Physician associates

“However, that in itself does not address the fundamental issues of scope and supervision. “Patients interacting with doctors’ assistants, and doctors working alongside them need urgent clarification.” DAUK has raised significant concerns about the regulation and expansion of PA and anaesthesia associate (AA) roles in the NHS. We’ve long called for a pause in their roll out over concerns about patient safety, scope of practice, and their supervision.

Scope and supervision

Dr Ellen Welch, DAUK’s vice chair and a GP, said: “This is a start but we still need to define scope of practice. “We also need to address the doctors’ concerns around supervision and who is responsible for these assistants and their work. “Anaesthetists United returns to the High Court next week with an important court case which aims to do that. “DAUK has given our support with a £30,000 contribution but they still need help funding their crucial challenge.” For more information on how to support this crucial legal challenge, please visit the Anaesthetists United donations page.

Supervision

However, the Doctors’ Association UK is concerned that the guidance is poor and does not address issues around supervision. These issues include the supervisor retaining responsibility and accountability for patient care. This means supervising doctors will be liable for mistakes, said Dr Steve Taylor, DAUK’s GP spokesperson. Dr Taylor said: “Doctors need to be sure that the task they are delegating is within the scope of the PA. “In many cases the supervisor will not have sufficient knowledge of the PA’s training, knowledge, or capabilities.

Patient safety

“Because the supervisor retains responsibility and accountability for patient care, the supervisor will need to be confident the patient is being treated appropriately, safely, and has been thoroughly assessed. “Supervision is not straightforward and currently there are no training requirements for supervisors. “This means patients primarily, as well as PAs and doctors, are being placed in positions that are not ideal at best and unsafe at worst. “The delegating doctor retains responsibility for patient care, and therefore will be liable for mistakes. Patient safety and care needs to be paramount.

Medico-legal minefield

“This effectively places doctors in a medico-legal minefield and open to GMC referrals for mistakes, as medical defence organisations such as the MDU make clear.” Dr Taylor added: “Doctors will remain responsible for the overall management of the patient, decisions around transfer of care, and the processes in place to ensure patient safety. “Although AAs and PAs remain accountable for their actions, a doctor will retain responsibility for the overall management of the patient and the system of supervision.” Dr Taylor said the guidance lacked certainty for doctors, failed to address significant patient safety concerns, and did not provide a comprehensive framework for supervision of PAs and AAs.

Certainty and clarification

He said: “More certainty and clarification is needed, and employers need to be aware of the significant implications of supervision, including training, assessment and monitoring. “This was highlighted by Nuffield Trust in respect to general practice supervision of other roles, but can also be extended to hospitals.” Please support our work by contributing to our crowd funder or by becoming a member.

Judicial review

In seeking a judicial review, Anaesthetists United argued in the High Court that PAs and AAs, who are not doctors, are performing roles beyond their competence and training. It was also argued that by not setting their scope of practice, the GMC was putting patients at risk. The case has been heard by Mr Justice Chamberlain, the lead High Court Judge dealing with judicial review cases. It has passed its first legal hurdle and has been granted permission to proceed to a full High Court hearing, which is set to be held before Easter. In reaching his decision, Mr Justice Chamberlain, said: “The claim raises serious issues of importance to the relevant professions and to patients which should be determined on a reasonably expedited basis.”

Legal ruling welcomed

The ruling was today welcomed by our chair Ms Helen Fernandes. She said: “We have been consistent supporters of this crucial legal challenge and provided substantial financial backing. “We are delighted with the ruling and that it will now go to a full judicial review. “With this ruling, as well as the independent Leng Review, we feel even more strongly that the roll out of PAs and AAs now needs to be paused. “Questions around the appropriate regulation, scope of practice, supervision, and ultimately patient safety need to be answered. It’s too important to blindly carry on. “It’s also unsettling for the many PAs and AAs who are already in post, and their teams and their patients.

Patient safety

“We recognise PAs and AAs need to be regulated. However, it must be done by the most appropriate body, which is not the GMC. “GMC regulation only blurs the lines between doctors and non-doctors, confuses the public, and risks patient safety.” Anaesthetists United is aiming to raise another £150,000 to cover its costs in the next stage of the case. For more information on how to support this crucial legal challenge, please visit the Anaesthetists United donations page. And please support the work of DAUK.

Not fit for purpose

Ms Fernandes said huge concerns still remained about the proposed regulation framework for physician associates. She said: “While regulation of any health professional is welcome, it is only as good as the nature of the regulation. “We urge the GMC to address the concerns raised by DAUK, royal colleges, BMA and swathes of the medical profession. “The proposed framework for regulation is not fit for purpose and will not protect patients. “Nor will it protect doctors, who the GMC hold responsible for the supervision of PAs and AAs, often when they are not necessarily able, aware, or at times appropriate. “We’ve always said that PAs and AAs are and can be valuable members of the healthcare team, but only when their role is compatible with their non-medical training and knowledge, and when appropriately placed by their employer. “Their employer should ensure they are supervised and those that are supervising and responsible have full knowledge of the same.”

Physician associates

Ms Fernandes also responded to ‘misleading information’ about the historic role of PAs in the NHS She said: “PAs in their current form have not been in the NHS for 20 years. “Misleading information about this and belittling concerns about the roles of PAs and AAs by alleging that doctors are being protectionist or outwardly toxic in the social media space is disingenuous. “It does not address the real concerns that we will continue to voice in the name of patient safety.” Support our work by becoming a member or donating to our Go Fund Me.

Safety concerns

Posting on X, formerly known as Twitter, he said: “Thank you Baroness Keeley of Worsley and Baroness Bennett for bringing medical profession and the public’s concerns to this debate.” DAUK has welcomed the review but called for it to be open and thorough, with patient safety at its core. He said speaking out had brought about the review. DAUK has been working with medical organisations, politicians and the media to highlight to the public the rollout of physician associates. “With most healthcare interventions, you establish risk before rollout, and certainly before extending the rollout after concerns have been raised,” he said. Dr Kneale expressed concerns that supervision of PAs and AAs has been inadequate, as well as concerns about national standards and consistency in competence. “The only framework we have is a university qualification with, in some cases, a 100 per cent pass rate,” he said.

Physician associates

He also expressed concern that PAs are replacing doctors on rotas, and questioned whether they could ‘safely diagnose without the same training’. “It’s clear many doctors share significant concerns,” he said. “At the Royal College of Physicians EGM, motions highlighting these issues were backed by more than 90 per cent of consultants. Those supervising PAs. This is not a fringe view.” He added: “We need transparency and honesty when discussing the scope, competence, and limits of PAs. Without this, I have little faith in the upcoming review.” Watch the House of Lords debate on the review of physician associate and anaesthesia associate roles. This video is available for the next 11 months and requires a TV licence to watch it. Support our work by becoming a member or donating to our Go Fund Me.

GMC guidelines

Ms Fernandes said: “To delegate within GMC guidelines is that you have to know what the person you are delegating to is capable, trained, and competent for the task ahead. “For planned care where there is a named and present consultant, this process is satisfactory. “However, in reality patient-led care is driven by a set of at times unpredicted and unanticipated circumstances with many doctors working shifts, moving departments, and having no detailed knowledge of any PA or AA they may be working with. “The GMC is not addressing the reality of patient care and is allowing a huge patient safety issue to develop in real time.”

Patient safety

Ms Fernandes said there was also a patient safety risk around the scope of practice for PAs and AAs. The GMC report says that ‘our educational standards set out the capabilities that PAs and AAs require for registration, but they do not impose ceilings on what individual PAs and AAs can do once registered. ‘This is because competence varies by individual – and will be shaped by a PA or AA’s supervised training and experience,’ it continued. Ms Fernandes said: “The GMC has chosen to avoid limiting scope in their regulation of PAs and AAs, which the legislation gave them the opportunity to. “Delegating it to the employer and/or colleges, which at best is advisory and not making it mandatory, is failing patients in protecting them.”

Transparency and openness

Dr Matt Kneale, DAUK committee member, added that concerns remained about the transparency and openness of the consultation, and the time it has taken for the results to be made public. He said that Freedom of Information Access requests for the GMC to release raw data from the consultation earlier were refused for the reason of research. Dr Kneale said: “The research had nothing to do with the consultation everyone replied to and the data requested, but related to focus groups only. “It’s also alarming that in some instances, case studies didn’t even reference PAs and AAs but instead doctors. “Why is the public commenting on doctors when talking about MAP regulation under the GMC? It conflates the working groups further and adds to public confusion.”

GMC consultation

The GMC consultation, which ran between March and May this year, attracted more than 3,000 responses, from individuals as well as organisations, including from DAUK. The GMC said that changes to its initial proposals, based on feedback in consultation responses, include:

• An initial proposal for a single GMC case examiner to make decisions on fitness to practise cases involving PAs or AAs has been changed. Instead, there will now be two case examiners.
• A specific requirement has been included for course providers to ensure student PAs and AAs inform patients when they are involved in their care. This builds on standards required of practising PAs and AAs to introduce themselves and explain their role.
• Behaviours indicative of serious misconduct have been expanded to include cases where a PA or AA has deliberately misled patients or others about their registered status. This mirrors the approach taken with doctors.
• A new provision that confirms the GMC cannot ask PAs and AAs to provide evidence of reflective practice when applying to join, leave or re-join the GMC register.

The GMC will begin regulating PAs and AAs from 13 December. Initially, a small number will be invited to apply for registration before the end of the year. The regulator will then invite the rest of those on existing voluntary registers by the end of January 2025. From December 2026 it will be an offence to practise as a PA or AA in the UK without GMC registration.

Regulation

GMC Chief Executive Charlie Massey said: “Regulation is a vital step towards strengthening patient safety and public trust. “It will provide assurance to patients, employers and colleagues that physician associates and anaesthesia associates have the right level of education and training, meet the standards we expect, and can be held to account if serious concerns are raised. “This was, by its nature, a very technical consultation. But the feedback we have received has been extensive and helpful. “We are grateful to everyone who took the time and effort to participate. By doing so they have, unquestionably, improved the regulation of these professions.’ Read the GMC report Regulating physician associates and anaesthesia associates – Proposed rules, standards and guidance: report on the public consultation. Support our work by becoming a member or donating to our Go Fund Me.

Unregulated

“For 18 months, we’ve worked with other medical organisations, the media, and politicians to bring accountability and awareness to a previously unregulated landscape. “The review needs to address concerns that the scope of medical associates should be nationally standardised, led by the regulator and not delegated to NHS trusts that have consistently failed to engage medical associate professionals (MAPs) safely. “We’re mindful there are many MAPs already in posts and respect the work they do. “This process may be unsettling to many PAs and AAs, their teams, and the patients they’re seeing. Which is why we want to see it conducted and concluded in a timely manner without affecting the quality and depth of the review. “On the point of regulation, we recognise that PAs and AAs need to be regulated. However, the GMC is not the right body for that.

Patient safety

“GMC regulation will only blur the lines between doctors and non-doctors, confuse the public, and compromise patient safety.” Ms Fernandes said DAUK was ready to submit evidence to the review. “We hope it will bring much-needed clarity and consistency,” she said. “And delivers meaningful safeguards for patient safety, transparency, and a clear national framework.” Professor Gillian Leng CBE will independently lead the review. She is an experienced leader in the UK health care system, has championed patient safety, and has a deep understanding of the British medical system. Announcing the review, Mr Streeting said: “Many physician associates are providing great care and freeing up doctors to do the things only doctors can do. “But there are legitimate concerns over transparency for patients, scope of practice, and the substituting of doctors. These concerns have been ignored for too long, leading to a toxic debate where physicians feel ignored and PAs feel demoralised.

Independent review

“This independent review, led by one of the UK’s most experienced healthcare leaders will establish the facts, take the heat out of the issue, and make sure that we get the right people, in the right place, doing the right thing.”

Professor Leng said: “To promote patient safety and strengthen the NHS workforce, it’s crucial we have a comprehensive review of the role of PAs and AAs. This will cover recruitment and training, scope of practice, supervision and professional regulation.

“As I conduct this review, I am looking forward to speaking to a broad range of stakeholders and to gathering evidence from the UK and abroad so that we can reach a shared understanding of these roles and their place in wider healthcare teams.”

Support our work by becoming a member or donating to our Go Fund Me.

Campaign

We are campaigning for a pause in the expansion of the roles until serious questions over their training, scope of practice, regulation, and pay are addressed. PAs are not a substitute for doctors, who undertake years of study and medical training and are highly-skilled in the care they provide for their patients, and this must be reflected in pay. It is estimated that a newly-qualified PA is paid £11,000 more per year – or 35 per cent more – than a newly-qualified doctor. Speaking to the Daily Mail, Dr Kneale said: “You can see why many junior doctors are angry. “Not only are we being replaced by another profession, but we are being replaced by people who are less qualified – and get paid more.” DAUK is also deeply opposed to Government plans for PAs to be regulated by the General Medical Council (GMC). DAUK has concerns about the oversight of post-graduate qualifications, training, and scope of practice, as well as about fitness to practice and supervision.

Regulation

While we recognise the need for PAs to be regulated, the GMC is not the body to do this. GMC regulation will only blur the lines between doctors and non-doctors, confuse the public, and compromise patient safety. Support the work of DAUK by becoming a member or donating to our Go Fund Me. Access the full feature in the Daily Mail.