Dr Indranil Chakravorty MBE PhD FRCP
DIVISION & DIVERSITY – A DOCTOR’S DILEMMA
There are two issues that appear to be dividing the medical profession as we approach the festive season. Both are controversial and there are no right or wrong answers. Yet, the elephant(s) in the room is the formulation of the plan for rebuilding the NHS and the impact of both these issues on widening the inequalities that exist in the profession, which in turn reflects modern British society. We, as members of the profession, representative of the diversity that enriches the NHS and society should and do have a voice that must be heard and contribute constructively to the national debate.
What are the issues that we will attempt to touch in this brief editorial?
- Firstly, anything that is said about the current Terminally Ill Adults (End of Life) Bill (1) or better known as the ‘Assisted Dying Bill’ that is going through its second stage in the UK Parliament will be controversial, will divide the room and cause distress to one and all.
- The second is the role of medical associate professionals in the UK NHS, which is imminently entering joint registration with the General Medical Council, this month.
Let’s talk about the ‘Assisted Dying Bill’.
Perhaps, it is foolhardy to attempt to provide a balanced perspective to this question as a doctor, and to a readership of doctors and nurses. Remembering that due to the feverishly protected legacy principles of autonomy, no two self-respecting professionals ever tend to agree entirely on any issue, least of all one that is so controversial. However, it is important that we continue the debate and discourse on this vital issue for the sake of our patients, and for us professionals.
The bill proposes that anyone above the age of 18 years, resident of England and Wales and be registered with a GP for at least 12 months, with the mental capacity to make the choice and be deemed to have expressed a clear, settled and informed wish, free from coercion or pressure, expected to die within six months, may make two separate declarations, witnessed and signed (by them or a proxy on their behalf), about their wish to die. The bill requires that two independent doctors must be satisfied the person is eligible – and there must be at least seven days between the doctors’ assessments. A High Court judge must hear from at least one of the doctors and can also question the dying person, or anyone else they consider appropriate. There must be a further 14 days after the judge has made the ruling (although this can be shortened to 48 hours in some circumstances).
What is the impact on Doctors?
Under the bill, a doctor could prepare the “approved” substance (the bill does not detail what medication this is) but the person themselves must take it. No doctor or anyone else would be allowed to administer the medication to the terminally ill person. The doctor would stay with the person until they had self-administered the substance and died (or the doctor determines the procedure has failed). The person could decide not to take it, in which case the doctor would have to remove the substance immediately. Doctors would also not be under any obligation to take part in the assisted dying process. Deaths covered by the assisted suicide bill would not need to be investigated by a coroner.
At the recent interviews for medical school entrance, many young aspirants vouched how they would dedicate their lives to the care of patients, putting patients first and the principles of medical ethics of beneficence, non-maleficence, autonomy, and justice. If this bill passes all the stages in parliament, then all doctors would be faced with the role of assisting and witnessing a patients ending their lives of their own free will. The only requirement would be that ‘they were of sound mind and have a condition with an expected survival of less than six months. Let’s consider 3 important components of this bill as doctors.
- Being of sound mind i.e. demonstrating mental capacity
- Having a terminal illness with an expected survival of less than six months, and
- To be able to make this decision of their own accord, without coercion or pressure
Although there are established principles of assessing mental capacity, any assessment of capacity is based on specific decisions, context, time sensitivity and subject to change. Every doctor who has had to assess the mental capacity of patients understands how fragile and dynamic such assessments are and how different professionals may easily reach a different conclusion in the same circumstances. We are not even considering the impact of language, culture, ethnicity, age, memory, underlying health conditions and mental health challenges that may affect such decisions or assessments. It is at best a poor estimation and subject to multiple dynamic factors that will be almost impossible to standardise and train for. Take for example the accuracy and quality of documentation in medical certification of death which is at least an incontrovertible fact, and the debates and discussions doctors are having with medical examiners or Coroner’s courts where ‘experts’ frequently disagree.
Having a terminal illness is again an uncertainty, as most survival data demonstrate time and again that patients fall within statistical parameters with predicted survival within broad estimates. It is almost impossible for any doctor or expert to agree that an individual patient will certainly survive less than six months. Many of us who are in this business of making predictions in the day-to-day work with end-of-life patients know how frequently we are proven wrong. Human physiology, individual factors, and willingness to live or die are not definable.
Then we are left with the quagmire of diversity, socio-economic factors, education, understanding of language, the inefficiency of translation from English, the religious and cultural context, the influence of family dynamics that influence health and affect mental capacity. We will need to consider the impact of depression, early dementia, physiological factors of blood sugar control, electrolyte imbalance, dehydration, constipation etc. The list of factors that impact a ‘sound mind’ adversely is demonstrated every day in fractious conversations between psychiatrists and physicians. Any doctor who undertakes this assessment also must be independent of any relationship with the patient, therefore independent when making this decision. This rules out General practitioners, oncologists and any consultants who may be managing these patients over a period of time. Although this is not specified in the proposed bill.
We, as doctors mostly from diverse backgrounds, are fully aware of the impact of a patient’s minoritised background on adverse health outcomes. How can we be assured that patients from minoritised backgrounds will have stable, reliable, and safe decisions as per the proposals in the bill/ There is no evidence that this bill has gone through an equality, diversity and inclusion impact assessments and there are certainly no added safeguards for patients from minoritised backgrounds. As for doctors, the bill allows doctors to exclude themselves from having to be part of this process. The multiple instances of delayed, missed, or mistaken diagnosis leading to poorer outcomes, that we are only just beginning to recognise, based on multiple factors of deprivation and diversity for minoritised patients is mind-boggling. It is perhaps ignorant of anyone to expect that patients from such backgrounds will have a fair, safe and just assessment, under the principles of this bill.
Regulation of Medical Associate Professionals
Let’s touch briefly on the controversy that continues to rage for the role of 3,500 MAPs in the UK NHS, who are due to be regulated by the GMC UK this month, following the passing of the statute in UK Parliament in Dec’23 (2). One by one, the British Medical Association, and many of the medical royal colleges have conducted surveys of their members and reported results which indicate a majority of opinions which raise concerns regarding the role, scope of practice, lack of supervision, inappropriate substitution of doctors and instances of compromises to patient safety in relation to the training and employment of MAPs in the UK NHS. The British Association of Physicians of Indian Origin (BAPIO) has also undertaken its own survey and focus groups which were reported earlier this year(3). The concerns from the doctors who have responded to these surveys are similar and consistent. The issue of supervision and safety appear to be paramount in the minds of doctors, as it should be. However, there are public debates of anecdotal evidence of ‘harm’ from MAPs assessing patients which do the rounds and attract multiple views on social media, some even make it to news outlets and are being discussed in parliament. In hospitals, MAPs appear to have been used to work not alongside or under supervision of doctors, but as replacements for gaps in rotas or as autonomous practitioners with extended and often unspecified scope of practice. While in general practice, there are multiple instances of MAPs working autonomously, seeing unspecified patients across all age groups or specialities and with little or no direct supervision from GPs.
Both of these practices are inadvertent extensions of scope and role, which is probably a direct result of three factors; 1) the concept that MAPs are pluripotent in their 2-year training and therefore able to be utilised flexibly, 2) that they are persistent gaps in doctors rotas due to lack of workforce availability – although this concept has been debunked by the huge numbers of international medical graduates who have successfully passed the PLAB exams and have full registration to practice in the UK, and 3) the incentives provided by NHS England through workforce innovative schemes such as ARRS for employment of professionals other than doctors.
All of these factors highlight a lack of joined-up thinking at the top of the leadership tree both for the UK NHS and the Department of Health and Social Care, with little or no counsel or influence from the medical royal colleges and the doctors’ unions. The relationship between the political masters and the medical professionals has been fractious even before the royal statute which established the Royal College of Physicians of London in 1552 and will continue. The recent industrial action by a rejuvenated BMA and other unions towards the end of the last government’s political term has only made this relationship worse. Finally, the public satisfaction in the NHS has reached an all-time low, so there is little love or favour from the public that we serve. In this toxic soup, we now face the inevitable statutory regulation of MAPs by the GMC UK on the same register as doctors. Hence, the latest campaign of ‘no confidence in the regulator’ appears to be gaining appeal in social media. It will be fair to say that the regulator by its apparently controversial actions in relation to differential outcomes for doctors, the lack of sensitivity in fitness to practice investigations, its apparent silence when facing questions from doctors in relation to MAPs, the lack of demonstrable scientific methodology in reaching its conclusions from public consultations are factors which has driven the trust in the regulator also to an all-time low.
The current pathway of ignoring the rising emotions amongst the vocal minority of doctors, and assuming that the apparently silent majority of 390,000 professionals on the GMC UK register will be a problem that will peter away, is probably equally foolhardy. Doctors are resilient, fiercely autonomous, and highly motivated. Hence, the only counsel for the DoHS and GMC UK would be to listen and listen proactively to the rising concerns. The medical royal colleges need to take the lead and organisations such as BAPIO and its alliance members (who represent 41% of the medical workforce) need to be at the roundtable and seek workforce solutions. There have to be solutions that will make it safe for patients, efficient for the NHS workforce, economically viable, provide a clear role and scope for MAPs as dependent professional colleagues, and most importantly create a pipeline for employment and career progression for the thousands of international medical graduates that are willing to provide service to the people of the UK.
References
- Terminally Ill Adults (End of Life) Bill (https://bills.parliament.uk/bills/3774)
- The Anaesthesia Associates and Physician Associates Order 2024 (https://www.legislation.gov.uk/uksi/2024/374/contents/made)
- BAPIO MAP Report 2024 (https://sushrutajnl.net/index.php/sushruta/issue/view/28)