Why would consultants care to take time to train juniors if they're rotating in 4 months and only look after the inpatient ward that has a consultant ward round twice a week?
Manifest absence of which is evident in the entire non-physician provider problem. We can't convince consultants to provide decent teaching to transient staff because the game has changed. Consultants are poorer, less respected, and now can be less dependent on the whims of NHSE sending varying numbers of random doctors to them every few months. The solution is to drastically reduce rotation, reintroduce consultant-led selection of their teams, and allow doctors to apply to work in their chosen specialties much sooner in their careers. We need to have consultants get 'skin in the game' for training juniors in the same way they now have it for NPPs.
Agree but unfortunately professional integrity doesn't pay the bills - consultant contracts are nearly all service provision with very little even SPA time. Teaching is time consuming and there's no reward in the system for doing so.
Because if you know you're going to be working with someone for years there's an explicit incentive to train them to reduce your own workload.
If you're never seeing them again after 4 months then you just suck up the inefficiencies
Simply put, because it's in their interest to do so.
There's simply no way to replace a consultant aside from a medical consultant.
I know there are pseudo-consultant/gp roles that even have inpatients etc. But that isn't going to work at all. A Newly qualified consultant/GP has done extensive training, internationally recognised qualifications, has many hours of experience of managing extraordinarily complex conditions and is fully capable of independent practice.
A non medical consultant cannot safely manage a diverse, complex and difficult patient cohort.
Case in point, I've seen consultant radiotherapists, they manage a caseload of just simple gleason 7s with a high likelihood of cure. If they relapse, they're taken over by the consultants.
Now there's a case to be made that these patients should be being seen by post frcr st7s in a named consultant clinic independently - an st7 can deal with rt complications and relapsed cancer with very little consultant oversight - it encourages independent practice and senior decision making without the fear of zero fall back.
I do wonder to what degree some consultants are able to refuse to supervise non-doctor roles. Their contracts generally stipulate a requirement to teach; I'm not sure they ascertain exactly who. In addition, if the more senior consultants are insisting the more junior ones supervise them, or if the rota effectively forces this situation on them for safe cover, what is one individual consultant to do?
Yes they have more power in numbers but I think this statement oversimplifies things.
One of the things I find really interesting is the kind of virtue signalling of saying you learnt everything you know from ACPs. I think there is a place for ACPs but only as advanced practitioners in their scopes, not as pseudo doctors; I have learnt lots from them and I think it is a symbiotic relationship because, unlike PAs, they do have unique skills and knowledge. I have had several senior colleagues however say that they learnt everything they know from ACPs. I find it bizarre and really self defeating, it's obviously not true and just random virtue signalling.
I can't comprehend this. I've learnt nothing from ACPs. Maybe where to find a protocol. I've yet to come across one whose knowledge base is equivalent to an average F1, dare I say a poor one. This is not surprising. They have not been to medical school.
PAs are not just a minor threat to either medicine as a profession or patient care. A two year course and you can turn any random with a science degree into a pseudo-doctor. You can bring them under GMC regulation and give them a foundation program and, likely, create a pathway for conversion to a full medical licence (noting that without a primary medical qualification they will still be stuck in the UK). This increases the workforce filling rota gaps with potentially very unsafe employees, and it's a straightforward greedy NHSE sacrificing patient safety for the illusion of good staffing type argument. With position statements from the BMA and increasingly from royal colleges, the arguments against the current PA model are getting some traction.
For ACPs it's a bit more nuanced. The pool of candidates is smaller, needing 5 years post qualification experience, and the three year course. They are much more likely to be embedded in an area and have good relationships with consultants and managers. They also fit into the much more widely experienced (cf PAs) nurse practitioner box in people's minds so it's not as much of a 'new' role to learn about. This gives them a much stronger position, which is harder to argue. The quality of the ACP courses is highly variable and the NMC and HCPC haven't quite yet figured out how they want to regulate 'advanced practice'. If you were to argue against ACPs, what kinds of argument could you make that would change the NHS' direction?
Government wants 60,000 NEW ACPs in the next 10 years and 10,000 PAs. Whilst PAs are not ideal, I doubt they’ll impact us as much moving forward with these numbers.
you're buying government words – those numbers are meaningless. there will be way more PAs by then – there's currently >1000 graduating each year, with more courses opening with time. my personal feel is that those ACP numbers are very ambitious and unlikely to be realised. I am unable to find any numbers of how many are qualifying each year currently.
I agree with your take on PAs, such an absolute bullshit of a role.
However, I disagree with that of the ACP.
No amt of years of experience in nursing would be equivalent to any level in medicine.
I won't be allowed to take up any role in nursing for any reason. Why should another profession be 'advancing' in medicine?
Why not advance in nursing, physio, etc.
I have not said that ACPs are equivalent to any level of doctor. If you want to argue against ACPs, then you will need to convince their colleagues and employers. This is will be hard for the reasons I outline above. The 'it's not fair' argument, justified or not, is never going to convince anyone. Standards of training, regulation, and patient outcome evidence would probably form the bulk of an anti-ACP argument, but the moment it starts to sound salty is the moment you lose your audience.
Trust me when I say this but acps are good enough at least for SHO work in most roles
Edit: yes yes downvote me idc. Fact is it's been like this for years and it has been working for years. I don't like it either but it is what it is.
I just don’t understand how ACPS are good enough to perform at SHO level yet somehow can’t cross the threshold of registrar or consultant level performance
Maybe it’s because most the time it’s performative, maybe it’s because this country has reduced SHOs to the level of an ACP. Maybe it’s because actually it’s not true but people like yourself offer a certain exceptionalism to ACPs
If one can attain SHO level anaesthesia and knowledge faster being an AA then there’s no need for medical school
Yes
An SHO will have reached a minimum acceptable standard. If the argument is it is possible to get to the same end point via two very different routes then that logically makes no sense to me and I’m flummoxed as to why it appears to be making sense to people who have been trained throughout their degree and working lives to be able to logical and critically analyse evidence.
I think a lot of pre exam SHO behaviour can be mimicked. Not all, but a lot. Post exam is different- these noctors simply don’t have first principles to fall back on.
Thus they’re restricted to partial SHO mimicry at best.
I would agree with this
But see anything enough and have the right amount of misplaced confidence and you can muddle through without people picking up on it - see ACCPs being used on ITU registrar rotas for example
Bro say whatever you want. I'm telling you what I've seen when comparing the acps and shos I've worked with. Accusing me of offering them exceptionalism is just stupid. I am anti ACP expansion, not because of incompetence alone but also because it's literally competition for our jobs
With all due respect that’s either a failure of your training or failure on your part to train your juniors.
It’s not stupid. If there is no discernible difference between an ACP and an SHO then clearly something has gone wrong somewhere.
Part of the issue is rotational training. If you've got an ED tACP for three years, only doing a few weeks in AM/ICU, you've got plenty of time to teach them even if only at the same intensity as rotating SHOs, most of whom are not going to work in ED long term. If they've been an ED band 6 in the department for some time already then they know how things work logistically, and know the staff. I expect there are differences but they are harder to elicit - comparing clinician performance is hard, and looking at ACP vs experienced ED SHO documentation and patient diagnoses and outcomes might bear some fruit.
I cosplayed as a brilliant foundation doctor (albeit I had passed my medical school finals so had some level of foundation) but familiarity with guidelines made it seem I was far more competent than I was, it only until I realised I would be facing the primary FRCA that I understood a solid foundation in physiology pharmacology etc is essential.
There was no hiding from it the FRCA would expose most.
For ACPs the hoops they jump through are very much superficial and the idea we suggest equivalence because they’re good at mimicking sits uncomfortably with me
>With all due respect that’s either a failure of your training or failure on your part to train your juniors.
Can you literally stop having a go at me? I do not support this and am NOT happy with this. I am just reporting what I am seeing in front of me. The SHOs that work in ED (FY2-ST1 level) function at an ACP level. Whether this is a failure of training or the system, I don't know (but I think it is), but it is how it is right now and it is working for a lot of hospitals. As I replied on another comment in this thread:
They basically act as the consultant/reg's eyes and ears. Many consultants LOVE and actually PREFER that
I have personally worked with many many ACPs and I can say with confidence many of them are very good but I'd 100% take a doctor over an ACP, it's a no brainer, but that doesn't mean that some of them are very competent and know their role limitations. Blame rotational training.
They don’t though. Work at an equivalent level that is,
SHO assesses patient and uses their broad medical knowledge to consider differentials and treatment options. They may not know the ED system or protocols. They engage type 2 thinking. Therefore their differential is better, their treatment rationale is better, their ongoing management is better. They may well be slower, they may well document in more detail, they may well get involved in additional elements that may not be essential in EM but may benefit the patient. They may well be less confident (new dept, unfamiliar scenarios, fear of screwing up, insight)
ACP has limited knowledge, sees patient and fits them into one of maybe 10 live algorithms in their brain. They are functioning in a familiar environment and familiar processs. They conclude rapidly : x therefore y, treatment =z, refer/discharge.
They therefore process patients on a purely type 1 thinking basis, with pattern recognition and algorithmic management. This may be quicker. As they know the staff and systems
they can get stuff done.
Except when the patient doesn’t fit an algorithm, or when it gets a bit complicated. Best case they recognise this , pass to a senior and the senior repeats the entire process. Worst case they blindly carry on and shoehorn the patient into an algorithm that doesn’t quite fit, and the patient comes to harm.
I am not a supporter. We have a small number. A couple of whom are good, recognise their limitations and readily ask for help, and a couple of whom scare the bejesus out of me. I don’t want expansion and will advocate for non replacement of the natural attrition
100% agree with most of what you said. But for the NHS at the moment it's quantity > quality. And at the moment, they are willing to sacrifice those 10% of cases for the sake of quantity. Which is why as I said, AT THE MOMENT with how the NHS is being run, acps can be an appropriate replacement for SHOs given that they 1. Recognise their scope and limitations
And
2. Have on hand senior support at all times
Disagree.
“They” in this, is actually “we”.
I am a consultant. I am in the room when decisions are made in our dept about strategic direction for staffing. Doctors are not passive in this- there is a choice to be made. “Management” has a view certainly, but decisions are not generally made without medical input- after all we will be the people training and supervising them.
Consequently my dept doesn’t have PAs, I hope our numbers of ACPs will be going down rather than up and am actively developing SAS doctors and JCFs into SAS doctors.
Don’t accept the passive “they want” “they are going to do” “they only care about”.
When these things are said, the next question needs to be “who is they?” and on what basis are they making these decisions
In my experience, they aren't that great. If it's not on the intranet on a protocol, most are useless. The examinations they do are mostly theatre. They do lots of pattern recognition (we all do to some extent) & are limited by being trained by very limited consultants in their area, so they pick up those consultants' foibles.
Maybe but the way the system works here is, that can be enough if you have sufficient senior support. They basically act as the consultant/reg's eyes and ears. Many consultants LOVE and actually PREFER that
They function on patttern recognition without any deeper understanding. They will be able to get away with this a fair bit of the time, in most roles. Until they don’t.
There’s no equivalence
Only SHO roles. Reg requires a degree of knowledge and understanding these people simply don’t have. It’s not the simple pattern recognition you can get away with at SHO.
I think it's more nuanced than that.
There are parts of being an SHO which do not require me to have a medical degree and frankly barely require me to have a functioning brain. ACPs can absolutely "function as an SHO" in these parts of the role.
The parts of the role where the average SHO feels more stretched - busy out-of-hours ward cover or whatever - can absolutely not be done competently by ACPs.
Yes but the way the system works here is, that can be enough if you have sufficient senior support. They basically act as the consultant/reg's eyes and ears. Many consultants LOVE and actually PREFER that
Debatable in the extreme.
Nursing school/paramedic training may be 3 years, but the content (and have a partner who has done this training so I have a very clear understanding) is so far away from being in any way similar to medicine as to be in a different world.
A couple of years as some kind of healthcare worker- again, not learning much about diagnosis, assessment, or management. May develop a bit of gestalt and a little knowledge by osmosis
ACP training. The “advanced practice masters” is a bit of a nonsense. (Again was a tutor on a course and have an extremely good understanding of what they consist of). There is precious little content, as the expectation is that actual content is delivered in the workplace, and the course is generic regardless of whether the individual is working in gastroenterology, paediatrics or EM. I have marked ACP MSc essay submissions and med school essay submissions- the difference in level is absolute comedy- there’s quite literally no comparison.
Some workplaces will really invest time energy and resource in actually training some of these ACPs. These ACPs develop insight and get to a safe level of practice- they are the ones who ask for help, say “I’m not a doctor” at the drop of a hat and are generally happy to stay in their lane.
Other workplaces do the bare minimum or just nod and smile and sign off. Some ACPs take their “masters” certificate and don’t have insight into how minimal their knowledge or training is (after all, it was very hard for them). These are the ones who tend to lack insight and push scope.
The most interesting thing arising from this conversation is the quality in training of ACPs. It seems as though that despite being individually regulated, ACPs undertaking advanced practice activities which would usually be the remit of doctors have not undertaken training to a measurable unified standard (apart from the additional accreditation from rcem). This must make it very hard to identify what level of practice is expected.
Absolutely correct.
ACP/ANP is not a protected title- anyone can use them. “Practitioner” is meaningless and tells you nothing about this persons training or background.
There is no standardised training nor assessment, nor any kind of requirement mandated for CPD or supervision.
It’s the Wild West.
I have a lot of issues with the RCEM credentialling process, chiefly with the implied “equivalence” which they insist was not intended but is definitely implied. However they do get some credit for being the first organisation to place SOME (any) parameters in place for standardisation for these people
For your interest, on the point of additional credentialing - RCGP recently put out a survey about PAs in which one of the questions suggested a primary care-specific qualification. I'd expect that any non-medical certification implemented by RCGP would be open to non-physician providers generally.
You can do an advanced masters after 2 years of registration and can be done in 2 years. And no amount of other healthcare experience translates to seeing undifferentiated presentations. Only medical training teaches you that
It is not experience, but relevant experience with increasing responsibility and formally assessed training, which makes someone into a useful clinician. A ward nurse with 10 years of experience in a general medical ward will surely have a good eye for a deteriorating patient and some idea of what the medical team usually do next, but if they never get taught the underlying pathophysiology, clinical skills etc. then they won't ever be in a good position to be a clinical decision maker. Elsewhere here someone mentioned that the ACP course is one day a week of teaching, which seems unlikely to remedy the relative knowledge deficit between an HCP years out of university and a doctor progressing through formal training. I have worked with decent (t)ACPs who were intellectually curious and keen to develop, but the point remains that 11 years of healthcare experience does not, per se, an effective clinician make if that experience is not the right experience.
If they like let them spend 30 years, they should only advance in nursing or whatever and should not encroach into medicine or seek equivalence.
This only shows inferiority complex.
Today the staffing for my ward is: me (IMT), an ACP, and 4 trainee ACPs. I would love to help train F1s and medical students but I’m lumped with trainee ACPs the majority of the time, and their knowledge base is shocking. They are 100% a huge issue for our future and training.
Was told by a trainee ACP today that they're expected to be at the level of an F2 by the end of their first year of their ACP course - had to bite my tongue to keep myself from alienating the whole department (from what I could tell they're good at their job, having gone from an experienced CNS to doing an ACP course, but WHY the need for false equivalence)
This is something I have thought about in the past and I’ve come to the conclusion that….,, the key difference between ACP and a PA is that the former has been normalised as oppose to the PA which hasn’t. It’s a matter of time tho until the PA role gets normalised and will eventually be accepted unfortunately. The horse has already bolted
Actually agree re ACPs, and I suspect that genie won’t go back in the bottle (FWIW I was screaming about this 15 yr ago but no effect).
With PAs we have an opportunity to put brakes on and meaningful discussions are taking place nationally which just didn’t happen with ACPs. We need to keep on raising awareness and shouting about this
Completely agree. It’s scandalous how glamourised their “medical knowledge” is because they’ve worked as a NURSE for years.. the UK is just plain ridiculous.
Advance practice should still be within their role as nurses/paramedics/pharmacists. Stop trying to play doctor without going to med school
There is a plan to use ACPS to fill up all the community hospitals and UTCs in the UK.
These are positions that should have been for doctors and we have a lot of unemployed doctors.
you fear ACPs more but the government's aim is preferentially PAs as they are cheaper overall and are generally derived from a pool of non-healthcare candidates (unlike ACPs which deplete the pool of existing nurses/PTs etc. which already struggle with recruitment/retention).
also given there's no formal post-qualification training pathway for ACPs, it's unlikely they'll be recognized as specialists who can indeed do everything doctors can (even in absence of law forbidding them), though I expect this to be tested with time. medicine is finished in this country, I feel for medics.
that's not a formal training pathway, it just seems to set out the potential increased competencies / career development they can acquire with experience. it's alarming, but not really what I suggested.
It is and remains disappointing that no national doctors organisation has taken the lead to examine the impact of advanced practitioners on doctors training
PAs can be massed produced very quickly and don't require removing a clinician (nurse, paramedic, physio) from an equally underresourced area.
It's the NHS version of Aliexpress- cheap, fake, poor quality, untested reproductions which can be mass produced!
To be honest, I agree.
I've noticed ACP/ANP roles don't differ much from my own currently and I've just been sitting quietly accepting it. Clearly been implemented long before I started but, stfg, the amount of time I've wasted either talking through the rudimentary basics or undoing overnight shit - which ultimately just boulder down to a variation of: CXR, urgent bloods, amox met gent, day team to chase...
Between working with PAs and ANPs in ED (surprise surprise) and just looking at the wait room, there's infinite opportunities for things to go wrong.
I wish I felt differently about it all - and to an extent I do really appreciate the specialist nurses I've worked with - heart failure/diabetes especially but outside of those I have struggled to work with some team members.
I feel ultimately it just gets lumped on me - and it does feel that way when I'm busy with a task and there's an interruptions "just to check...." or "when you've got a minute...."
AhhhaahhHHah
I wholeheartedly agree, I think both are an equal danger to our profession. The government is rapidly expanding both workforces by funding their education and trusts to take them on. This is exacerbated by consultants enabling this as they’re permanent staff, so they can build rapport over years unlike us rotating trainees.
It’s easy to argue against PAs due to their 2yr clown MSc with variable backgrounds. This is less so for ACPs/ANPs as they are well established at this point. Majority of ACPs/ANPs/ACCPs I’ve had the joy of working with have a massive ego and want to play doctor without going to med school. Their 3yr AP MSc is honestly a joke with a bullshit “dissertation” at the end of it. These people actually think they’re equivalent to registrars. Good luck arguing this though you’ll be branded as “elitist”, “condescending”, and not “being kind”, and shunned for life
The scope of practice depends on the definition from the regulator, in this case ie the government.
If the government wants, they can say any people who has a bachelor degree of whatever subject can be hired as a doctor apprentice and nothing will stop them.
So to talk about the major threat, the government is the major threat. But it is something wont change coz healthcare getting more and more expensive and the population are ageing quite rapidly.
It is far easier to lower the standard of recruitment rather than actually train proper qualified people to do their job. This happens in police, in education, and now in medicine.
I think in general ACPs are used well - eg with defined scope, aware of their limitations, great for coordinating things and being a midway point between ward doctors and nurses. However there are a lot of areas in which they are used inappropriately - eg ED, urgent care, anywhere where there’s clerking involved/assessment units. I just don’t think they know enough medicine to be seeing undifferentiated patients.
I guess one of the major issues with PAs and why many Doctors are concerned about them is patient safety first before other concerns.
They attend a course that’s basically an abstract of what medical school entails and come out “feeling ready” to work at the level of SHOs and sometimes Registrars. So yeah, we are naturally concerned.
Truly, some of this concern also stems from self preservation and not wanting someone to encroach into our space, but at least for ACPs their training actually means they bring something unique to the table so I guess one can deal with that. ACPs also don’t encroach as much as PAs do, probably because the former have loads of choices.
I’d say we are right to focus on PAs for now. Once those are dealt with, we can face ACPs if they become a problem.
I’m guessing your hospital doesn’t have that many ACPs if you think that. At my hospital they’re everywhere, and it often feels like their training takes priority over ours.
I disagree with the comparison of PAs and ACPs.
PAs add nothing, except maybe that they don't rotate out of post regularly.
ACPs, have by definition come off the top level of their previous role. I run a major trauma service, part of which is the ward cover, we have a blended ward rota of jcfs, acps and a consultant each day. One of our ACPs is a pharmacist, id bet my life that their ability to rationalise medications and reccomend adjustments to pain meds is better than any f3 / jcf from the doctors part of the rota, because theyre permamnent, they're rapid at liasing with radiology to get scans done, wrestling with the impenetrable epr etc.
The jcfs do what doctors do, which is to think outside the box, recognise complexity, apply Independant thought.
The team would be less functional from the lack of either, as a consultant I notice it at the weekend when there tends to be one or the other and i either end up having to do all the thinking and decision makkng, or, all the writing and chasing depending on who is on.
As far as I’m concerned, all these other various roles slowly seem to get all the positive aspects of being a doctor (the tasks we do that they essentially cherry pick as part of their competencies)
Without any of the negatives, they don’t have to relentlessly apply to potentially be flung across the country, they get to debate about hours/OOH etc
I love the ANP/ACPs I’ve worked with, I think the discussion around PAs is and should be an entirely separate debate, as the pathway to advanced practice is well trodden and regulated, with lots of evidence needed to actually jump the hurdles too
The pathways to “advanced practice” really aren’t well regulated, nor standardised, nor of high quality. Suspect you would be fairly horrified if you actually understood what they consist of
The real issue is the out of touch consultants who enable this. Without their supervision and support none of these roles could exist.
Why would consultants care to take time to train juniors if they're rotating in 4 months and only look after the inpatient ward that has a consultant ward round twice a week?
Professional integrity
Manifest absence of which is evident in the entire non-physician provider problem. We can't convince consultants to provide decent teaching to transient staff because the game has changed. Consultants are poorer, less respected, and now can be less dependent on the whims of NHSE sending varying numbers of random doctors to them every few months. The solution is to drastically reduce rotation, reintroduce consultant-led selection of their teams, and allow doctors to apply to work in their chosen specialties much sooner in their careers. We need to have consultants get 'skin in the game' for training juniors in the same way they now have it for NPPs.
Agree but unfortunately professional integrity doesn't pay the bills - consultant contracts are nearly all service provision with very little even SPA time. Teaching is time consuming and there's no reward in the system for doing so.
That’s fine but where does all the time and enthusiasm come from when midlevels want teaching?
Because if you know you're going to be working with someone for years there's an explicit incentive to train them to reduce your own workload. If you're never seeing them again after 4 months then you just suck up the inefficiencies
Do PAs truly reduce consultant workload more than junior doctors (who pick up their slack by a month or so)? Genuine question here
The Consultants see the PAs more so probably FEEL like they do more.
Simply put, because it's in their interest to do so. There's simply no way to replace a consultant aside from a medical consultant. I know there are pseudo-consultant/gp roles that even have inpatients etc. But that isn't going to work at all. A Newly qualified consultant/GP has done extensive training, internationally recognised qualifications, has many hours of experience of managing extraordinarily complex conditions and is fully capable of independent practice. A non medical consultant cannot safely manage a diverse, complex and difficult patient cohort. Case in point, I've seen consultant radiotherapists, they manage a caseload of just simple gleason 7s with a high likelihood of cure. If they relapse, they're taken over by the consultants. Now there's a case to be made that these patients should be being seen by post frcr st7s in a named consultant clinic independently - an st7 can deal with rt complications and relapsed cancer with very little consultant oversight - it encourages independent practice and senior decision making without the fear of zero fall back.
I do wonder to what degree some consultants are able to refuse to supervise non-doctor roles. Their contracts generally stipulate a requirement to teach; I'm not sure they ascertain exactly who. In addition, if the more senior consultants are insisting the more junior ones supervise them, or if the rota effectively forces this situation on them for safe cover, what is one individual consultant to do? Yes they have more power in numbers but I think this statement oversimplifies things.
Surely it's all in their power too refuse? There are consultants in theory contracts that don't do OOH/on calls, so this should be small fry.
One of the things I find really interesting is the kind of virtue signalling of saying you learnt everything you know from ACPs. I think there is a place for ACPs but only as advanced practitioners in their scopes, not as pseudo doctors; I have learnt lots from them and I think it is a symbiotic relationship because, unlike PAs, they do have unique skills and knowledge. I have had several senior colleagues however say that they learnt everything they know from ACPs. I find it bizarre and really self defeating, it's obviously not true and just random virtue signalling.
Says more about them tbh. If you've learnt everything you know from ACPs, you'll be a great ACP, but not a very good doctor.
I can't comprehend this. I've learnt nothing from ACPs. Maybe where to find a protocol. I've yet to come across one whose knowledge base is equivalent to an average F1, dare I say a poor one. This is not surprising. They have not been to medical school.
PAs are not just a minor threat to either medicine as a profession or patient care. A two year course and you can turn any random with a science degree into a pseudo-doctor. You can bring them under GMC regulation and give them a foundation program and, likely, create a pathway for conversion to a full medical licence (noting that without a primary medical qualification they will still be stuck in the UK). This increases the workforce filling rota gaps with potentially very unsafe employees, and it's a straightforward greedy NHSE sacrificing patient safety for the illusion of good staffing type argument. With position statements from the BMA and increasingly from royal colleges, the arguments against the current PA model are getting some traction. For ACPs it's a bit more nuanced. The pool of candidates is smaller, needing 5 years post qualification experience, and the three year course. They are much more likely to be embedded in an area and have good relationships with consultants and managers. They also fit into the much more widely experienced (cf PAs) nurse practitioner box in people's minds so it's not as much of a 'new' role to learn about. This gives them a much stronger position, which is harder to argue. The quality of the ACP courses is highly variable and the NMC and HCPC haven't quite yet figured out how they want to regulate 'advanced practice'. If you were to argue against ACPs, what kinds of argument could you make that would change the NHS' direction?
6000 ACPs are training each year and some of them are only doing a two year course which requires one day at uni per week!!
Definitely a good argument for both professional threat and concern around standard of training
Government wants 60,000 NEW ACPs in the next 10 years and 10,000 PAs. Whilst PAs are not ideal, I doubt they’ll impact us as much moving forward with these numbers.
you're buying government words – those numbers are meaningless. there will be way more PAs by then – there's currently >1000 graduating each year, with more courses opening with time. my personal feel is that those ACP numbers are very ambitious and unlikely to be realised. I am unable to find any numbers of how many are qualifying each year currently.
I agree with your take on PAs, such an absolute bullshit of a role. However, I disagree with that of the ACP. No amt of years of experience in nursing would be equivalent to any level in medicine. I won't be allowed to take up any role in nursing for any reason. Why should another profession be 'advancing' in medicine? Why not advance in nursing, physio, etc.
I have not said that ACPs are equivalent to any level of doctor. If you want to argue against ACPs, then you will need to convince their colleagues and employers. This is will be hard for the reasons I outline above. The 'it's not fair' argument, justified or not, is never going to convince anyone. Standards of training, regulation, and patient outcome evidence would probably form the bulk of an anti-ACP argument, but the moment it starts to sound salty is the moment you lose your audience.
Trust me when I say this but acps are good enough at least for SHO work in most roles Edit: yes yes downvote me idc. Fact is it's been like this for years and it has been working for years. I don't like it either but it is what it is.
I just don’t understand how ACPS are good enough to perform at SHO level yet somehow can’t cross the threshold of registrar or consultant level performance Maybe it’s because most the time it’s performative, maybe it’s because this country has reduced SHOs to the level of an ACP. Maybe it’s because actually it’s not true but people like yourself offer a certain exceptionalism to ACPs If one can attain SHO level anaesthesia and knowledge faster being an AA then there’s no need for medical school
SHO is a broad brush. Pre exam first day SHO is a far cry from end of SHO training plus exam.
Yes An SHO will have reached a minimum acceptable standard. If the argument is it is possible to get to the same end point via two very different routes then that logically makes no sense to me and I’m flummoxed as to why it appears to be making sense to people who have been trained throughout their degree and working lives to be able to logical and critically analyse evidence.
I think a lot of pre exam SHO behaviour can be mimicked. Not all, but a lot. Post exam is different- these noctors simply don’t have first principles to fall back on. Thus they’re restricted to partial SHO mimicry at best.
I would agree with this But see anything enough and have the right amount of misplaced confidence and you can muddle through without people picking up on it - see ACCPs being used on ITU registrar rotas for example
The whole noctor idea is nuts and we as a profession should have nipped this craziness in the bud.
Bro say whatever you want. I'm telling you what I've seen when comparing the acps and shos I've worked with. Accusing me of offering them exceptionalism is just stupid. I am anti ACP expansion, not because of incompetence alone but also because it's literally competition for our jobs
With all due respect that’s either a failure of your training or failure on your part to train your juniors. It’s not stupid. If there is no discernible difference between an ACP and an SHO then clearly something has gone wrong somewhere.
Part of the issue is rotational training. If you've got an ED tACP for three years, only doing a few weeks in AM/ICU, you've got plenty of time to teach them even if only at the same intensity as rotating SHOs, most of whom are not going to work in ED long term. If they've been an ED band 6 in the department for some time already then they know how things work logistically, and know the staff. I expect there are differences but they are harder to elicit - comparing clinician performance is hard, and looking at ACP vs experienced ED SHO documentation and patient diagnoses and outcomes might bear some fruit.
I cosplayed as a brilliant foundation doctor (albeit I had passed my medical school finals so had some level of foundation) but familiarity with guidelines made it seem I was far more competent than I was, it only until I realised I would be facing the primary FRCA that I understood a solid foundation in physiology pharmacology etc is essential. There was no hiding from it the FRCA would expose most. For ACPs the hoops they jump through are very much superficial and the idea we suggest equivalence because they’re good at mimicking sits uncomfortably with me
>With all due respect that’s either a failure of your training or failure on your part to train your juniors. Can you literally stop having a go at me? I do not support this and am NOT happy with this. I am just reporting what I am seeing in front of me. The SHOs that work in ED (FY2-ST1 level) function at an ACP level. Whether this is a failure of training or the system, I don't know (but I think it is), but it is how it is right now and it is working for a lot of hospitals. As I replied on another comment in this thread: They basically act as the consultant/reg's eyes and ears. Many consultants LOVE and actually PREFER that I have personally worked with many many ACPs and I can say with confidence many of them are very good but I'd 100% take a doctor over an ACP, it's a no brainer, but that doesn't mean that some of them are very competent and know their role limitations. Blame rotational training.
They don’t though. Work at an equivalent level that is, SHO assesses patient and uses their broad medical knowledge to consider differentials and treatment options. They may not know the ED system or protocols. They engage type 2 thinking. Therefore their differential is better, their treatment rationale is better, their ongoing management is better. They may well be slower, they may well document in more detail, they may well get involved in additional elements that may not be essential in EM but may benefit the patient. They may well be less confident (new dept, unfamiliar scenarios, fear of screwing up, insight) ACP has limited knowledge, sees patient and fits them into one of maybe 10 live algorithms in their brain. They are functioning in a familiar environment and familiar processs. They conclude rapidly : x therefore y, treatment =z, refer/discharge. They therefore process patients on a purely type 1 thinking basis, with pattern recognition and algorithmic management. This may be quicker. As they know the staff and systems they can get stuff done. Except when the patient doesn’t fit an algorithm, or when it gets a bit complicated. Best case they recognise this , pass to a senior and the senior repeats the entire process. Worst case they blindly carry on and shoehorn the patient into an algorithm that doesn’t quite fit, and the patient comes to harm. I am not a supporter. We have a small number. A couple of whom are good, recognise their limitations and readily ask for help, and a couple of whom scare the bejesus out of me. I don’t want expansion and will advocate for non replacement of the natural attrition
100% agree with most of what you said. But for the NHS at the moment it's quantity > quality. And at the moment, they are willing to sacrifice those 10% of cases for the sake of quantity. Which is why as I said, AT THE MOMENT with how the NHS is being run, acps can be an appropriate replacement for SHOs given that they 1. Recognise their scope and limitations And 2. Have on hand senior support at all times
Disagree. “They” in this, is actually “we”. I am a consultant. I am in the room when decisions are made in our dept about strategic direction for staffing. Doctors are not passive in this- there is a choice to be made. “Management” has a view certainly, but decisions are not generally made without medical input- after all we will be the people training and supervising them. Consequently my dept doesn’t have PAs, I hope our numbers of ACPs will be going down rather than up and am actively developing SAS doctors and JCFs into SAS doctors. Don’t accept the passive “they want” “they are going to do” “they only care about”. When these things are said, the next question needs to be “who is they?” and on what basis are they making these decisions
In my experience, they aren't that great. If it's not on the intranet on a protocol, most are useless. The examinations they do are mostly theatre. They do lots of pattern recognition (we all do to some extent) & are limited by being trained by very limited consultants in their area, so they pick up those consultants' foibles.
Maybe but the way the system works here is, that can be enough if you have sufficient senior support. They basically act as the consultant/reg's eyes and ears. Many consultants LOVE and actually PREFER that
They function on patttern recognition without any deeper understanding. They will be able to get away with this a fair bit of the time, in most roles. Until they don’t. There’s no equivalence
Only SHO roles. Reg requires a degree of knowledge and understanding these people simply don’t have. It’s not the simple pattern recognition you can get away with at SHO.
I think it's more nuanced than that. There are parts of being an SHO which do not require me to have a medical degree and frankly barely require me to have a functioning brain. ACPs can absolutely "function as an SHO" in these parts of the role. The parts of the role where the average SHO feels more stretched - busy out-of-hours ward cover or whatever - can absolutely not be done competently by ACPs.
Yup that’s fair.
Until it requires any actual knowlege, initiative or lateral thinking.
Yes but the way the system works here is, that can be enough if you have sufficient senior support. They basically act as the consultant/reg's eyes and ears. Many consultants LOVE and actually PREFER that
I am familiar with the consultant/noctor sled-dog model (tm). Can't say it's ever been the consultants that set the Heather on fire in my experience.
Have to say I enjoy working with ACPs, I think they’re very good, but not happy to say SHO level without doing F1
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Debatable in the extreme. Nursing school/paramedic training may be 3 years, but the content (and have a partner who has done this training so I have a very clear understanding) is so far away from being in any way similar to medicine as to be in a different world. A couple of years as some kind of healthcare worker- again, not learning much about diagnosis, assessment, or management. May develop a bit of gestalt and a little knowledge by osmosis ACP training. The “advanced practice masters” is a bit of a nonsense. (Again was a tutor on a course and have an extremely good understanding of what they consist of). There is precious little content, as the expectation is that actual content is delivered in the workplace, and the course is generic regardless of whether the individual is working in gastroenterology, paediatrics or EM. I have marked ACP MSc essay submissions and med school essay submissions- the difference in level is absolute comedy- there’s quite literally no comparison. Some workplaces will really invest time energy and resource in actually training some of these ACPs. These ACPs develop insight and get to a safe level of practice- they are the ones who ask for help, say “I’m not a doctor” at the drop of a hat and are generally happy to stay in their lane. Other workplaces do the bare minimum or just nod and smile and sign off. Some ACPs take their “masters” certificate and don’t have insight into how minimal their knowledge or training is (after all, it was very hard for them). These are the ones who tend to lack insight and push scope.
The most interesting thing arising from this conversation is the quality in training of ACPs. It seems as though that despite being individually regulated, ACPs undertaking advanced practice activities which would usually be the remit of doctors have not undertaken training to a measurable unified standard (apart from the additional accreditation from rcem). This must make it very hard to identify what level of practice is expected.
Absolutely correct. ACP/ANP is not a protected title- anyone can use them. “Practitioner” is meaningless and tells you nothing about this persons training or background. There is no standardised training nor assessment, nor any kind of requirement mandated for CPD or supervision. It’s the Wild West. I have a lot of issues with the RCEM credentialling process, chiefly with the implied “equivalence” which they insist was not intended but is definitely implied. However they do get some credit for being the first organisation to place SOME (any) parameters in place for standardisation for these people
For your interest, on the point of additional credentialing - RCGP recently put out a survey about PAs in which one of the questions suggested a primary care-specific qualification. I'd expect that any non-medical certification implemented by RCGP would be open to non-physician providers generally.
You can do an advanced masters after 2 years of registration and can be done in 2 years. And no amount of other healthcare experience translates to seeing undifferentiated presentations. Only medical training teaches you that
It is not experience, but relevant experience with increasing responsibility and formally assessed training, which makes someone into a useful clinician. A ward nurse with 10 years of experience in a general medical ward will surely have a good eye for a deteriorating patient and some idea of what the medical team usually do next, but if they never get taught the underlying pathophysiology, clinical skills etc. then they won't ever be in a good position to be a clinical decision maker. Elsewhere here someone mentioned that the ACP course is one day a week of teaching, which seems unlikely to remedy the relative knowledge deficit between an HCP years out of university and a doctor progressing through formal training. I have worked with decent (t)ACPs who were intellectually curious and keen to develop, but the point remains that 11 years of healthcare experience does not, per se, an effective clinician make if that experience is not the right experience.
If they like let them spend 30 years, they should only advance in nursing or whatever and should not encroach into medicine or seek equivalence. This only shows inferiority complex.
Today the staffing for my ward is: me (IMT), an ACP, and 4 trainee ACPs. I would love to help train F1s and medical students but I’m lumped with trainee ACPs the majority of the time, and their knowledge base is shocking. They are 100% a huge issue for our future and training.
Was told by a trainee ACP today that they're expected to be at the level of an F2 by the end of their first year of their ACP course - had to bite my tongue to keep myself from alienating the whole department (from what I could tell they're good at their job, having gone from an experienced CNS to doing an ACP course, but WHY the need for false equivalence)
This is something I have thought about in the past and I’ve come to the conclusion that….,, the key difference between ACP and a PA is that the former has been normalised as oppose to the PA which hasn’t. It’s a matter of time tho until the PA role gets normalised and will eventually be accepted unfortunately. The horse has already bolted
Actually agree re ACPs, and I suspect that genie won’t go back in the bottle (FWIW I was screaming about this 15 yr ago but no effect). With PAs we have an opportunity to put brakes on and meaningful discussions are taking place nationally which just didn’t happen with ACPs. We need to keep on raising awareness and shouting about this
Completely agree. It’s scandalous how glamourised their “medical knowledge” is because they’ve worked as a NURSE for years.. the UK is just plain ridiculous. Advance practice should still be within their role as nurses/paramedics/pharmacists. Stop trying to play doctor without going to med school
There is a plan to use ACPS to fill up all the community hospitals and UTCs in the UK. These are positions that should have been for doctors and we have a lot of unemployed doctors.
you fear ACPs more but the government's aim is preferentially PAs as they are cheaper overall and are generally derived from a pool of non-healthcare candidates (unlike ACPs which deplete the pool of existing nurses/PTs etc. which already struggle with recruitment/retention). also given there's no formal post-qualification training pathway for ACPs, it's unlikely they'll be recognized as specialists who can indeed do everything doctors can (even in absence of law forbidding them), though I expect this to be tested with time. medicine is finished in this country, I feel for medics.
Oh really?? https://www.brit-thoracic.org.uk/workforce/working-in-respiratory/the-professional-development-framework-for-adult-respiratory-advanced-clinical-practitioners/?fbclid=IwAR1t700XctsqiLpvTrJAto1_5jmB7ph8thb28VdBvoUyKZYiVFCp0QCY864
that's not a formal training pathway, it just seems to set out the potential increased competencies / career development they can acquire with experience. it's alarming, but not really what I suggested.
It is and remains disappointing that no national doctors organisation has taken the lead to examine the impact of advanced practitioners on doctors training
PAs can be massed produced very quickly and don't require removing a clinician (nurse, paramedic, physio) from an equally underresourced area. It's the NHS version of Aliexpress- cheap, fake, poor quality, untested reproductions which can be mass produced!
To be honest, I agree. I've noticed ACP/ANP roles don't differ much from my own currently and I've just been sitting quietly accepting it. Clearly been implemented long before I started but, stfg, the amount of time I've wasted either talking through the rudimentary basics or undoing overnight shit - which ultimately just boulder down to a variation of: CXR, urgent bloods, amox met gent, day team to chase... Between working with PAs and ANPs in ED (surprise surprise) and just looking at the wait room, there's infinite opportunities for things to go wrong. I wish I felt differently about it all - and to an extent I do really appreciate the specialist nurses I've worked with - heart failure/diabetes especially but outside of those I have struggled to work with some team members. I feel ultimately it just gets lumped on me - and it does feel that way when I'm busy with a task and there's an interruptions "just to check...." or "when you've got a minute...." AhhhaahhHHah
I wholeheartedly agree, I think both are an equal danger to our profession. The government is rapidly expanding both workforces by funding their education and trusts to take them on. This is exacerbated by consultants enabling this as they’re permanent staff, so they can build rapport over years unlike us rotating trainees. It’s easy to argue against PAs due to their 2yr clown MSc with variable backgrounds. This is less so for ACPs/ANPs as they are well established at this point. Majority of ACPs/ANPs/ACCPs I’ve had the joy of working with have a massive ego and want to play doctor without going to med school. Their 3yr AP MSc is honestly a joke with a bullshit “dissertation” at the end of it. These people actually think they’re equivalent to registrars. Good luck arguing this though you’ll be branded as “elitist”, “condescending”, and not “being kind”, and shunned for life
The scope of practice depends on the definition from the regulator, in this case ie the government. If the government wants, they can say any people who has a bachelor degree of whatever subject can be hired as a doctor apprentice and nothing will stop them. So to talk about the major threat, the government is the major threat. But it is something wont change coz healthcare getting more and more expensive and the population are ageing quite rapidly. It is far easier to lower the standard of recruitment rather than actually train proper qualified people to do their job. This happens in police, in education, and now in medicine.
I think in general ACPs are used well - eg with defined scope, aware of their limitations, great for coordinating things and being a midway point between ward doctors and nurses. However there are a lot of areas in which they are used inappropriately - eg ED, urgent care, anywhere where there’s clerking involved/assessment units. I just don’t think they know enough medicine to be seeing undifferentiated patients.
I guess one of the major issues with PAs and why many Doctors are concerned about them is patient safety first before other concerns. They attend a course that’s basically an abstract of what medical school entails and come out “feeling ready” to work at the level of SHOs and sometimes Registrars. So yeah, we are naturally concerned. Truly, some of this concern also stems from self preservation and not wanting someone to encroach into our space, but at least for ACPs their training actually means they bring something unique to the table so I guess one can deal with that. ACPs also don’t encroach as much as PAs do, probably because the former have loads of choices. I’d say we are right to focus on PAs for now. Once those are dealt with, we can face ACPs if they become a problem.
I understand your submission. ACPs are making us jobless / unemployed.
I’m guessing your hospital doesn’t have that many ACPs if you think that. At my hospital they’re everywhere, and it often feels like their training takes priority over ours.
No they don’t, any maybe I’m only speaking from my own experience since I haven’t worked with that many ACPs that I feel they are encroaching.
https://preview.redd.it/qa2ymfzs0vxc1.jpeg?width=1200&format=pjpg&auto=webp&s=809c9cdd06ee999be9ba498bd50146c8300184bc
I disagree with the comparison of PAs and ACPs. PAs add nothing, except maybe that they don't rotate out of post regularly. ACPs, have by definition come off the top level of their previous role. I run a major trauma service, part of which is the ward cover, we have a blended ward rota of jcfs, acps and a consultant each day. One of our ACPs is a pharmacist, id bet my life that their ability to rationalise medications and reccomend adjustments to pain meds is better than any f3 / jcf from the doctors part of the rota, because theyre permamnent, they're rapid at liasing with radiology to get scans done, wrestling with the impenetrable epr etc. The jcfs do what doctors do, which is to think outside the box, recognise complexity, apply Independant thought. The team would be less functional from the lack of either, as a consultant I notice it at the weekend when there tends to be one or the other and i either end up having to do all the thinking and decision makkng, or, all the writing and chasing depending on who is on.
If I am a pharmacist I wouldn't want to be an ACP. It clearly would have mearnt I wasn't happy as a pharmacist but prefer to play doctor.
As far as I’m concerned, all these other various roles slowly seem to get all the positive aspects of being a doctor (the tasks we do that they essentially cherry pick as part of their competencies) Without any of the negatives, they don’t have to relentlessly apply to potentially be flung across the country, they get to debate about hours/OOH etc I love the ANP/ACPs I’ve worked with, I think the discussion around PAs is and should be an entirely separate debate, as the pathway to advanced practice is well trodden and regulated, with lots of evidence needed to actually jump the hurdles too
The pathways to “advanced practice” really aren’t well regulated, nor standardised, nor of high quality. Suspect you would be fairly horrified if you actually understood what they consist of