Our much-loved, much-treasured NHS has been under consistent attack from privatisation, from shifting towards the disastrous American healthcare model that is based on profit rather than care, and from underfunding. Now there’s a further regulatory step that many doctors and patients feel is a significant blow that could take away the very foundations of doctor-based care.
That’s the order providing for the registration of ‘physician associates’ (PAs) and ‘anaesthetist associates’ (AAs), a statutory instrument that will be heard in the House of Lords on Monday. Because this is a statutory instrument, not a bill, the Lords cannot amend it, only accept or reject it. The Commons barely noticed it at all.
Fatal motion: physician associates and anaesthetist associates
That’s why I have tabled a ‘fatal motion’ opposing it. Theoretically the House could throw out the regulation. But that would demand backing from the Labour Party, which I don’t expect to get.
So the odds are that the government’s plans will go ahead. Unless they listen to me, and more importantly many doctors and patients, who are calling for a rethink.
The Green Party is absolutely not opposed to the existence of PAs or AAs, or to their registration. This is an obviously necessary step. We respect those who’ve studied and laboured to achieve their qualifications.
What we are questioning is the detail of the proposals, the lack of democracy in their preparation and implementation and the way they are further heating the already angry relationship between doctors and the government.
I have never seen a larger flood of more passionate, or fearful expressions of opposition to any other statutory instrument, from doctors and patients, combined with strong lobbying in opposition to the order from the British Medical Association and the Doctors’ Association UK. I also absorbed the views of our hardworking and under-celebrated Secondary Legislation Scrutiny Committee (SLSC) about the major change in oversight of the NHS that this represented.
Role of the House of Lords in representing people
As a Green in the House of Lords, I see one of my roles as representing those who otherwise will not have a voice, whether calling out a policing bill clause that explicitly targets gypsy, Roma and traveller people, or speaking up for the rights of benefit recipients to be protected from benefit sanctions.
I wouldn’t have predicted doctors would fall into that category, but as the date for the House to consider the order approached, with little attention and the risk that it would slip through without substantive debate – with the establishments on both side of the House lining up in support – I thought that the voices of concern I was hearing deserved a full hearing.
That was after I found many of my concerns were shared by independent (crossbench) peer and medical professor Baroness Findlay of Llandaff, who has put down a ‘regret’ motion expressing concern about confusion over the use of the title ‘associates’ and experienced Lib Dem peer Baroness Brinton who reflected that in her ‘regret’ motion, plus the concerns of the SLSC and the place of the General Medical Council (GMC) as regulator, rather than the Health and Care Professions Council (which looks after physiotherapists, paramedics, and many other similar professions).
Fears of a two-tier NHS
Their motions – and mine – address concern from doctors and patients that PAs in particular are being asked, or pushed, to go beyond their appointed role and level of training (two years post-graduate, versus ten years for GPs), and could be used to replace doctors. That’s also the concern of patients, which I share, particularly for those areas of the country struggling to recruit medical professionals at all levels, but particularly doctors, generally the most rural and remote, but also the most economically deprived.
This could – many fear – lead to a ‘levelling down’ within the NHS. There is a fear – widespread in our increasingly privatised and overloaded service – of a two-tier medical system being forced on us.
Defenders in the system will say that this is not the intention, that there are only around 1,500 PAs a year being trained, compared to (in the future) 15,000 doctors. But there’s intention, and then there’s outcome.
Democratic oversight in ‘redesigning’ the NHS
The second major point is about democracy. One description I heard for the order was that it was part of a process of “redesigning the whole system” of medical regulation, something that the SLSC highlighted. Effectively medical regulation is being taken away from parliamentary oversight and handed to independent bodies like the GMC.
The NHS is the jewel in the crown of the British state, its condition a subject of fervent political concern and debate. Control and oversight must not be taken away from democratic control. Ye,s there is select committee scrutiny, the Professional Standards Authority (PSA), and the ‘nuclear’ option of the privy council stepping in. But the PSA itself in a carefully worded briefing says we “need to keep under review as the reforms are rolled out the accountability framework proposed to balance the increased autonomy for regulators with greater accountability”.
And that’s not the same as a working parliament (and that’s a whole other issue, but let’s hope we can get one some time) having direct oversight of how the professionals in the NHS are regulated.
Conflict between government and doctors
Finally, there’s the relationship with doctors. That the government and they are at loggerheads is a statement of the obvious. And some are seeing the concern around this order as part of that conflict. Which it is.
But the answer to that is not to plough through, but to stop, seek a reset, find a way to negotiate and compromise. And for foundational changes in the structure and training of the workforce, which everyone agrees is needed, to be done through a full and proper debate, through amendable legislation.
The response I’m getting from establishment quarters is that there is not enough time to do this. But what can be more important than getting our NHS back on sound foundations? Surely that is a priority for government time, whichever government that is.
