4 November 2023

“Associate” medics were meant to assist doctors, not replace them

GP practices have been able to hire physician associates, and what they are allowed to do has gone under the radar.

Photo by Christopher McLallen / Millennium Images, UK

An extraordinary general meeting of the Royal College of Anaesthetists (RCoA) held on 17 October looks like the start of a revolution in UK medicine. Or, more precisely, a counter-revolution.

The EGM was called by Anaesthetists United, an ad hoc group of RCoA members formed over the summer because of escalating disquiet about the potential impact of anaesthesia associates (AAs) on both patient safety and medical training. AAs – and physician associates (PAs), their counterparts in other areas of medical practice – are a relatively new role in the NHS, dating back to 2003. Practitioners hold an undergraduate degree, usually in a life-sciences subject, then take a two-year abridged version of selected aspects of a medical degree. They were originally envisioned as assistants, who would relieve doctors of routine procedures and administrative tasks. Indeed, their initial title was exactly that: physician or anaesthetic assistant.

Over the austerity decade, though, the PA/AA role began morphing. In 2013, the “assistant” title was quietly dropped in favour of the more ambiguous “associate”. Numbers have been growing. There are now around 3,000 PAs and 300 AAs working in the NHS, with targets of 10,000 and 2,000 respectively by 2035-36. And concern is mounting that instead of aiding fully trained doctors, PAs and AAs are replacing them.

The alarm was first raised by the BBC’s Panorama programme last year, which alleged that the US corporate Operose Health, which currently runs around 70 general practices in England, was using PAs in place of GPs without full supervision (the company denied this was the case). Then, this July, a coroner reported on the tragic case of Emily Chesterton, a 30-year-old actor who died from a blood clot in her lungs. Chesteron had twice consulted a PA at her local surgery (not an Operose practice), believing that she was seeing a GP, and had been assured that her calf pain and breathlessness were due to a sprain and anxiety. The coroner found that, had she consulted a qualified doctor, it was likely that she would have lived.

The case provoked a large response on social media, with front-line doctors posting example after example of hospital departments and general practices where AAs and PAs are filling the roles of doctors. In some instances AAs were reported to be running their own surgical lists; elsewhere, PAs were plugging gaps in consultant and GP rotas, with patients oblivious as to their qualifications. PAs and AAs are supposed to be supervised at all times by senior doctors, but other instances of misdiagnosis by PAs have illustrated how often they are left working in isolation.

All other healthcare workers are accountable to a regulatory body – yet, despite being promised for over a decade, the regulation of PAs and AAs has still not been forthcoming. Nor has there been any definition of the limits of these new roles. Government-imposed restrictions on the number of doctors permitted to train as specialists have left hospitals starved of middle-grade medical staff. Departments have seized on the availability of PAs and AAs to fill the gaps. General practice has seen a crisis in retaining GPs. There has been no new money to secure additional doctors, but desperate practices have been able to recruit PAs, paid for by ring-fenced central funding. What these PAs and AAs are allowed to do has gone under the radar. If anyone were to ask, the question would be covered by that fig leaf of “supervision”.

At the RCoA EGM, around 90 per cent of attendees voted for a moratorium on AA recruitment pending a review and consultation. There are now grass-roots campaigns growing among physicians, GPs, radiologists and ophthalmologists. Patient safety is a prime concern, together with the degradation of training opportunities for the next generation of doctors.

Steve Barclay, the health secretary, has tried to characterise the concerns raised in the House of Commons by Barbara Keeley, Emily Chesterton’s MP, as an illustration of the Labour Party’s resistance to reform in the NHS. Neither Barclay, nor Rishi Sunak or Jeremy Hunt, would settle for anything less than fully qualified doctors treating them or their families under their private medical insurance. Fortunately for NHS patients, a grass-roots doctors’ counter-revolution is underway, insisting that the rest of us deserve the same level of professional expertise when we ourselves need medical or surgical care.

[See also: David Hockney’s clumsy late style]