Given both an international crisis in health care staffing and a drive ro reduce costs, highly skilled workerws are being replaced by those with fewer skills and less training. How does this play out? In the UK, Physician Associates (PAs) are now widely discussed. Largely because of plans to increase their numbers, public confusion about what they are and how safe they are, doctors’ complaints against professional bodies (Royal Colleges). The worry is that PAs are simply ‘doctors on the cheap’ and pose significant risks to patients while undermining planned increases in medical staff. We highlight some of these issues.
What are Medical Associate Professionals (MAPs)?
Since 2003, PAs are one of several MAPs, who currently work in the NHS in a avariety of roles. 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 300%), and MAPs from approximately 180 to 2,000 NHS Long Term Workforce Plan. MAPs complete only a two-year postgraduate course (1,600 hours of clinical experience and teaching) but the NHS deploys them instead of doctors. That includes care of patients 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 risked patient safety. The BMA has called for a halt in recruitment until their role is reconsidered.
What are PAs qualified to do?
The Royal College of Physicians (of the Royal College of Physicians) states that: ‘PAs are healthcare professionals with a generalist medical education, who work alongside doctors… . .. under their supervision ….They are complementary to GPs …..and in no way a replacement for any other member of the general practice team…(This) does not mitigate the need to address the shortage of GPs’. The College says that PAs work within a defined scope of practice and limits of competence.
These accord with guidelines developed by the Department of Health and Social Care (DHSC),and professional bodies. After a PA degree programme, PAs must pass a National Examination..
Seeing “undifferentiated patients” is controversial. In 2020, a PA could be the first contact for patients with undifferentiated problems. However, a later statement in GP contract 2024/5 states: ‘#17. non-GP doctors (sic) should not see undifferentiated patients’. It is both telling and confusing that PAs seem to be referred to here as ‘non-GP doctors’ . Some GPs question the usefulness of PAs in general practice altogether, since the supervision required is onerous, and they flag patient safety concerns.
The NHS England (NHSE) National Medical Director Sir Steve Powis said: ‘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’.
Representing all the colleges, the Academy of Medical Royal Colleges (AOMRC) produced a consensus statement on PAs, stating that: ‘PAs are not doctors and cannot and should not be used as a substitute for doctors’. In addition, training opportunities for junior doctors need to be prioritised and protected. The AOMRC also emphasised the importance of supervision.
The issue of professional regulation
Oversight was established by the RCP in 2015 ‘to provide clarity to the public on the different scope of practice of a doctor and a PA’. MAPs currently only have voluntary professional registration. But the government pushed the General Medical Council (GMC) to become the regulatory body for MAPs. The GMC is the independent regulator of doctors in the UK. The BMA set out three demands:
- PAs and AAs be regulated by the Health and Care Professions Council (HCPC)
- They should be called ‘Physician Assistants/Anaesthesia Assistants’
- A moratorium on PAs/AAs until clarity about their role and scope of practice was achieved.
The debate on regulation (Draft Anaesthesia Associates and Physician Associates Order – AAPAO) took place in a parliamentary committee session, but lacked depth to assess this 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 – because the hospital had a PA.
In a radio interview on PAs, Conservative peer Lord Bethell showed his lack of understanding while not endearing himself to GPs: ‘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’. 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.
But as KONP has pointed out, people often have very complex symptoms with a many possible causes – some serious, some not. It takes 10 years to train a GP with on-going learning. 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 symptoms which do not fall into any algorithm.
A Conservative MP and doctor, Dan Poulter, put it this way to Parliament: ‘When the PA 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 (are) 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’.
Push back against expansion of MAPs by rank and file doctors
Many doctors remain concerned that PAs are a threat to patient safety. Members of both the Royal College of Anaesthetists and of the RCP forced their college executives to call an extraordinary general meeting (EGM) to explore this. At the meeting of Anaesthetists, 89% of college members voted for a pause in recruiting anaesthesia associates until after a survey, a consultation, and an impact assessment of doctors in training.
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. Negative publicity ensued 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 whether there is a plan to replace doctors with PAs: ‘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 the NHS and England needs an additional 50,000 doctors to bring it into line with European countries. NHSE points to its plan to double the number of medical school places over the next decade, to ensure an extra 60,000-74,000 doctors plus 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 for 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. In addition, junior doctors already see bottlenecks in training. For example, in 2021, 700 anaesthetic trainees could not continue despite 680 unfilled anaesthetic consultant posts. The government ignores retention of doctors, as many threaten to leave the NHS because of poor pay and working conditions; and only 56% of those entering core training remain at work in the NHS eight years later. The Panorama programme on Centene showed in one London general practice that PAs were effectively working as GPs without supervision. A general practice in Surrey made three of its GPs redundant due to ‘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 (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 to train a doctor.
The National Audit Office recently examined the modelling used of long-term workforce planning assumptions. There is a gap between estimated demand for GPs and number of expected GPs. NHSE anticipates moving work from fully qualified GPs to trainees (!). This seems very unlikely, and it is more plausible that PAs will be called upon to close this gap.
How to ensure that MAPs do not replace doctors
The BMA asserts that MAPs can play an important part in NHS teams. Because of their concerns the BMA has produced guidance with the aim of protecting patients and safeguarding medical training for the doctors of the future.
Key concepts in this document include that MAPs should follow, and not give medical directives; but act upon the medical decisions of a doctor and do not make independent treatment decisions; and that national standards for supervision of MAPs must be set.
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, are caught in the middle of arguments about their future. A worried ‘union’ for PAs (United Medical Associate Professionals – UMAP) warns of GP practices implementing the BMA’s scope of practice of potential legal consequences. The union argues that it is ‘inappropriate’ for the doctors’ union to ‘unilaterally redefine and attempt to impose a scope of practice on another profession’, and highlight a lack of ‘stakeholder engagement or peer review’. MAPs currently in post should be supported, supervised and not forced to work outside their competence.
Conclusions
Some commentators have raised fundamental questions about PAs. What special skills is it that PAs bring to the multi- disciplinary team 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?
The BMA framework should be welcomed by all bodies since its aim it to ensure PAS do not substitute for doctors . However, the government wishes to blur 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. The failure to address doctor retention through improved pay and work conditions also suggests that NHSE and the AOMRC reassurances must be taken with a large pinch of salt.
It is instructive to look at the United States where PAs (called Physician Assistants) can work without medical supervision and are 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 from profit-based providers to reduce labour costs. The cost savings of increasing Physician Assistants relative to physicians is substantial. However, evidence indicates that Physicians 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: 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 tell employers that for the sake of patients (and for MAPs), the BMA scope of practice must be adopted and implemented.