is a clear yes. But to make this a sensible career choice, we need certification — theory and practical exams and so on — and job titles that are transferable wherever somebody works. At present we simply to not have this. The dentists have done this and — key to any debate — practitioners (hygienists etc), whether they are dentists or not are registered with the General Dental Council. Now, the GDC is not a very popular organisation, but the idea of formal certification —something that means that practitioners can move jobs easily — is a key component of making this system work. Institutions matter, as do incentives.