Roger Watson, Editor-in-Chief
You may not be aware that in the NHS there are people with roles that are like doctors and nurses, but they are neither. Depending on your view these people can be either ‘super nurses’ or ‘sub-doctors’. But do they work?
A recent review of research compared these ‘substitute doctors’ roles with doctors in long-term care of older people. The results show they are better than doctors at improving health of patients, preventing secondary complications and completing care processes. They are equally as good as doctors at preventing deaths, providing medications and completing mandatory physical examinations. They are also cheaper. This is important as more older people spend their final years in long-term care, which is expensive and health service resources are scarce.
There are two main substitute doctors roles are Nurse Practitioners and Physician Associates. They are different but have very similar roles in assisting or even substituting for doctors. Nurse Practitioners are Registered Nurses with advanced training in diagnosis and treatment. Physician Associates are science graduates with similar advanced training.
Like most of these advanced roles, Nurse Practitioners and Physician Assistants started in the USA. Nurse Practitioners began in the USA in the 1940s and they were trained in areas like midwifery and anaesthetics where they could work independently. Physician Associates started in the USA in the 1960s and their role was designed to assist doctors directly with examining patients and prescribing drugs. The two roles have spread across the world and Nurse Practitioners now exist in over fifty countries and Physician Associates exist in over ten countries.
Nurse Practitioners can perform many of the tasks of doctors and are generally well accepted in advanced roles by doctors. But less is known about the new Physician Associate roles and some doctors are worried. The role is recognised as one that can assist doctors but replacing doctors is another matter. The lack of professional registration, which helps to define a role, is one worry. It leads to a ‘fluid’ role which could be used to undermine the role of the doctor and take away training opportunities for junior doctors. Other than that, Physician Associates lack many of the skills required to work independently or unsupervised.
Nurse Practitioners – who have several titles – have existed for over twenty years in the UK and since this is not a ‘registerable’ profession, the exact numbers are not know but there are many hundreds working in the UK. Physician Associates have only existed here for about ten years and the government wants to increase their numbers. This is also not a registerable qualification and exact numbers are not known. But in 2014 there were around 200 in the UK with plans to increase that and more than double the number of training places from 100 to 225. The recent research showing that they can be successfully used to replace doctors is good news for the UK government and for UK universities.
The future for substitute doctors in the UK looks very good. Funding issues in the NHS probably make them a necessity. The evidence that they are effective in at least one important role and often better and cheaper that doctors will surely encourage more growth in training places and numbers in the NHS.
One issue remains for both Nurse Practitioners and Physician Associates and that is regulation. Being a Nurse Practitioner is what is known as a ‘recordable qualification’ and Nurse Practitioners can choose to do this with the Nursing and Midwifery Council. Of course, all Nurse Practitioners are Registered Nurses and must keep that status to work as Nurse Practitioners. For Physician Associates, there is the Faculty of Physician Associates at the Royal College of Physicians of London. Registering with them is only encouraged but not compulsory.
Proper registration and regulation of substitute physician roles will increase confidence in them and lead to wider acceptance. It is doubtful if people will turn up at doctors’ surgeries and say, ‘can I see the substitute physician?’. But soon it is more likely that this is who they will see.
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Lovink MH, Persoon A, Koopmans RTCM, Van Vught AJAH, Schoonhoven L, Laurant MGH (2017) Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the aging population: a systematic literature review Journal of Advanced Nursing doi: 10.1111/jan.13299