What Union Should Medical Associate Professionals Be In?
Authors: Brocha Goode and Emma Runswick
This is the third of many pieces arising from the BMA’s Annual Representative Meeting 2019, explaining our position on the debates which occurred there.
At the 2019 BMA ARM, supporters of the Broad Left brought forward a motion that the BMA should unionise Physician Associates (PAs), as well as other Medical Associate Professionals (MAPs), and create a branch of practice for MAPs within the BMA. It fell, save for the last part where the RB agreed to work with ‘groups’ representing PAs and MAPs in the future for the benefit of all. The main arguments against consisted of keeping the BMA a doctors’ union, and not wanting to ‘water down’ the role of the BMA in protecting the rights of doctors. Why did supporters of the Broad Left bring this motion forward?
Physician Associates and other Medical Associate Professionals
Therole of the Physician Associate was created recently by the UK government as apotential solution to the workforce crisis created by the Modernising MedicalCareers programme, which reduced the numbers of middle-grade doctors.University training programmes for PAs run across the UK, and they will soonjoin medical rotas in large numbers. We are told that in 10 years there will be10,000 PAs working in the NHS. The role is ill-defined, but includes assessingpatients, requesting investigations and creating management plans.
There is no specific trade union for PAs.
Other MAPs exist in smaller numbers in Surgery,Anaesthetics and Critical Care. Some groups have no direct entry, drawing onlyon highly qualified and experienced nurses. The Advanced Critical CarePractitioners are one such group. Some of these groups already haverepresentation, many do not.
The Problem – We all need a union
It is important to separate the question ofunionisation from your feelings about MAPs. It is no longer important whetheryou support or oppose PAs or MAPs as a concept. Individual interactions with PAsor other MAPs are irrelevant to the issue at hand. PAs exist.
They are workers. They are our colleagues. They arevalued members of the Multi-Disciplinary Team. The concept of a PA comes fromthe USA, where it is a well-defined role separate to that of a doctor. In theUK, however, this is not the case - their roles often overlap with taskstraditionally performed by doctors. Their training, though shorter, is sosimilar that students share clinical skills sign-offs with medical students. NHSEngland has decided that their role is so similar to F1s that from August, PAswill be placed on some F1 tracks and rotas.
The current implementation of PAs by NHS managersand Universities has the potential for competition and conflict. We are alreadyseeing concerns about training opportunities and worry about the poordifferentiation of our roles by both professions. The position of the PA isalso open to abuse. A person in a fluid role can be asked to take on more responsibilitythan they are trained or paid for. PAs have not yet been given prescribingrights or professional registration, yet they are asked to make managementplans for patients. Doctors, who hold professional registration, must then ‘supervise’and take the legal responsibility for these plans, without additional time.This situation is bad for PAs, for doctors, and for patients.
Misplaced resentment is growing between theprofessions, but these problems were not created by PAs. These problems werecreated by the poor definition of their role and poor implementation – theseare problems created by the government and managers and the fault lies withthem. Without representation by a strong established union, PAs may findthemselves mistreated and exploited to the detriment of themselves, doctors andpatients.
The Royal College of Nursing (RCN) as a Model
Similar issues were raised by nurses whenHealthcare Assistants, and more recently Nursing Associates, were introduced. The Royal College of Nursing, the trade union andprofessional association for nurses, decided that the smartest way to deal withthese issues was not to argue worker vs worker, but to fight together as unionvs government. The RCN recruited these new staff groups into their union and wonproper definition of those new roles. This ensured that Nursing Associatescould not be asked to take on responsibility that they weren’t trained for and protectedthe role of the Registered Nurse.
The RCN recruit and organise Nursing Associates andHealthcare Assistants without accepting that the roles are equivalent to thatof a Registered Nurse. The RCN maintains its role as a trade union and as aprofessional association whilst accepting members that do not have professionalregistration.
We should look at the RCN as a model. Theyknow that division causes weakness, and unity gives strength. This strength allowedthem to protect all groups of nursing staff. Their common needs as a nursingfamily trumped their differing qualifications.
Conflict and Commonality – Why the BMA?
In the BMA, we have several existing Branches ofPractice with frequently conflicting views. Werepresent GP Partners and GP Salaried Doctors; Students and Academics;Consultants and Juniors. PAs, like these groups, are in the medical family, justlike Nursing Associates are in the nursing family. Royal Colleges have acceptedthis. The GMC and the government both agree. We have more in common than thatwhich divides us. Where conflicts between Branches of Practice occur, the BMAhas systems to resolve that. These could be extended to include our colleaguesfrom other professions.
We shouldn’t leave PAs and other MAPs to seekpiecemeal representation by the general unions operating in the NHS. If therewas an existing union with enough MAP members for them to be effectively representedas a group, we would be advocating they join it. MAPs are currently spreadacross several unions, but mostly go without.
We also shouldn’t wait for years forthem to form their own union with a fraction of the strength we have now, afterthe damage has been done. Asking MAPs to create a new union is a nearimpossible task and would suck up all their work for the foreseeable future. Bythe time they were set up and had gained negotiating rights all the big debateswould be over, to the detriment of staff and patients. Furthermore, in separateunions, there would be no effective way of managing any conflicting interestsbetween us.
That conflict has the potential to include use ofone professional group against the other during industrial disputes. As itstands, PAs are a risk to doctors’ terms and conditions and doctors are a riskto PAs’. Doctors’ pay and PAs’ ability to refuse out-of-hours work could comeunder attack from management making unfavourable comparisons. Working together,that risk could be eliminated.
Solution
We should seek national recruitment, organisationand bargaining for Physicians Associates and other MAPs through the BMA, so wecan work together for agreed and common goals including:
- High quality training;
- Professional registration for allmembers of the clinical workforce;
- Adequate role differentiation, so onecannot be asked to do the job of the other during rota shortages or uniondisputes.
For many in the medical profession, this tastesbad. It tastes like an acceptance of medical understaffing, of reduction intraining standards. Some argue that unionising MAPs puts the definition of adoctor, or of the BMA, at risk. The BMA was set up to define and defend therole of the registered medical practitioner. Now, the BMA needs to do so again.
How do we work to define our roles as separate on the MDT without working together?How do doctors and MAPs protect their roles and working conditions without thepower of a strong well defined and well-funded union? Unionising is the right solutionto the issues we face, and the only real solution right now.
The RCN has given us the model. We should berecruiting and unionising PAs. For similar reasons, we should recruit otherMAPs, such as Surgical Care Practitioners or Anaesthetic Associates, that don’thave a trade union home. We cannot afford to let this snowball away.