A number of doctors have spoken to the ECHO as the row over physician associate roles in the NHS intensifies
If you were to ask a cross section of people working in the National Health Service about their biggest concerns right now, the list would undoubtedly be a lengthy one. Relentless pressure, staffing issues, low pay and the prospect of another gruelling winter would all be in the mix. But there would likely be another issue at the top of many medic’s lists of concerns – physician associates.
There is growing concern about the roles of physician associates within the health service. You may have heard of them but you also may not have. This is potentially a big part of the issue.
The NHS first began using physician associates (PAs) more than twenty years ago. Anaesthesia associates (AAs) were introduced shortly afterwards. The idea is that these staff members work alongside doctors to support them in hospitals and GP surgeries. They are trained to take medical histories, carry out physical examinations and to develop and deliver treatment and management plans.
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Physician associates train for just two years before being deployed into the health service, whereas doctors train for between four and six years. The Department of Health states that while PAs can work autonomously, they must always be under the supervision of a fully trained and experienced doctor. PAs cannot prescribe medication but they can diagnose.
At present there are around 4,000 PAs working in the health service, but there are plans to increase that number to 10,000 in the coming years as part of an NHS workforce plan. For many doctors and others working in the NHS, there are increasing concerns about the direction of travel when it comes to these positions and how these roles are being used at present. Both the Royal College of GPs and the British Medical Association (BMA), have called for a halt of the recruitment of physician associates while rising concerns are addressed around safety and clarity of roles.
The ECHO has spoken to a number of medics working within the NHS in Merseyside who have expressed their serious concerns about how physician associates are being used, pointing to individual experiences to highlight what they say are serious dangers. The staff members we spoke to asked to remain anonymous for fear of reprisals.
“Patients don’t understand the role or aren’t told about the role,” explained a surgeon based in Merseyside. “If I ask my family members, they have no clue what a PA or an AA is but they’re working in most departments now. Even when meeting patients, a small ID badge isn’t always clear who the patient is seeing. They will often say, “I’ve already seen the doctor,” when they’ve seen the PA.”
This experience appears to marry up with research compiled by the BMA, who found that 86% of doctors believe the public doesn’t understand the difference between PAs and doctors. The same survey found that 87% of doctors believe PAs can be a risk to patient safety.
The doctors we spoke to would certainly agree with both points. One doctor, based in a Merseyside hospital’s Accident and Emergency department, said: “What people need to know is the huge reliance on PAs in A&E. There is a huge amount of them in A&E, I’m pretty sure they outnumber the doctors on some shifts.
“PAs are not supposed to work when there is not a consultant there and there is not a consultant at my hospital at night. So the doctors are completely burnt out from being relied on for night shifts. There are PAs working at my hospital who are not being supervised properly. It is completely irresponsible.”
Several doctors said that PAs are actually creating more work for them, rather than lessening their load. One said: “As a registrar, I am expected to supervise PAs but I find them very nerve-wracking to work with. I can’t rely on their examinations or differential diagnosis as doctors that don’t double check PA work have been reprimanded as negligent. I would rather just see the patient myself.”
There have been a number of high profile cases that have brought the issue of PAs into the national spotlight. 30-year-old Emily Chesterton died in November 2022 after suffering a pulmonary embolism. Having visited her local GP practice in London, she was twice misdiagnosed by a physician associate, who failed to realise the severity of her condition. Ms Chesterton’s parents believe she would still be alive if she had seen a GP and are backing the BMA’s calls for limits on the role of PAs in the NHS.
Headlines were also recently created here in Merseyside concerning the region’s much-loved children’s hospital Alder Hey. The Liverpool hospital has admitted that it stopped using a PA within its children’s safeguarding team after concerns were raised by the police and Crown Prosecution Service about the reliability of evidence from someone in that role in court cases. Alder Hey previously confirmed that one physician associate jointly undertook child sexual abuse medicals with a forensic medical examiner between May 2019 and October 2023.
For working doctors in Merseyside, the problems with PAs focus on safety, transparency and fairness. One surgeon said: “A doctor working in surgery or medicine might train for around 5 years or so. A GP will train for at least 5 years on top of 5 years med school. However a PA will immediately start work in a department and depending on where they are start being given unregulated roles.”
“If PAs need 2 years and then can work as a GP, what is the point of the 5 years of training, on calls and nights that a GP trainee undergoes?”
Another doctor at a Merseyside hospital said: “PAs have not lessened the burden on me, they have increased it. I have constantly found myself having to do my job and theirs and answering lots of questions. I don’t think people are aware of what is going on. It feels like they have skim-read some bits of medicine and are now doing the job of a doctor.
“Patients 100% deserve to know the difference and they don’t. If your job title is vague then are they really consenting to that treatment. You have elderly patients who hear the word physician and think its something very different. I think people are being misled.”
That same doctor said that on her ward two doctors left and one physician associate was then hired, with the doctors never replaced. She added: “Even if a PA is 90% as good as a doctor, do you want to be that 10% who doesn’t get the right level of care? I would be terrified to be cared for at my hospital right now.”
It is important to say that there are of course two sides to this story and there are those that believe that physician associates are both vital cogs in the NHS machine and are also under attack from others. Writing in The Guardian earlier this year, Formby doctor Shaun Meehan hit out at “bullying and frankly disgusting attacks on trained health professionals who are working under intolerable pressure to keep our patients safe.” He added: “I have worked with all types of NHS staff, and PAs deserve their status as health professionals delivering excellent care under supervision, as do nurse practitioners and others.”
A woman with experience working in the health and care sector, who asked not to be named, added: “No PA is out to be devious and do harm and what this whole story is missing is the good and caring people in these roles who are doing amazing jobs, with the trust and supervision of their clinical leaders. They are being scapegoated by medical professions who are worried about their jobs and rather than target leadership across NHS, Royal Colleges etc they are attacking individuals and this is doing real harm.”
So where do things currently stand in this growing debate? The Academy of Medical Royal Colleges – which brings together leading doctors and surgeons – has now called for an independent review of PAs and AAs in England. In a letter to Health Secretary Wes Streeting and NHS boss Amanda Pritchard, the academy said there has been an “increasingly acrimonious and destructive debate about their expansion” of the use of PAs in the NHS.
Academy chair Dr Jeanette Dickson said: “We want an independent, evidence-based, rapid review to help us make a decision about how best to delineate their roles and where they might best fit into the system.” NHS England said it is considering the request.
Responding to the concerns raised by doctors for this article, a Department of Health and Social Care spokesperson told the ECHO: “Physician associates have played an important role in the NHS for over two decades, but we are clear they should be supporting, not replacing, doctors and should receive the appropriate level of supervision by healthcare organisations. The NHS has issued clear guidance on the deployment of PAs in the NHS and we expect trusts to follow this.”
Dr Rob Barnett, North West Regional Council chair of the British Medical Association, said: “The BMA has been absolutely clear that when physician associates are employed in general practice and hospitals, they should work to a well-defined and limited scope of practice. They do not have the level of training or expertise a doctor has.
“Patients in Liverpool and across the North West value the close relationships they’ve built with their GPs over the years and deserve to know that the standards of care they expect are upheld.
“Earlier this year, we set out what PAs should and should not do – in the first such scope of practice, so that patient safety is maintained. The document offers a range of guidance including ensuring proper in-person supervision by qualified doctors and clearly defining the scope of responsibilities for Medical Associate Professionals.”
