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.

Motion 108 ARM 2019

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

The role of the Physician Associate was created recently by the UK government as a potential solution to the workforce crisis created by the Modernising Medical Careers programme, which reduced the numbers of middle-grade doctors. University training programmes for PAs run across the UK, and they will soon join medical rotas in large numbers. We are told that in 10 years there will be 10,000 PAs working in the NHS. The role is ill-defined, but includes assessing patients, 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 only on highly qualified and experienced nurses. The Advanced Critical Care Practitioners are one such group. Some of these groups already have representation, many do not.

The Problem – We all need a union

It is important to separate the question of unionisation from your feelings about MAPs. It is no longer important whether you support or oppose PAs or MAPs as a concept. Individual interactions with PAs or other MAPs are irrelevant to the issue at hand. PAs exist.

They are workers. They are our colleagues. They are valued members of the Multi-Disciplinary Team. The concept of a PA comes from the USA, where it is a well-defined role separate to that of a doctor. In the UK, however, this is not the case – their roles often overlap with tasks traditionally performed by doctors. Their training, though shorter, is so similar that students share clinical skills sign-offs with medical students. NHS England has decided that their role is so similar to F1s that from August, PAs will be placed on some F1 tracks and rotas.

The current implementation of PAs by NHS managers and Universities has the potential for competition and conflict. We are already seeing concerns about training opportunities and worry about the poor differentiation of our roles by both professions. The position of the PA is also open to abuse. A person in a fluid role can be asked to take on more responsibility than they are trained or paid for. PAs have not yet been given prescribing rights or professional registration, yet they are asked to make management plans 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 the professions, but these problems were not created by PAs. These problems were created by the poor definition of their role and poor implementation – these are problems created by the government and managers and the fault lies with them. Without representation by a strong established union, PAs may find themselves mistreated and exploited to the detriment of themselves, doctors and patients.

The Royal College of Nursing (RCN) as a Model

Similar issues were raised by nurses when Healthcare Assistants, and more recently Nursing Associates, were introduced. The Royal College of Nursing, the trade union and professional association for nurses, decided that the smartest way to deal with these issues was not to argue worker vs worker, but to fight together as union vs government. The RCN recruited these new staff groups into their union and won proper definition of those new roles. This ensured that Nursing Associates could not be asked to take on responsibility that they weren’t trained for and protected the role of the Registered Nurse.

The RCN recruit and organise Nursing Associates and Healthcare Assistants without accepting that the roles are equivalent to that of a Registered Nurse. The RCN maintains its role as a trade union and as a professional association whilst accepting members that do not have professional registration.

We should look at the RCN as a model. They know that division causes weakness, and unity gives strength. This strength allowed them to protect all groups of nursing staff. Their common needs as a nursing family trumped their differing qualifications.

Conflict and Commonality – Why the BMA?

In the BMA, we have several existing Branches of Practice with frequently conflicting views. We represent GP Partners and GP Salaried Doctors; Students and Academics; Consultants and Juniors. PAs, like these groups, are in the medical family, just like Nursing Associates are in the nursing family. Royal Colleges have accepted this. The GMC and the government both agree. We have more in common than that which divides us. Where conflicts between Branches of Practice occur, the BMA has systems to resolve that. These could be extended to include our colleagues from other professions.

 We shouldn’t leave PAs and other MAPs to seek piecemeal representation by the general unions operating in the NHS. If there was an existing union with enough MAP members for them to be effectively represented as a group, we would be advocating they join it. MAPs are currently spread across several unions, but mostly go without.

We also shouldn’t wait for years for them to form their own union with a fraction of the strength we have now, after the damage has been done. Asking MAPs to create a new union is a near impossible task and would suck up all their work for the foreseeable future. By the time they were set up and had gained negotiating rights all the big debates would be over, to the detriment of staff and patients. Furthermore, in separate unions, there would be no effective way of managing any conflicting interests between us.

That conflict has the potential to include use of one professional group against the other during industrial disputes. As it stands, PAs are a risk to doctors’ terms and conditions and doctors are a risk to PAs’. Doctors’ pay and PAs’ ability to refuse out-of-hours work could come under attack from management making unfavourable comparisons. Working together, that risk could be eliminated.

Solution

We should seek national recruitment, organisation and bargaining for Physicians Associates and other MAPs through the BMA, so we can work together for agreed and common goals including:

  • High quality training;
  • Professional registration for all members of the clinical workforce;
  • Adequate role differentiation, so one cannot be asked to do the job of the other during rota shortages or union disputes.

For many in the medical profession, this tastes bad. It tastes like an acceptance of medical understaffing, of reduction in training standards. Some argue that unionising MAPs puts the definition of a doctor, or of the BMA, at risk. The BMA was set up to define and defend the role 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 the power of a strong well defined and well-funded union? Unionising is the right solution to the issues we face, and the only real solution right now.

The RCN has given us the model. We should be recruiting and unionising PAs. For similar reasons, we should recruit other MAPs, such as Surgical Care Practitioners or Anaesthetic Associates, that don’t have a trade union home. We cannot afford to let this snowball away.

BMA Ambassador Scheme

Emma Runswick

BMA ambassadors receive:
− £30 GiftPay vouchers for every new member
− 25% off your annual membership (if you recruit 6 new members)
− a new ambassador welcome pack
If you would like to become a BMA ambassador click below, send the email and we’ll do the rest.

BMA email 10th April

I’ve been a rep for 6 years and now sit on BMA Council, one of two medical student members. I have a trade union background before that, and have been busily recruiting and organising for the BMA since I joined medical school.

When I first heard about the ambassador scheme, I found it distasteful. I don’t require an incentive to recruit to our union. I have an ideological commitment to trade unionism – we have to fight together to win together. I encourage others to join because I think it is in their interest to do so. The scheme was set up by the commercially named Marketing Department 🤮 without consultation with representatives.

However, there are positives to the ambassador scheme. I joined because it gave me easy access to all the materials like leaflets, pens and the BMA tablecloth that I had previously been unable to get access to. I had been nicking these from the BMA staff at some events, but always rapidly ran out.

It also gave us a bigger say in what went ON the leaflets – we got the marketing team to come to Medical Students’ Committee as part of the ‘membership challenge’ 🤢 and we made changes – to promote the work of the union for both individual members who need help and members as a collective.

I used the Amazon voucher they gave me (it used to be amazon, no longer because of tax dodging and bad employment practices) to buy my BMA medical school branch a tripod and other equipment for recording and webcasting our events.

I use the ambassador scheme enough that they know I am recruiting, but I don’t use the ‘official link’ that gives me a voucher unless we know collectively what we are going to spend it on. I may use it again for leafleting for medical students about the new junior doctor contract, as at the moment it’s unclear what funding there will be for specifically penultimate and final years who have a vote.

I have encouraged other medical student representatives to join the scheme for these reasons, and most of Medical Students’ Committee are on the scheme. I hope that in time, the ambassador scheme will die out and become a basic and essential part of the rep’s role.

Ideally, there would be an easier way for medical student reps and activists to get access to materials, and I think it’s likely that my use of the scheme is the exception rather than the rule, but I reckon I’ve recruited ~60 members alone, and many more at designated events, where BMA send staff to support recruitment. I have gained £0 financially.

Organising 101: Recruitment

This is based on the training Emma Runswick delivered for BMA Medical Student Representatives. It has some use for all of us, but the chosen examples may not fit your environment.

_______________________________________________________________

My name is Emma and I’m a Trade Union Activist. As elected representatives, you are too.

Our job is to build the strength of the union, so we can achieve more for our members. As students, we also have another job – to prepare our members for the challenges of work, and encourage them to stand up for themselves and become representatives as doctors.

We get our power from numbers, from the density of our membership. Like herd immunity, we are all better protected the more of us that are members. A representative of 98% of a medical school’s students has more clout than a representative of 65% of students. We also draw strength from the activity and engagement of our members. Where members tell reps about problems, and are prepared to act together to solve them, we have levers available that don’t exist with a passive membership. When there is competition for representative roles, reps have to show they are effective and accountable. So when we think about organising, what we aim for is full union membership, with significant activism and engagement of the ‘lay’ (not rep) members.

To achieve that, we have to stop thinking about recruitment and retention as something done by adverts and freebies. Recruitment is not a one-step job, nor one conversation. A rep may have to have several conversations over months to recruit somebody. More conversations would be required to recruit a member into activity. Other conversations are required to retain members when things inevitably go wrong, or when members have joined for free in freshers’ week and have no idea what the union does. Organising is an ongoing and constant process, which we all have to engage in all the time.

To assist you, it may be useful to develop a script. Mine goes something like:

*Pick something relevant to them – for pre-clinical students, a good example is UKMLA; for clinical students, travel bursaries, UK Foundation Programme Office, disability adjustment in exams; for junior doctors, contracts and training; etc.

Recruitment is not just a job for freshers’ week and inductions, though you should go to these. Like recruits like – you will recruit members far better and far more usefully than most BMA staff, because you know what it is like and what they need. Recruitment is also for teaching, grand rounds, medical formals, lunchtime, coffee breaks, and general conversations. Ask final year students if they have their contract or rota, if they have checked it using the BMA tools, if they are a BMA member. Ask your colleagues what they think of UKMLA, how much travel has cost them this block, whatever. Slip it into conversation. TELL PEOPLE YOU ARE THE BMA REP. Wear your lanyard and badges.

Organising is essential if we want our union to be strong. We can all play a part in that.

You can get materials for recruitment – leaflets, free stuff – from https://www.bma.org.uk/about-us/how-we-work/local-representation/local-negotiating-committees/promotional-materials

You can also access rewards for recruitment by joining the Ambassador Scheme: https://www.bma.org.uk/membership/bma-ambassadors

Those wanting to be active can have a look at this https://www.bma.org.uk/about-us/get-involved/represent-and-volunteer

 

Addendum Issues:

Junior Doctors’ Contract: sympathise! They are right, we didn’t do as well as we would have wanted in that dispute. However, we took an organisation that hadn’t struck in 40 years on strike, and we won significant concessions. If you compare the initial contract ‘offer’ to the one imposed, you can see how effective striking and negotiating was. We weren’t prepared for an industrial dispute that big, and if we want to do better, we have to be more organised, and we have to be stronger. We need you to be a member, and then people like us can change the union so we never give up a mandate like that again.

Chris Day/whistle-blowing: nobody really knows what happened there, even Council members like those on the Broad Left. However, everybody now agrees that we do have whistleblowing protection if needed from detriment by our training provider. Now, we need to be acting to make sure nobody has to whistle-blow. We work in understaffed and unsafe environments, and if we want to improve those, we have to break the locum cap, campaign for visa restrictions to be removed, win better policies for cover and training, fight for better pay, and ensure better workforce planning. Those are all things your union does with and for you, and we are stronger if we have more members. On Chris Day specifically, hopefully there will be a frank conversation when his personal Employment Tribunal case is concluded about what happened and the role of the BMA.

Medical Student Rep Training

This year, the BMA Medical Students’ Committee got a new style of training for the first time. Replacing the long lectures about the internal organisation of the BMA and the library were two sections devoted to trade union work.

First, we enabled new representatives to plan a little of their year: thinking about working as a team with their rep colleagues nationally and locally; planning events; meeting the staff who support them. Beth McMahon, Keele representative, talked about how to build a community and share information with your members and with the committee. MSC reps are representing and accountable to the members who elected them. Emma Runswick, BMA Council member, gave some training on recruitment, emphasising that high membership and density was the source of our trade union power, and that recruitment is not a one-step process, nor an advertising conversation.

We then ran a session called ‘problem solving’, a member casework task based on the representation experiences of Emma Runswick whilst a BMA activist. We covered exam failure, welfare and professionalism issues, and group campaigning.

Both sessions were well received and mark a significant departure from the service provision model of representation the BMA is committed to elsewhere in the organisation.

The changes were the result of heavy pushing from the student left working with BMA staff, and the contributions of many reps to the training day working group. We hope the changes will continue and spread into other branches of practice.