John Puntis, Co Chair Keep Our NHS Public takes an indepth look at the issues surrounding Medical Associate Professionals.
Physician Associates (PAs) have been much discussed of late for reasons that include a plan for a huge increase in numbers, public confusion about their professional status and competencies, questions about professional regulation, and a push back by doctors against their Royal Colleges, specialty organisations and employers for not reacting to concerns over both patient safety and effects on doctor training. Campaigners’ main worry is that PAs are simply ‘doctors on the cheap’ and present significant risks to patients while undermining commitments to increase numbers of medical staff. A report by the KONP General Practice Working Group highlights some of these issues.
What are Medical Associate Professionals?
PAs are the main group within the category of ‘Medical Associate Professionals’ (MAPs). This also includes Anaesthesia Associates (AAs) and Surgical Care Practitioners (SCPs). All are currently working in the NHS in a variety of roles across primary and secondary care.
By 2036/37 the government in England plans to increase the number of PAs from approximately 3,250 to 10,000 (an increase of over 200%), and AAs from approximately 180 to 2,000 as part of its NHS Long Term Workforce Plan. MAPs complete only a two-year postgraduate course (1,600 hours of clinical experience and teaching) but are being employed in the NHS in roles previously reserved for doctors, taking on increasingly complex tasks including the assessment and management of patients presenting with new and undiagnosed problems (‘undifferentiated patients’). In a recent survey by the British Medical Association (BMA), a large majority of doctors expressed concerns that PAs and AAs used in this way were ‘sometimes’ or ‘always’ a risk to patient safety. The BMA has called for a halt in recruitment to these roles while their regulation and scope of practice are reconsidered.
What are PAs, and what are they taught during their two-year course?
PAs were first introduced to the NHS in 2003. The Faculty of Physician Associates (FPA – hosted by the Royal College of Physicians) states that:
‘PAs are healthcare professionals with a generalist medical education, who work alongside doctors as an integral part of the multidisciplinary team. PAs work under the supervision of a fully trained and experienced doctor….They are complementary to GPs rather than a substitute…..and in no way a replacement for any other member of the general practice team…By employing a PA, it does not mitigate the need to address the shortage of GPs or reduce the need for other practice staff’.
The FPA states that physician associates work within a defined scope of practice and limits of competence, and:
- take medical histories from patients
- carry out physical examinations
- see patients with undifferentiated diagnoses
- see patients with long-term chronic conditions
- formulate differential diagnoses and management plans
- perform diagnostic and therapeutic procedures
- develop and deliver appropriate treatment and management plans
- request and interpret diagnostic studies
- provide health promotion and disease prevention advice for patients.
Currently, physician associates are not able to:
- prescribe
- request ionising radiation (e.g. x-ray or CT scans)
This reflects the description by universities of their postgraduate degree courses (see for example Leeds University website). These are managed in accordance with the Competence and Curriculum Framework developed by the Department of Health and Social Care (DHSC), the Royal College of Physicians (RCP) and the Royal College of General Practitioners. Once they have completed a PA degree programme, all candidates must pass the PA National Examination, which is delivered by the RCP Assessment Unit.
Is training adequate in preparing for these roles?
Seeing undifferentiated patients is among a number of roles seen as controversial. In 2020, the NHSE contract specification for GP Primary Care Network, paragraph B6.2, made it clear that a PA must be given responsibility for providing first point of contact care for patients presenting with undifferentiated problems ‘by utilising history-taking, physical examinations and clinical decision-making skills to establish a working diagnosis and management plan in partnership with the patient’. However, in the amended GP contract for 2024/5 it states: ‘17. Supporting guidance will also be issued to clarify that non-GP doctors (sic) should not see undifferentiated patients, and that they continue to be required to operate within their sphere of competence’. ‘Non-GP doctors’ might possibly be a reference to SAS doctors, who are in fact qualified doctors (who the RCGP is also keen not to be seen as a substitute for GPs). But if this is the case, does it in fact also apply to the lesser trained PAs who are not doctors?
Seeing ‘undifferentiated patients’ is not mentioned in the Competence and Curriculum Framework, which does say, however:
‘It is expected that over time the supervisory relationship will mature and whilst the doctor will remain in overall control of the clinical management of patients, the need for directive supervision of the Physician Assistant will diminish’.
The BMA has recommended that, as well as not seeing undifferentiated patients, PAs should not be receiving any specialty referrals or be in roles requiring them to give specialty advice. They should not make unsupervised treatment decisions or management plans. Some GPs have questioned the usefulness of PAs in general practice altogether, given the level of supervision required, and have highlighted patient safety concerns. The National Institute for Health and Care Excellence (NICE) says that the clinical and cost-effectiveness of providing PAs is unknown and therefore requires research.
In a letter from NHS England (NHSE) to the RCP in February, National Medical Director Sir Steve Powis clarified its position:
‘PAs are trained to examine, diagnose and treat patients under the supervision of doctors…PAs are not doctors, and cannot and must not replace doctors…they are trained to work collaboratively with other health professionals as supplementary members of a multidisciplinary team. Pas must always work within a defined scope of competence; they are not independent medical practitioners and must be supervised appropriately by doctors.’
NHSE also emphasises that patients must always be told they are seeing a PA and not a doctor.
Representing all the colleges, the Academy of Medical Royal Colleges (AOMRC) produced a consensus statement on PAs, also stating that: ‘The Academy is clear that PAs are not doctors and cannot and should not be used as a substitute for doctors’ and that PAs should be deployed only where there is a defined role and workforce need for them within a wider team. In addition, training opportunities for junior doctors need to be prioritised over those of PAs and protected.
The AOMRC also emphasised the importance of supervision and suggested that each specialty should develop its own framework for what PAs could do.
The issue of professional regulation
The FPA was established by the RCP in 2015 to give PAs a professional home, set standards and oversee the PA managed voluntary register, while lobbying government over introducing statutory regulation for PA. One of the reasons given for establishing the FPA (and an ambition that would appear as yet unfulfilled) was ‘to provide clarity to the public on the different scope of practice of a doctor and a PA’. Until 2013 PAs were known as Physician ‘Assistants’ but government supported the change to ‘Associate’ as the DHSC felt the term ‘Assistant’ would reinforce an impression that lowly assistants (not doing complex work?), would not need to be regulated and this would thereby hold the profession back.
MAPs currently only have access to voluntary professional registration. Using secondary legislation, the Government pushed for the General Medical Council (GMC) to become the regulatory body for MAPs. The GMC is the independent regulator of doctors in the UK, formed in 1858 with a focus on supporting good and safe patient care. The BMA argued that the GMC taking on MAPs would unhelpfully blur the distinction between doctors and non-medically qualified professionals, and set out three demands:
- PAs and AAs should not be regulated under the GMC, but by the Health and Care Professions Council (HCPC)
- ‘Physician Associates/Anaesthesia Associates’ should be known as ‘Physician Assistants/Anaesthesia Assistants’ to provide clarity for patients
- there should be a moratorium on employment of PAs/AAs until there is clarity and material assurances about their role and scope of practice
The HCPC currently regulates fifteen different groups including paramedics and operating department practitioners and physiotherapists. This, rather than the GMC, would appear to be the appropriate regulatory body for MAPs. The debate on regulation (Draft Anaesthesia Associates and Physician Associates Order – AAPAO) took place in a parliamentary committee session that lacked depth for such an important issue. For example, former Health Secretary Thérèse Coffey remarked that after she had waited nine hours in one hospital, she went to a different hospital the next day and was seen more quickly. She attributed this to the hospital having a PA. On this basis, she argued that employing PAs was the best way to ensure patient care and safety.
In a radio interview on PAs before the parliamentary committee sat, Conservative peer Lord Bethell showed his woeful depth of understanding of the issues while failing to endear himself to GPs by stating that: ‘GPs don’t face huge amounts of complexity. Most interactions are incredibly straightforward. Certainly, my own experience over the last 20 years of going to my GP, it really hasn’t required 10 years of training to deal with my small problems’. Clearly an implication that, in Lord Bethell’s opinion at least, PAs could easily take on work currently being performed by GPs in assessing patients presenting with new problems.
In fact, as KONP has pointed out, people often consult with very complex stories, and their symptoms have a wide number of possible causes – some serious, some not. It takes ten years to train a GP, and then learning continues throughout working life. GPs are expert medical generalists who can diagnose, treat, prioritise and manage multiple and complicated conditions. Their particular strength is using their communication skills and clinical knowledge to make sense of presentations which do not fall into any algorithm. This last point is pertinent not least because some have suggested that PAs are part of the drive towards ‘algorithmic medicine’ when the patient journey becomes automated.
A Conservative MP and doctor, Dan Poulter, gave a more sensible perspective to Parliament:
‘When the physician associate role was introduced, it was clearly seen as part of the solution to a shortage of doctors…. By freeing up doctors from administrative tasks and minor clinical roles, it allowed them to see more complex patients…. Unfortunately, physician associates and anaesthesia assistants have been employed in the NHS in roles that stretch far beyond that original remit, and… they appear to be working well beyond their competence. That has raised serious patient safety concerns.’
However, the AAPAO was approved by the House of Lords, meaning that in one year from now, the GMC will become the regulatory body for MAPs.
Push back against expansion of MAPs by rank-and-file doctors
As shown in the BMA survey, many doctors are concerned that PAs represent a threat to patient safety. A reflection of this concern has been that members of both the Royal College of Anaesthetists and of the RCP have forced their college executives to call an extraordinary general meeting (EGM) in order to explore the issues. At the meeting of Anaesthetists, 89% of college members voted in favour of a pause in the recruitment of anaesthesia associates until a survey of members and a consultation have been completed and the impact on doctors in training had been assessed and reviewed.
Five motions were put to the EGM of the RCP including a reiteration that PAs are not doctors; a reminder that only doctors were able to authorise prescriptions and some types of investigations; a call for evidence around safety, effectiveness, costs and clinical outcomes for PAs; the need for more information regarding the impact of PAs on doctor training; a call that the pace and scale of the roll-out of PAs should be limited until the medicolegal issues of regulation, standards and scope of practice were addressed. This final motion was not endorsed pre-vote by the leadership on the grounds that it was not within the power of the RCP to deliver, yet together with the other motions it was still passed by a large majority, highlighting the split between leaders and grass roots. The meeting was followed by huge recriminations after it became clear that data from a college survey had been misrepresented to suggest more support for PAs than was actually the case. This resulted in much negative publicity and a spate of resignations from various college posts together with accusations that the leadership was ‘in bed with the government’.
Are doctors right to worry they are being replaced by MAPs?
The GMC has asked NHS England (NHSE) to address the perception that there is a plan to replace doctors with PAs, stating that: ‘We believe governments should also consider what they can say about future training numbers to make it clear that their workforce plans envisage significant growth in doctor numbers, as well as amongst PAs and AAs’.
In December 2023, there were 8,758 medical vacancies in NHS hospitals and add to that 4200 GP fulltime vacancies. England would need an additional 50,000 doctors to bring it into line with similar European countries. NHS England points to its commitment in the workforce plan to double the number of medical school places over the next decade, saying this will ensure an extra 60,000-74,000 doctors in addition to a total of 10,000 PAs in the NHS by 2036/37. The AOMRC repeats this reassurance, implying that with rising demand there is more than enough work to be done by both doctors and PAs.
But just how reassured should doctors be? There has already been back pedalling on the increase in numbers of new medical student places (just 350 for 2025/6) and no new capital funding for medical schools that want to take on more students. In addition, junior doctors already see bottlenecks in training. For example, in 2021, 700 anaesthetic trainees were unable to continue their progress despite 680 unfilled anaesthetic consultant posts.
The Government has done little to improve retention of doctors, with many threatening to leave the NHS because of poor pay and working conditions, and only 56% of those entering core training remaining at work in the NHS eight years later. The Panorama programme on Operose (Centene’s UK operative) showed in one London general practice that PAs were effectively working as GPs and without supervision. Perceived lack of supervision was also flagged up among major concerns identified in the BMA membership survey. A general practice in Surrey has recently made three of its GPs redundant claiming ‘new ways of working’ including the use of non-medical staff, while other qualified GPs report difficulty finding a job. Richard Meddings, chair of NHSE but a banker by trade, argues that the medical staffing crisis could be solved not by improving retention and training more staff but by slashing the time it takes to train a doctor, implying (like Bethell) that doctors are currently overtrained.
The National Audit Office has recently examined the modelling used by NHSE in its long-term workforce planning assumptions. There is a gap between estimated demand for GPs and number of GPs coming through. NHSE unacceptably anticipates that this gap will be filled by moving work from GPs who are fully qualified to those in training (!), and to specialist and associate specialists (SAS) doctors in primary care. This seems a plan unlikely to bear fruit, and given the increasing numbers of PAs who, unlike doctors, can be employed through the Additional Roles Reimbursement Scheme, it would appear more plausible that PAs will be called upon to close this gap.
How to ensure that MAPs do not replace doctors
The BMA agrees that MAPs can play an important part in NHS teams, and that doctors will continue to value, respect and support the staff they work with. Because of concerns that, post-regulation, the GMC plans to leave it to employers and the Royal Colleges to set safe parameters on scope of practice for MAPs, the BMA has produced guidance with the aim of protecting patients and safeguarding medical training for the doctors of the future.
Key concepts that are tabled by the BMA include:
- MAPs follow, and do not give, medical directives; they act upon the medical decisions of a doctor and do not make independent treatment decisions
- MAPs must not see undifferentiated patients (i.e. patients presenting to a GP or hospital with a new problem)
- national standards for supervision of MAPs must be set and adhered to, including that supervision is voluntary and must be consented to by consultants and GPs
Included in the document are tables using a traffic light system outlining work that MAPs are expected to do, what they may do under the direct supervision of a doctor, and what they must not do.
We should spare more than a thought for the 3,250 MAPs currently working in the NHS as valued team members, and through no fault of their own, caught in the middle of arguments about their future. MAPs currently in post should be supported, supervised and not forced to work outside their competence. A worried representative body for PAs (United Medical Associate Professionals – UMAP) has warned GP practices implementing the BMA’s scope of practice of potential legal consequences arguing that it is ‘inappropriate’ for the doctors’ union to ‘unilaterally redefine and attempt to impose a scope of practice on another profession’, and they highlighted a lack of ‘stakeholder engagement or peer review’. In response, the BMA pointed out its scope of practice document was ‘designed to assist the doctors whose job it is to supervise these roles’ and was written by doctors ‘in the absence of such a guide on a national scale’.
Conclusions
After the RCP EGM debacle some commentators have raised fundamental questions about PAs they say require answers. What special skills is it that PAs bring to the multi- disciplinary team (this is very clear for a dietician for example) and what is their scope of practice to be? If they are ‘medical skills’ as such, what then is unique about the profession of medicine and what has been excluded from a five-year course in reducing it to a two year one for MAPs?
Given common agreement across royal colleges, the DHSC, NHSE and the BMA that MAPs are not substitutes for doctors, must work within a defined scope of competence and under doctors’ supervision, the BMA framework should be welcomed by all of the above, with its aim of making sure this distinction works in practice and in the interests of everyone – patients, MAPs and doctors. However, the change of name from ‘assistant’ to ‘associate’, and the insistence that regulation should be by the GMC and not the more obvious HCPC, suggest that the Government wishes to see a blurring of boundaries between MAPs and doctors as a strategy for substituting a cheaper alternative for the latter. The long-term workforce plan looks unlikely to deliver the numbers of doctors we need and the failure to address doctor retention through improved pay and work conditions also suggests that the reassurances from NHSE and the AOMRC must be taken with a large pinch of salt.
It is instructive to look at what has happened in the United States where PAs (called Physician Assistants) are permitted to work without medical supervision and are now growing in number at a much faster rate than doctors. This has been driven by an increase in demand for health care and the push by for profit providers to reduce labour costs. The cost savings of increasing Physician Assistants relative to physicians is substantial, however, evidence indicates that Physician Assistants both over investigate and over treat patients compared with physicians – in other words, quality of care deteriorates.
As the editor of Pulse magazine has pointed out with respect to PAs in England:
‘It boils down to one thing: they are being used because they are cheaper than trained doctors. This replacement of doctors with PAs is a scandal. Not because we are seeing a spike in avoidable deaths or the like (yet). It is a scandal because it is an acknowledgement that lower standards of care are a literal price worth paying for a cheaper service.’
Campaigners should put it to NHS employers that for the sake of patients (and indeed of MAPs), the BMA scope of practice must be adopted and implemented.
John Puntis, Co-chair Keep Our NHS Public
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