The growth of associate roles within the NHS in a move to remedy the acute medical staffing crisis is raising valid concerns within the medical profession. The relentless expansion of ‘physician associates’ and ‘anaesthesia associates’ has been slipped in largely unnoticed by patients.
The role of the medical associate professions (MAPs)
MAPs in the UK consist of several groups of practitioners who are not qualified in medicine but are allowed to undertake some aspects of healthcare previously done by doctors. Their introduction is part of government’s plans to grow the multidisciplinary NHS workforce, as set out in the NHS Long Term Workforce Plan. I will be discussing two of these groups in particular.
Physician associates (PAs) work alongside doctors, providing medical care as an integral part of a multi-disciplinary team. PAs were originally introduced in 2002, and now there are about 4,000 working in GP practices and primary care networks. But the plan envisages having 10,000 PAs in place by 2036/7. Their role and responsibilities are laid out in information from the DHSC. They are allowed a degree of autonomy but are supervised by a medically trained and experienced doctor.
Similarly, anaesthesia associates (AAs) work within the anaesthetic team under the supervision of a consultant anaesthetist, with responsibilities such as reviewing patients before surgery, initiating and managing medications, administering anaesthetics, giving fluid, and blood transfusions, during surgery and post-surgery care.
Physician associates: training and pay
There is a stark difference between the education and training of doctors and associates in terms of rigour, knowledge, experience and the length of training. To take the example of GPs, doctors must study for four to six years to achieve a medical degree. Then they take part in the two-year-long UK foundation training programme, followed by the GP specialty training programme by open competition of at least three years including 18 months in approved hospital posts, and 18 months in an approved GP practice. By contrast, training to be a physician associate is a two year postgraduate course, following a first degree in in a health, biomedical science or life-sciences subject. Alternatively, experienced allied health professionals may be considered for training. So from the government’s perspective training costs are low and the timescale is short.
Typically, salaries for a newly qualified physician associate start at around £32,306, rising in the 2nd year to £40,057 and eventually to between £47,126 and £53,219 with experience. So a newly qualified PA may be only five years post A levels, and will be earning significantly more than a new medic. An F1 (first year) doctor is currently on £29,384 and a year later this has risen to £34,012 while working longer hours. And bear in mind that most doctors on qualifying are carrying £50-100,000 debt from their studies. Is it surprising that morale among young doctors is so low?
There is government reimbursement to GP practices for employing PAs (The ARRS scheme) but not for doctors and nurses, so PAs are being employed preferentially – to a degree that in some areas young doctors for the first time are struggling to find work as GPs.
Legitimate concerns: no more Emilys
Senior doctors have challenged the growing use of associates. The British Medical Association recently called for a moratorium on the recruitment of MAPs, including physician associates and anaesthesia associates, on the grounds of patient safety. Professor Phil Banfield, BMA chair of council, argues that the expansion of MAPs has seen “terrible cases of patients suffering serious harm after getting the wrong care from MAPs.”
Just one example: a year ago Emily Chesterton, a 30 year old woman, died following misdiagnosis after seeing a physician associate twice with calf pain. She was told that she had a sprained ankle and when presenting a second time with symptoms such as shortness of breath and a hot and painful leg, she was sent away with a prescription for anti-anxiety medication. She died three weeks after seeking advice. Worryingly, a case review found that Emily was never told that she was not seeing a GP. At her inquest, the coroner said that had she been referred to hospital, “the likelihood is she would have been treated for pulmonary embolism and would have survived”. The practice terminated the PA’s contract and has stopped employing PAs.
The latest development is a worrying report in the Telegraph:
” … doctors at 24 trusts in England claim to have witnessed PAs prescribing drugs and requesting ionising radiation – both would be illegal. At a third of trusts, they report seeing PAs introduce themselves as ‘doctor’ or not correct those who wrongly identify them.”
The BMA is calling for stricter regulation and says there is confusion among patients who may not realise that they are not actually seeing a doctor. This blurring of roles erodes confidence that patients are being treated by a highly qualified medical doctor. In fact, a survey of doctors sponsored by the BMA found that 86% reported that they felt patients were not aware of the difference between these roles, creating scope for patient confusion about the level of care they are receiving. In a separate survey of the public, 29% of patients said they did not know whether or not they had been seen by a PA. Some patients even believed that the term ‘associate’ indicated a higher level of expertise than that of a trained doctor.
Regulation
The government has moved to quell criticism by introducing legislation by statutory instrument on regulation by the General Medical Council. This, it claims, will improve patient safety and pave the way for the expansion of MAP roles. Many doctors are challenging this development as Dr Rachel Clarke noted on X:
“The government doesn’t want you to know it, but it is currently conducting a massive, under evidenced, cost-cutting experiment in the NHS.”
Similarly, experienced anaesthetists are attempting to halt the roll out of anaesthesia associates. They emphasise the risk to patient safety and allege that associates are not sufficiently supervised in short-staffed hospitals. Imagine a situation where AAs are giving anaesthesia to patients, in separate operating theatres, being supervised by one consultant.
Is this change to patient care justified?
No one doubts the important role that multidisciplinary teams play in modern medicine. Doctors welcome support from assistants in undertaking certain tasks and admin. However, the plan to introduce many more MAPs is fraught with danger. A two-year postgraduate course does not a doctor make. Most patients have no idea that the professional caring for them, whether in general practice, or anaesthetising them, is a proper doctor.
GPs are saying that the use of PAs changes the ethos of general practice. While a doctor practises whole person medicine, PAs are trained to deal with one problem at a time. Supervision is time consuming, taking away time from seeing their patients and consequently there are fewer GP appointments available. Anecdotally, close supervision and limitation to a narrow scope of practice are waived in the real world.
What about patients? Do we have the right to expect to see our GP with whom we may have a longstanding relationship? Will we even be informed of the status of the person we see?
The decision to have PAs and AAs regulated by the GMC – until now the body reserved for the regulation of doctors – blurs the lines between the two. These changes are happening at a time when the number of training places in medicine is failing to meet demand. It is difficult to see the roll-out of PAs as more than a way to save money while undermining the highly skilled and valued doctors we need, and indeed the NHS itself.
Editor’s note: It is the intention of this article reflect on government policy rather than to cause offence to physician associates as individuals or as a profession.
(Article updated in light of Telegraph article, 28 January 2024)
Please see also letter in response to this article.
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