Partha Kar: Sorting out the mess around medical associate professionals

The whole situation around medical associate professionals (MAPs) is an unqualified mess. What had been dismissed as social media noise has snowballed into something much larger. Statements have been issued by NHS England and the General Medical Council; the BMA is now walking into the debate1; and the medical royal colleges are starting to show unease.

The present debate—occurring at the same time as disputes about doctors’ pay—has created a cohort of medical trainees asking why these MAP roles exist and why there’s no national regulatory framework or definition of scope for them. Trainees are looking at the weirdness of it all, finding themselves unable to attend training days or pick up training opportunities, while MAPs do. Cue understandable friction.

Leaving the scope of these roles vague has meant that individual NHS trusts and GP surgeries have used them as they see fit, which is questionable at best and dangerous at worst. In 2019 the Department of Health and Social Care decided that the General Medical Council should regulate these roles. Yet it’s still not clear what regulation means, and there’s a concern that there’d be no differentiation between the registration numbers for doctors and those for MAPs. This all fuels the narrative that MAPs are “doctors on the cheap.”

These roles are also being introduced at a time when numerous challenges already face the medical workforce. One of the most rapidly growing groups is doctors who are “other”—not consultants, GPs, or in formal training programmes. Such doctors are conglomerated in data points under the label “SAS/LED” (specialist, associate specialist, and specialty doctors; and locally employed doctors).

The rise in the number of these doctors has been fuelled by a shortfall in training numbers, an increasing reliance on international colleagues, and doctors choosing to take more ownership of their careers. These doctors, who are often international medical graduates, have no structured career progression per se; they have varying degrees of supervision and support; and their roles are largely confined to jobs that others don’t want to do.

Supervision and mentoring are key issues here. Senior doctors don’t have time to supervise or mentor SAS/LED doctors (not a surprise, in the absence of structured job plans or the ability to see supervision and pastoral roles as a core component of being a senior), and SAS/LEDs have also been ignored by trusts and Health Education England—whose remit, in fairness, was once limited to trainees but is now the whole workforce. A problem arises when trusts seem to have time for physician associates and anaesthesia associates, with time to create pathways and support for them, yet there’s a stark absence of any national policy or steer around LED doctors from national bodies—which is odd, given datasets showing them to be the fastest rising group.

With datasets as they stand around discrimination against international medical graduates, any ignorance of this group raises more than questions about oversight. But how much is par for the course regarding how the NHS treats international graduates? The irony is that a lot of the issues such as scope or regulation are beyond the ambit of MAPs, and it’s fair to say those in charge of it haven’t helped in terms of the delay in getting these done.

To get us out of this mess, here are some suggestions:

• Consultation—We should have a rethink on the introduction of MAPs. Times change, circumstances change, and what applied when the issue was originally subject to consultation in 2017 may not apply in 2023. Suggesting that a consultation, once done, is done forever, has some Brexit referendum vibes to it, which we need to avoid.

• Job title—This needs to be looked at again. It’s extremely odd to call someone a physician associate when they’re in a surgical team or GP surgery. There’s also disquiet about the term “associate” rather than “assistant.” If reviewing this helps to calm nerves around seeking “doctors on the cheap” then it’s worth it.

• Scope—It’s time for the relevant medical royal colleges to nail this down. The scope of MAPs’ training requirements and practice should be clearly defined. Seniors need specific guidance on what risks they take if an MAP they’re supervising acts beyond their scope.

• Regulation—If the GMC regulates MAPs (and that’s an if), it needs to have a separate administrative wing to do so. There also needs to be a separate way of allocating registration numbers to individuals in these new roles.

• Batting order—There must be a clear priority list for deciding who is trained by senior doctors, given the small amount of time they have. Either that or ensure that seniors have adequate time to supervise them all.

It’s a mess—yet a pause, a rethink, with calm heads and a consideration of how to ensure that all can work together, is key. Soldiering on by ignoring the growing chorus of voices, or trying to push the agenda through, ignores a simple fact: that the existence and survival of MAPs is, as things stand, dependent on doctors—both seniors and other grades. If that relationship is fractured there’s a big problem, and old school bullying or gaslighting of those who raise their voice won’t settle the mood.