In 2003 the role of PA, then known as Physician Assistant, was introduced to the NHS. Some had trained as a Physician Assistant in the USA – a 3 year course there in comparison with 3 years in the UK. The numbers here were small and few of us were aware of them.
In 2005 the UK Association of Physician Assistants was created, but the members voted in 2013 to change their name to Physician Associates. In 2015 a Faculty of Physician Associates was set up by the Royal College of Physicians of London (RCP). Why did the RCP do this? Was there political pressure or a large financial incentive from NHS England? Had anyone looked across the Atlantic to see what PAs were doing there? PAs in the USA had been recommended as primary care providers since 1971, and indeed the role had started because of a perceived shortage of primary care doctors for rural areas. They were also thought to be cheaper than doctors. PAs had been able to prescribe in all states by 2007 and since at least 2011 had been progressively extending their scope into hospital specialties such as vascular and cardiothoracic surgery, nephrology, emergency medicine and psychiatry. The RCP was set up by Henry VIII in 1518 ‘in response to a critical need for more stringent guidelines around medical practice’ (according to the Wiley digital archives) and its current aim is ‘to improve the quality of patient care by continually raising medical standards’. It appears that the RCP found that their workforce surveys showed that medical staff were overworked, and viewed PAs as doctors’ assistants, with no thoughts at that time of doctor substitution. But why did the College take on PAs, having never before embraced non-doctors? Did anyone really think about what the PAs would be doing? Whether they would want to extend their role as has happened in the USA? Whether their presence would damage training opportunities for doctors and medical students – as a large majority of doctors report that it has done? What about cost-effectiveness? How would these new staff members be supervised? Crucially, is it safe for patients to be cared for by PAs? 87% of doctors in recent surveys think PAs are a threat to patient safety. All these questions were still unresolved when the Conservative Government produced its Workforce Plan in 2023, planning a huge increase in PA numbers.
The General Medical Council (GMC), a body set up in the 19th century to uphold medical standards by keeping a register of properly qualified doctors, has now decided to regulate PAs as well, and there appears to be a clear commitment to blur the boundaries between doctors and PAs. Universities have seen PA courses as a money-making opportunity and, alarmingly, the GMC has given blanket approval to all PA courses while admitting it has no idea what is being taught and that this might ‘cause some reputational damage’. There is a national exam, organised by the RCP (with a very high pass rate), but PAs can work for up to 2 years without having passed it or being on the register. No scope of practice is mandated, as this is entirely left to individual employers.
Doctors have been horrified to see that PAs – much better paid than many junior doctors, and usually with a better work-life balance – are now being widely used instead of doctors on medical rotas, sometimes even as middle grades . They are also seeing unselected patients in general practice. The Additional Roles Reimbursement Scheme (ARRS) introduced by the last Government has paid the salaries of PAs on condition that they do see unselected patients, but the fact that the funds cannot be used to appoint extra GPs and other funding has fallen has meant that doctors finishing their GP training cannot find work even though patients are desperate for more doctors’ appointments.
There is no doubt that NHS England is promoting the expansion of PAs, but what is the agenda here? To save money? Probably, but will it? PAs are cheaper to employ than fully trained GPs, but more expensive than junior doctors. Well-publicised cases of deaths following mistaken diagnosis by PAs have raised questions about how doctors can supervise PAs. The GMC can blame them for PAs’ mistakes, but to follow BMA supervision guidelines would make so much extra work that PA employment could never be cost effective. Experience in the USA suggests an ‘access-quality trade-off’. The patient can get an appointment, but PAs make more diagnostic errors than doctors, refer more and order more investigations. PAs in the USA order 5.6 times as many CT scans as doctors. A similar increase here if PAs could order X-rays would cause serious delays for other patients and huge capacity problems. Litigation is another likely cost.
Has anyone thought about patient safety? We know that the Department of Health and NHS England thought that care from PAs would be risky but continued with the programme. Why? And why have the Royal Colleges, particularly the RCP, compromised their reputations?
Is the PA project just ideological? Richard Wellings, of the Institute for Economic affairs wrote in 2012: ‘’Perhaps most importantly, the compulsory licensing of medical professionals should be abolished. Anyone should be at liberty to practice as a doctor or nurse, with patients relying on brand names or competing voluntary associations to ensure quality.’’ Is the aim to have a two-tier service, with NHS patients seen by a PA and only private patients seeing a doctor?
We do not yet know what the new Government will do, but Wes Streeting has not so far spoken about the issue of PAs and appears to support the last Government’s Workforce Plan. Surely there must be a complete change of leadership at the GMC, Health Education England and NHS England as well as further resignations of senior leadership at the RCP? All these bodies are well aware that PAs are being used instead of doctors, while pretending that is not happening.
Did anyone think this through? It would seem not, but care is being dumbed down and if medical training continues to be compromised this will progressively damage senior doctors’ expertise.
For the sake of all our patients and the quality of their care, the situation must be resolved.
Andrea Franks
Executive Committee member
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