Are NHS physician associates solution or risk to patients?

Most people have never heard of them, but the role of physician associates is fast becoming one of the biggest controversies engulfing the NHS.

If the Government has its way, they will become an increasingly common part of the workforce, but whether that is a good or a bad thing is still up for debate. So will they bolster capacity, or put patients at risk?

What's happened?

Physician associates (PAs) are nothing new. They first originated in North America in the 1960s, and are also found in New Zealand, Australia and the Netherlands.

They have been working in the NHS since 2002, albeit in small numbers.

In essence, they are a form of allied healthcare professional. Often nurses or bioscience degree graduates, they undertake a two-year postgraduate medical course designed to enable them to carry out a range of roles including taking medical histories from patients, performing physical examinations, diagnosing illnesses, seeing patients with long-term chronic conditions, performing diagnostic and therapeutic procedures, analysing test results, and developing care management plans.

The idea is that they can work autonomously, but always subject to the supervision of a fully-qualified medic.

Across NHS England, as of June 2023, there were a total of 3,215 PAs employed in either hospitals or primary care settings such as GP surgeries – equivalent to roughly 1.8 for every 100 doctors. In Scotland, there are 143 compared to a total medical and dental workforce of over 15,000.

Read more:

• Inside the NHS | What’s really going on behind Scotland’s A&E statistics?
• Doctors want clarity on role of physician associates to avoid patient confusion
• ‘Blurring of roles’ between doctors and less qualified staff must end – BMA
• 'Serious concern' over failure to fill consultant vacancies in Highlands and islands

The governments at both Holyrood and Westminster have set their sights on expanding their numbers.

A letter, dated November 2 and distributed to key stakeholders by the Scottish Government’s Health Workforce Directorate, states that Health Secretary Michael Matheson is “supportive of a gradual increase” in PAs (as well as similar ‘anaesthetist associates').

This follows an evaluation commissioned by ministers in 2022 and conducted by NHS Education Scotland (NES). The letter stressed that the intention was “not to replace existing healthcare staff” but was “necessary if we are to deliver an NHS Scotland which is fit for the future and capable of meeting the demands it faces”.

The UK Government has already set its own target to increase PA numbers in NHS England to 10,000 by 2036/37.

There are 143 physician associates working in NHS Scotland but a gradual increase is expected (Image: Newsquest)

What’s the problem?

An inquest in July this year into the death of 30-year-old Emily Chesterton coincided with announcements that the PA workforce was to be expanded in England, leading to increased scrutiny about what that could mean for patients.

Ms Chesterton had been seen twice at a London GP surgery by the same PA who failed to diagnose a deep vein thrombosis and a blood clot on her lung, and did not seek advice from a doctor. The actress – who presented with calf pain, a swollen and hot leg, shortness of breath and increasing difficulty walking, and mistakenly believed she had seen a GP – died in October 2022. The coroner in her case ruled that she should have been “immediately” referred to A&E.

Misdiagnosis is obviously not unique for PAs, but the problem for critics is that – unlike doctors, nurses, and other healthcare professionals – PAs are unregulated.

The UK Government has pledged to rectify this by bringing PAs under the remit of the General Medical Council (GMC) by the end of 2024 “at the latest”. However, this in itself has sparked a backlash.

In a statement last week, Professor Phil Banfield, chair of the BMA, insisted that adding staff without degrees in medicine to the doctors’ regulator “brings into question the competence and qualification of the whole medical profession”.

Dr Iain Kennedy, his counterpart at BMA Scotland, warned in a blog on November 9 that the planned expansion of PAs “will be used to paper over the cracks of the frankly dire medical workforce planning that has left us in the doctor vacancies crisis”.

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At the last count, NHS Scotland was missing over 500 consultants alone, with hundreds more vacancies for GPs and non-consultant physicians.

Reports at the weekend revealed that PAs in Scotland have been implicated in serious adverse events and so-called "never events" (preventable incidents with the potential to cause serious harm or death) in two Scottish health board areas.

It is unfair to malign PAs as inherently less safe than doctors when their whole function is to support medics, not to replace them. Nonetheless, there is a danger that they could be seen as a cheaper, quicker way to 'process' more patients through the system. To be safe, any increase in PA numbers must be balanced out by enough doctors available and able to supervise them.