Allowing physician associates to take on doctors’ responsibilities ‘costs lives’

Allowing physician associates (PAs) to take on the responsibilities of NHS doctors costs lives, an expert from the University of Oxford has said.

Professor Trisha Greenhalgh, lead author of new research on the issue, said not a single study has looked at whether PAs or anaesthetic associates (AAs) in the NHS are safe.

The health service has a plan to increase the number of PAs and AAs from around 3,500 at present.

The Royal College of Physicians and the British Medical Association (BMA) are among those who have raised concerns about the use of PAs and AAs.

Speaking to BBC Radio 4’s Today programme, Prof Greenhalgh said the only research that had been done – which included only a handful of PAs – has focused on settings where associates were seeing very low risk patients under close supervision.

“So it’s not really very surprising that there weren’t any safety incidents identified,” she said.

“But that doesn’t mean that these roles are safe and, in fact, to conclude that they’re safe from the basis of the evidence we’ve got is an error of reasoning that is likely to cost lives.”

Pressed on this issue, she continued: “I think if you’re going to say that on the basis of studies of physician associates doing ward work, looking at minor injuries in the A&E department, working in general practice, on the basis of that, to say: ‘Oh, well, it’s OK to substitute these associates with doctors on clinical rotas, it’s okay for them to do complex procedures, it’s okay for them to make independent decisions,’ then I think, yes, it will cost lives, and it already has done.

“We’ve got coroner’s reports … which are formal legal reports issued to prevent future deaths, and what they say is we need some major changes in the way that physician associates and anaesthetic associates are being deployed.”

She said work from other countries could not be translated to the UK as, for example, physician associates in the US had a different role and more training.

Prof Greenhalgh’s review, published in the British Medical Journal (BMJ), found studies relating PAs and AAs were severely lacking.

No studies have examined safety incidents, while others have concluded PAs seem “to struggle” when working in GP surgeries.

One of the main studies on PAs working in GP surgeries only included information for seven PAs.

Furthermore, some NHS staff had concerns about the competence of PAs and AAs “to manage undifferentiated, clinically complex, or high dependency patients … or prescribe”.

The review continued: “No evidence was found that physician associates add value in primary care or that anaesthetic associates add value in anaesthetics; some evidence suggested that they do not.”

PAs have hit the headlines in recent years over a spate of patient deaths linked to misdiagnosis.

Last week, a coroner said the PA who treated Pamela Marking before she died at East Surrey Hospital last year “had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination”.

Mrs Marking was seen by the PA and told she had a nose bleed before she was sent home, with her son believing she had been cared for by a doctor.

In fact, Mrs Marking had a hernia. The 77-year-old had to be readmitted to hospital and died four days later after complications with her care.

Witnesses from the East Surrey trust told her inquest that a PA was “clinically equivalent to a Tier 2 resident doctor” but there was no evidence to back this up, the coroner said.

Another high-profile death involved Emily Chesterton, 30, in November 2022 from a pulmonary embolism. She was misdiagnosed by a PA on two occasions.

PAs are graduates – usually with a health or life sciences degree – who have undertaken two years of postgraduate training.

According to the NHS, they should work under the supervision of a doctor and can diagnose people, take medical histories, perform physical examinations, see patients with long-term conditions, analyse test results and develop management plans.

In November, the Government launched a review of the role of PAs and AAs led by Professor Gillian Leng, president of the Royal Society of Medicine.

Her report is expected to be published in spring.

Prof Greenhalgh is among those who have been asked to speak to Prof Leng for her review.

Professor Martin McKee, co-author of the study from the London School of Hygiene and Tropical Medicine, shared these concerns.

He said: “The mismatch between policymakers’ enthusiasm for expanding these roles and the lack of rigorous research evidence should be a red flag.

“Workforce shortages are a real challenge, but they cannot be addressed by replacing doctors with people whose training maps poorly to the duties expected of them, and who may be inadequately supported, without a clear, evidence-based strategy.”

In December, the Royal College of Physicians published guidance saying PAs should “never function as a senior decision maker”, should never be allowed to decide which patients can be admitted to hospital or sent home, nor should they prescribe.

And in January, the Royal College of GPs wrote to Prof Leng to say there was “no role for PAs in general practice”

The letter, as seen by Pulse, included details of misdiagnosis and diagnostic errors by PAs, inappropriate prescribing and management, and GP concerns that “the hoped for benefits of the role in terms of addressing unmanageable workload in general practice were not in fact being realised due to the levels of supervision support and training required”.

Professor Phil Banfield, chairman of the BMA council, said NHS bodies and the Government had “collaborated in the headlong rush” to expand PAs and AAs without first amassing the evidence that their role was safe.

He added: “By maintaining a postcode lottery, bizarrely supported by the General Medical Council, in which different hospitals can decide what physician associates can and can’t do, the NHS has created a genuine public policy scandal.

“The lack of both evidence of safety and a national agreement on what these roles can do is a combination that in any other field would have set off a chorus of alarm bells – yet healthcare policymakers seem content to charge ahead, having ignored the genuine concerns of doctors as well as warnings from coroners.”

A Department of Health and Social Care spokesperson said: “The Secretary of State has launched an independent review into physician and anaesthesia associate professions to establish the facts and make sure that we get the right people in the right places providing the right care.

“Regulation of PAs and AAs by the General Medical Council began in December to ensure patient safety and professional accountability.”

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