A press release from the BMA on 16 November 2023 called for “an immediate halt to the recruitment of Medical Associate Professionals (MAPs) in the UK including Physician Associates (PAs) and Anaesthetic Associates (AAs).” The BMA is a professional association and trade union whose membership includes over two-thirds of practising doctors in the UK. On this occasion, the 69 voting members of the UK Council-the principal executive committee of the BMA- raised concerns over “patient safety” and recommended that recruitment of MAPs be paused until their proper regulation and supervision could be ensured. Council Chair Professor Phil Banfield further lamented the “relentless expansion” of MAPs, which was “blurring roles” and confusing patients.
In the UK, the term Medical Associate Professions includes Anaesthesia Associates, Physician Associates, and Surgical Care Practitioners. Physician Associates (PAs), the main source of the BMA’s concerns, are best described as collaborative healthcare professionals, who support doctors in primary care-in GP surgeries, and in secondary care- in hospitals, mainly in acute medicine and emergency departments. PAs, originally referred to as Physician Assistants, have been employed in the NHS since 2003. They are usually selected from the ranks of bioscience graduates who have since undergone postgraduate training at Master of Science (MSc) level, or from the products of undergraduate integrated Master of Physician Associate (MPA) programmes.
Full-time PA training typically lasts two years and consists of 46-48 weeks of study each year, including 1,600 hours of mandatory clinical training in a variety of settings. PA training is also open to other registered healthcare professionals, including nurses, midwives, and allied health professionals. Level 7 apprenticeship allows people to qualify as PAs while employed elsewhere. There is no statutory registration system for PAs, who are listed on the Physician Associate Managed Voluntary Register (PMVR), at the Faculty of Physician Associates within the Royal College of Physicians. Pay ranges from £41, 659 to £47, 672 per annum for a basic 37- to 42-hour working week.
Ideally, the PA supplements the role of, and is supervised by, an identifiable medical professional. PAs can take patient histories, and undertake physical examination, analysis of test results, diagnosis, follow-up of people with chronic conditions, diagnostic and therapeutic procedures, as well as formulate management plans, and advise on health promotion and disease promotion. Many of these functions are routine and repetitive, and PAs can thus free up medical time for more complex and time-consuming tasks. This wide remit of responsibility has worried some doctors and raised fears that PA expansion is more of a cost-cutting measure rather than a contribution to safe and high-quality patient care. This can thereby increase patient flow and throughput in busy departments that encounter a steady stream of patients at all times of day and night.
The concept of a PA is by no means new, having emerged in response to shortages and the uneven geographical distribution of doctors in America. As far back as 1965, Eugene A. Stead, Jr, professor and chair of medicine, first established a Physician Assistant educational programme at Duke University Medical Center in Durham, North Carolina. These pioneering PAs were intended to support rural doctors, who had difficulty accessing continuing medical education. Out of the first intake of four former US Navy medical corpsmen, three graduated on 6 October 1967-a day which is both commemorated as National PA day and happens to coincide with Stead’s own birthday in 1908. Since then, the profession has expanded rapidly to include more than 168, 300 practitioners in the US. This has been achieved by the active support of the medical profession, alongside accreditation standards for training, standardised examinations, national certification, continuing education programmes, and recertification.
Outside the US, development of the PA has been patchy and unregulated, often constrained by opposition from doctors and nurses and stifled by a lack of political support. PAs have been employed in at least sixteen countries, including Australia, Canada, the Netherlands, Germany, Saudi Arabia, Israel, Ghana, and Liberia. Hence, there is a dearth of studies on the benefits, or otherwise, of PA schemes outside America.
Back in the UK, despite the BMA’s concerns, it appears that there is wider professional and political support for the role of PA, especially as part of the solution to workforce shortages that are only worsening over time. Thus, in February 2021, Health Education England (HEE) commissioned Skills for Health to develop a Core Capabilities Framework for Medical Associate Professions, which appeared the following year. The project steering group included representatives from various NHS bodies, Medical Royal Colleges and Faculties, and the General Medical Council. The Framework laid down standards for professional values, behaviour, and practice; core clinical practice; leadership; education and life-long earning; and quality improvement, research and scholarship.
To understand the BMA’s unhappiness with PAs, one has to dissect the role of the PA. Nominally under medical supervision, the PA has a wide remit of practice, similar to that of a junior hospital doctor and even replicating many of the basic functions of a GP. It has been reported that PAs have been linked to delayed and mis-diagnoses, inappropriate treatments, and adverse events causing physical or psychological harm, although the extent of these complications, from which trained medical professionals are by means exempt, is not known. Anecdotes of adverse effects of PA-provided care have been reported when PAs work autonomously with minimal or no medical input, while the reported mistakes are no different from those more commonly attributed to doctors and nurses, either trained or in training.
With standardised training, statutory registration, and adequate supervision in the workplace, PAs should prove an asset to the NHS, as a self-selected and motivated group of people trained to deliver healthcare under carefully specified conditions. In a dynamic health care system, responding to ever-increasing demand, growing complexity of care, and rising costs, creative and innovative solutions must be embraced, and that includes a wider recognition of the synergistic contributions of PAs, just as the extended role of nurses has long become established practice.
Ashis Banerjee