My Lords, I note that the noble Baronesses, Lady Finlay and Lady Brinton, have laid regret amendments and that the noble Baroness, Lady Bennett, has laid a fatal amendment relating to this order concerning professional titles, supervision requirements and the General Medical Council as the regulator, along with constitutional concerns about how parliamentary oversight of regulatory bodies will be maintained in the future. These are important points that I will turn to shortly. I thank the noble Lords who took the time to engage with me on this order at a briefing session last week, when we had a very helpful discussion on the key issues.
Anaesthesia associates and physician associates are already a valued and integral part of the multidisciplinary healthcare team. We acknowledge that there have been some concerns around the AA and PA roles, but regulating these professions will help to increase the contribution that they can make to the UK healthcare sector while improving patient safety and professional accountability. As well as bringing AAs and PAs into regulation by the General Medical Council, this order paves the way for full-scale reform of the regulatory frameworks for all the healthcare professional regulators. This is a rare and significant opportunity to deliver a large-scale programme of reform that will implement improvements to patient and public safety, the system of professional regulation and the health and care workforce.
This order will give the GMC powers to register AAs and PAs it assesses to be appropriately qualified and competent; to set standards of practice, education and training and requirements for continual professional development and conduct for AAs and PAs; to approve AA and PA education and training programmes; and to operate fitness to practise procedures to investigate concerns and, if necessary, prevent or restrict an associate practising. The legislation provides a high-level framework for the GMC to regulate AAs and PAs and, importantly, gives the GMC autonomy to set out the details of its regulatory procedures in rules.
The GMC has committed to developing rules and processes for regulating AAs and PAs that will be subject to public consultation to enable regulation to begin by the end of this year. Once regulation begins, in keeping with the approach taken to bring other healthcare roles, such as dental nurses and dental technicians, into regulation, there will be a two-year transition period that will enable individuals to continue to work and use their relevant professional title while they go through the process of registering with the GMC. After the transition period, it will be a criminal offence to practise as an AA or PA without being registered with the GMC.
I now turn to the fatal amendment tabled by the noble Baroness, Lady Bennett, and specifically to the concern that this order represents a significant constitutional change without the required parliamentary oversight. I thank the Secondary Legislation Scrutiny Committee for its comments on this topic.
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There has also been the suggestion that the AA and PA roles are being used to replace doctors in delivering NHS services, alongside concerns about the level of supervision required. Let me be clear on this: the role of associates is to work with doctors, not replace them. AAs and PAs are distinct, complementary and valued professionals who, under appropriate supervision, can enrich the workforce skill mix, freeing up junior doctors and consultants to spend more time using their specialist skills and training to focus on complex clinical duties and decisions around patient care.
It is important to note that the NHS Long Term Workforce Plan sets out an aim to double the number of medical school places in England to 15,000 places a year by 2031-32, and to work towards this expansion by increasing places by a third, to 10,000 a year, by 2028-29. We have accelerated this expansion by allocating 205 additional medical school places for the 2024-25 academic year, with the process for allocating 350 additional places for the 2025-26 academic year already under way. This demonstrates our commitment to the medical profession and that we do not see PAs or AAs as replacements for doctors. There are currently more than 139,200 full-time equivalent doctors working in the NHS in England—that is over 42,000 more than in 2010—and there are fewer than 3,500 AAs and PAs.
Across the UK, each nation is considering the operational deployment of these roles within its workforce. In England, the long-term workforce plan commits to increasing the PA workforce to 10,000 by 2036-37 and the AA workforce to 2,000 over the same period. It is of course vital that this expansion is delivered safely, and the NHS is working with partners including the GMC, royal colleges and other stakeholders to ensure that associates can be effectively trained and integrated into teams across a range of specialities.
To summarise, regulation will provide a standardised framework of governance and assurance for clinical practice and professional conduct, to enhance patient safety and to enable PAs and AAs to make a greater contribution to patient care as part of the multidisciplinary team. I am content to bring forward this legislation today. The order is a positive step forward in the safe expansion and further integration of the AA and PA roles within the NHS. I commend this order to the House.
As an amendment to the above Motion, to leave out from “that” to end and to insert “this House declines to approve the draft Anaesthesia Associates and Physician Associates Order 2024 because it represents a significant constitutional change in regulation of healthcare professionals by omitting parliamentary oversight and approval for regulating anaesthesia associates and physician associates; and fails to address concerns within the medical profession about the supervision and titles of the roles.”
My Lords, I rise to move what the Minister has correctly identified as a fatal amendment that the House do not approve this order. This is on two primary grounds: the lack of democratic oversight and the concerns of the medical profession.
Before I begin, I want to make it clear that I am not opposed to the existence of physician associates or assistants, or their anaesthetist colleagues. I am not opposed to their regulation—indeed, I am keen to see them regulated—and I respect the efforts of current and future PAs and AAs who complete their studies and have the student debt to prove it.
I also want to be clear that, unless I get an indication from the House that it wishes me to do so, it is not my intention to put this amendment to the vote. My intention in tabling it was to ensure that the many hundreds of voices of concern that have reached me personally and the more than 21,000 doctors and patients who wrote to their MPs opposing this order are heard, and that the Government consider—seriously, I hope—whether they should go forward to regulate PAs and AAs in this manner, with this order.
I will first address the second part of my fatal amendment, about the views of doctors and patients. Sir Robert Peel invented the concept of policing by consent. I want to adapt that for these circumstances by saying that we must have regulation by consent. I am sure that all noble Lords engaged tonight are aware that the British Medical Association, the Doctors’ Association UK and the EveryDoctor group are opposed to this statutory instrument, for reasons on which I am sure we will hear much more from the noble Baronesses, Lady Finlay and Lady Brinton, with their regret amendments.
One of the very serious concerns is about clarity for patients and the confusion introduced by the title “associate”. On that I turn to a report from the BBC, an interview with Marion Chesterton, the mother of Emily, who tragically died after being seen twice by a PA and misdiagnosed. Marion said that her daughter
I should inform the House that if this amendment is agreed to, I will be unable to call the amendments in the names of the noble Baronesses, Lady Finlay of Llandaff and Lady Brinton, by reason of pre-emption.
My Lords, I declare that I am a doctor registered with the General Medical Council, a member of the BMA and a fellow of the Royal College of General Practitioners and the Royal College of Physicians.
We have physician associates and anaesthesia associates seeing patients, examining them and advising them, who are as yet unregulated. All responsibility for their behaviour rests with the doctor who is their supervisor from whom they have delegated responsibility. The professional scope of practice for these associates can vary widely across the country. It is determined at a local level and patients have no idea about the variation.
There is a golden thread in clinical care that the most experienced person delegates down. They delegate down tasks that they know the relevant team member has the skills to undertake. A key skill in medicine, gained with extensive experience, is the integration of all the relevant information, evaluation of risk and prioritisation. Currently a problem in the whole of the NHS is that we expect staff to refer upwards and the boundaries are unclear.
A case of non-accidental injury in a child has been brought to my notice where the expert evidence was provided by a physician associate whose relevant experience is unclear at best. This blurring is misleading to non-medical professionals, including the police, judiciary and legal professionals. Supervision must be mandatory and stipulated in the GMC’s Good Medical Practice.
The junior doctors’ discontent, which we have heard about already from the noble Baroness, Lady Bennett, is boiling over. After training, medical graduates emerge with huge student debts to work a 40-hour week for just over £32,300, only to find that after a two-year postgraduate programme a physician associate typically earns between £3,000 and £11,000 more, for only 37.5 hours a week. All this has inflamed tensions—although I would say that direct verbal attacks on physician associates and anaesthesia associates, who have trained in good faith and with good intent, are not appropriate and I would not condone them.
My Lords, I am grateful to follow both the noble Baronesses, Lady Bennett and Lady Finlay of Llandaff, and I have been crossing out large chunks of what I was going to say, which I hope will be helpful to Members of your Lordships’ House.
As both of the other noble Lords have, I want to start by saying that this is not an attempt to discredit the many PAs and AAs who do an extremely good job. We need to understand that, and we need to understand that our health system must change and modernise. The issue is what is happening in our NHS and how the role of PAs and AAs is impacting not just on patients—I will come to the detail of that in a minute—but on the working of supervising doctors and junior doctors. All of those groups are in crisis, and this just seems to be adding further problems.
I echo the points made by, I think, the noble Baroness, Lady Bennett, about the Secondary Legislation Scrutiny Committee, which the Minister referred to in his introduction. In the committee’s report to us, it says three times that the Explanatory Memorandum assumed understanding and that it was not good enough. I ask the Minister if he will work with his officials to ensure that any more Explanatory Memorandums that come forward, not just on this issue but on others, are very clear and do not assume prior knowledge.
All of us have said that PAs and AAs—I am not going to keep saying physician associate and anaesthesia associate because it takes too much time—are not a replacement for doctors, though not one of us believes that that is the case. I am going to start with the title. The Royal College of Physicians and the Faculty of Physician Associates, which sits within the RCP, has guidance on the associate title and introduction guidance for PAs, supervisors, employers and organisations. What it says is in complete contradiction to what is happening on the ground:
My Lords, I was a member of the GMC until the end of January, so at the council meetings I was involved in a number of discussions about the responsibilities of the GMC in the lead-up to this order being laid. Unsurprisingly, I strongly support it.
I listened to the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, and clearly they raised issues that the Minister will need to respond to. However, the combination of statutory regulation by the GMC and a proper governance framework within each employment body seems the most appropriate course for us to take. Therefore, I say to the noble Baroness, Lady Bennett, that passing the order is the best way to secure the safety of patients, which is why I hope the House will give it resounding support tonight.
My second point comes back to the noble Baroness, Lady Bennett, on democratic accountability and legitimacy. The Minister mentioned that a combination of the Health Act 1999 and the Health and Care Act 2022 has brought this order before us. Since I took the 1999 Act through this House, I feel some responsibility to stand up for what it essentially aims to do. The whole problem of regulation of the professions in the health service is that it has never had the priority it deserves from the Government. The Law Commission reported in 2014, and here we are 10 years later, just about getting round to the first tranche of orders that we need to modernise the regulation of our health professions.
If you rely on primary legislation to make this kind of change, nothing will ever change. It is slow enough with secondary legislation, but with primary legislation it becomes almost impossible to get sensible change made. All the regulatory bodies are utterly frustrated that they have very old-fashioned processes and procedures, because they do not have the discretion needed to make changes that would be to both the public’s and the professions’ benefit. Therefore, I am glad we have this order and I hope we can follow it through.
My Lords, I declare my interest as a NED of the NHS Executive. I support this order, for many of the reasons that the noble Lord, Lord Hunt, has just explained, but stress that I am extremely unhappy about the division between the reports from various medics and the associates that are planned. One of the big problems is that we do not value junior doctors enough. The phrase we use is inappropriate. I have been married for 43 years to a doctor who has been called a house officer, a senior house officer, a registrar and a senior registrar—those things would now be referred to as a junior doctor. I want to put that on record.
I also support what the two noble Baronesses have said, which is that we need a distinguishing factor for a qualified doctor, be that “MD” or whatever else is selected by the medical profession. I am a nurse, and I am proud of being a nurse. We have nursing associates, but I know that I am a registered nurse and I know that I have a doctorate, but I would never refer to myself as a doctor in the clinical area. These issues are difficult to deal with because we need to value people’s different experience and training.
I was appointed by a previous Secretary of State to chair the grandfathering of the paramedics on to the new register, when it came into being, and look at the success that that has been.
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I highlight that the delegated arrangements that give Parliament broad powers to make changes to the regulatory landscape via secondary legislation have been operating effectively for more than two decades. It is important to note that prior to the Health Act 1999 there had been growing public, parliamentary and professional concerns about the healthcare professional regulators and the delivery of public and patient protection. Important reforms had been delayed by the need for primary legislation to overhaul a number of Acts dating back to the middle of the 19th century. The delegated powers afforded by Section 60 of the 1999 Act allowed a start to be made on the large task of modernising and rationalising this legislation. These powers have facilitated some important changes and improvements to healthcare regulation, including bringing nursing associates into regulation and introducing revalidation for doctors.
In using the powers under Section 60 of the Health Act, the Government are required to consult publicly for three months on any draft legislation they intend to lay. In addition to a legislative consultation, in March 2021 the Government undertook a three-month policy consultation that invited views on the aims of this work. These consultations and the extensive engagement conducted throughout the project have been clear that one of the primary aims of the legislation is to bring anaesthesia associates and physician associates into statutory regulation by the GMC.
Following the legislative consultation, the legislation is subject to the affirmative parliamentary procedure. This requires the legislation to be debated in both Houses of Parliament and is why we are here today. This is a necessary and proper procedural requirement allowing for parliamentary consideration and scrutiny of the legislation.
The Government have sought, at every stage of the process, to engage a wide and diverse range of interested parties and to be clear on what this work will achieve. In addition to the helpful discussions I had with noble Lords at last week’s briefing session, it is my sincere hope that this evening’s debate will be a further example of this vital engagement and that fellow Peers will feel reassured.
I turn to the order itself. The principles set out in this order have long been sought by the regulators and were recommended by the Law Commission in 2014. At present, for a majority of healthcare regulators, the requirement for parliamentary approval of changes to their rules means that they are less able to respond quickly to amend their processes to reflect emerging workforce trends or concerns. We are providing the GMC with greater autonomy to set out the details of its regulatory procedures in relation to AAs and PAs in rules it publishes itself. The GMC will still be required to consult on its rules but will not need to secure the approval of Parliament or the Privy Council, giving increased flexibility to rapidly adapt its processes and procedures to changing requirements.
Although the order increases the number of areas that the GMC has autonomy over in respect of its day-to-day functions in relation to AAs and PAs, we recognise that there needs to be a system of checks and balances in place to ensure that the GMC continues to act in accordance with the needs of patients, registrants and the wider healthcare sector. The legislation places a number of duties on the GMC to ensure that the new powers are used reasonably and proportionately. For example, it must discharge its functions under this order in a way that is transparent, accountable, proportionate and consistent.
The GMC will remain accountable for any function, or part of a function, it delegates to another regulator or third party. Although the GMC already has the power to set its own fees for medical practitioners, and the same power is proposed for AAs and PAs, we are also introducing a requirement for the GMC to include in its annual report the evidence it has considered of the likely impact of any changes made to fees.
We are also retaining current accountability mechanisms. For example, the GMC will continue to submit annual reports to the Privy Council and copies will be laid before each House of Parliament, which will enable Peers and MPs to scrutinise the regulator’s activities and raise any issues in the House. There is also the Health and Social Care Select Committee, which can hold the GMC to account. As noble Lords know, it has held hearings with the GMC and other professional regulatory bodies on a number of occasions to oversee their work.
The Professional Standards Authority for Health and Social Care—the PSA—oversees the 10 health and care professional regulators and is an independent organisation accountable to the UK Parliament. It carries out performance reviews on all the regulators to see whether they have met the standards of good regulation and publishes its findings. It also has an escalation policy that would allow the PSA to escalate serious or intractable concerns to others, particularly the Government and Parliament. Finally, the Privy Council has a power to direct the GMC where it has failed to carry out its statutory functions using its default powers. I hope these points on how oversight and scrutiny of the healthcare regulators will be maintained in future will reassure the noble Baroness, Lady Bennett, and address the issues that were raised in the Secondary Legislation Scrutiny Committee’s report.
I turn to the role titles, which are referred to in the regret amendments tabled by the noble Baronesses, Lady Brinton and Lady Finlay, and the fatal amendment tabled by the noble Baroness, Lady Bennett. They have been the topic of much debate online, specifically about the use of the word “associate” rather than “assistant”. It is worth noting that AAs and PAs have been practising in the NHS for around 20 years, with the “associate” term being in use since 2019 and 2014 respectively. The titles reflect the fact that, as with nursing associates, they are part of a multidisciplinary team of healthcare professionals from various disciplines working together to deliver co-ordinated patient care.
As set out in National Institute for Health and Care Excellence—NICE—guidelines, all healthcare professionals should introduce themselves and explain their role to the patient regardless of their job title. In addition, in advance of regulation the GMC has published interim standards for AAs and PAs, which make it clear that professionals should always introduce their role to patients and set out their responsibilities in the team.
The noble Baroness, Lady Brinton, also outlined concerns in her regret amendment around the decision for the GMC to take up the regulation of the AA and PA roles. The assessment of the appropriate regulatory body for AA and PA regulation was completed in 2019 following a public consultation. The majority of respondents to that consultation were in favour of the GMC taking on regulation, including the professional bodies representing the roles and the medical royal colleges, including the Royal College of Anaesthetists, the Royal College of General Practitioners and the Royal College of Physicians.
The GMC is the right regulator for these roles. Regulation will give the GMC responsibility and oversight of AAs and PAs, in addition to doctors, allowing it to take a holistic approach to education, training and standards. This will enable a more coherent and co-ordinated approach to regulation and, by making it easier for employers, patients and the public to understand the relationship between the roles of associates and doctors, help to embed them in the workforce.
“didn’t know she hadn’t seen a doctor”.
Marion added—and this is something that I think people should focus on:
“Physician associate sounds grander than a GP”.
I pick up a point made by the Minister about PAs and AAs having been around for 20 years, an often-cited statistic. If we look back to 2014 and 2015, there were fewer than 50 PA and AA graduates. There were literally handfuls in the system. It is only when you get to 2018 that you start to see the figures leaping up to 400 graduates, and the Government’s aim is to head towards the figures that the Minister cited. So we may not have seen much confusion, but there were few people to be confused about within the system. This is a situation that is arising now, and that demands a reconsideration.
However, I will largely leave the arguments about titles, and the General Medical Council as regulator, to the regret amendments. What I want to focus on is the word “consent” and the concerns of doctors and patients in the context of the state of our medical system.
We debate as junior doctors are in the middle of their 10th strike action. We debate as one in seven British-trained doctors is working overseas. We debate after a BMA poll found last year that around 40% of junior doctors plan to leave the NHS as soon as they can find another job.
We need to make changes to the system. That is something on which the Minister and I, and I think pretty well everyone, are agreed, but we can make changes to the system only with the consent of all those involved. There is a moral argument for that, but also a very powerful practical argument. The Government need to work co-operatively and sensitively, and to listen to our medical professionals rather than ride roughshod over their serious concerns—concerns that are shared by many patients and that have filled my social media feed in recent days.
The first part of my amendment is about democracy. The order got virtually no scrutiny or consideration in the other place. We, of course, have no opportunity to amend it to tackle the issues that the noble Baronesses will focus on in their regret amendments. We have only the extraordinarily rarely used option of rejecting it. I have not had any indication from the Labour Party that it would support that, and I assume that its silence on the Order Paper means that it supports the Government’s path, but I ask the Labour Front Bench to consider whether we have to take this back to the drawing board. That is a question I put to it directly.
The Minister raised the report of our hard-working and, I fear, underappreciated Secondary Legislation Scrutiny Committee, which makes it very clear that this is not just about PAs and AAs but is meant to be the model for broad and widespread changes to medical regulation in the future. The committee’s report says that this is
“the first use of powers inserted into the parent Act by the Health and Care Act 2022 to give the GMC direct powers to make and amend standards and procedures for these associates”,
while, as it says in bold,
“removing the process from Parliamentary oversight”.
It is interesting that the Committee says:
“The Explanatory Memorandum should have been more explicit on this point and on what safeguards remain”.
In testimony, under questioning from the committee of your Lordships’ House, the department confirmed that
“changes in registration processes etc will no longer be laid before Parliament in any form, they will just be posted on the GMC’s website … however members of either House can respond to consultations if they wish”.
I am glad about that.
This has really not been made clear through the process, as the committee highlights. I think it is worth focusing on the fact that had it not been for the amendments from the noble Baronesses and me we would not even be doing this in the main Chamber. We would be in the secondary Chamber, getting, as we all well know, very little attention at all.
I particularly want to highlight, in case noble Lords did not receive it, the briefing from the Professional Standards Authority, which has responsibility for overseeing the GMC’s activities. It said, in what I think one would describe in bureaucratic terms as a carefully worded briefing, that we
“need to keep under review as the reforms are rolled out the accountability framework proposed to balance the increased autonomy for regulators with greater accountability”.
I wish to make a final point to address the fear and concerns of many patient groups and communities—which the Minister alluded to—that their communities and their families will lose ready or perhaps any access to doctors and be relegated to a second tier of NHS services, with PAs with two years of medical training versus GPs with 10. In the letter following up the very useful briefing that he arranged last week—and I think him very much for that and for the letter—the Minister makes reference, as he did in his speech, to the Government’s aim of doubling the number of medical places in England to 15,000 by 2031-32.
The Minister gave, I believe, the same figures as were reported in the Observeron Sunday. These were in a leaked letter from the Health Minister and the Minister for Skills, Apprenticeships and Higher Education to the independent regulator, the Office for Students. The figures in that letter have been interpreted as significant back-pedalling on the Government’s final aim and total. I ask the Minister whether he remains confident and can guarantee to the House that we are on target to achieve that final figure, given that we do not seem to be taking very strong steps in that direction.
The way those figures came out can only amplify the fears of many communities that those who can pay can go private, as increasing numbers of Britons feel they are forced to do. Patients at the centre of well-serviced areas where doctors can supplement their NHS pay with private work will keep access to a service like that now available, while other areas—the kinds of areas that are often talked about as being in need of levelling up—will get a second-class service.
We have to think about the context of this. Our NHS is battered by privatisation, with nearly 10% of services, including more than half of under-18 inpatient psychiatric services, now provided by for-profit providers. We have seen the disaster of PFI schemes, now set to cost £80 billion for the original £13 billion investment—the equivalent of £1,200 for everyone in the UK. We have seen this jewel in the British crown worn away by austerity—a decade in which investment in infrastructure and new technology collapsed and the pay of junior doctors and midwives in particular plummeted in real terms.
Please let us not deliver another blow. Please withdraw this order either tonight or afterwards. Take the path of consensus. Take the path of democratic oversight. Bring this forward as legislation that can be debated, amended and properly scrutinised. Please listen to the fear of communities. I ask everyone in this debate but particularly the Labour Front Bench to consider that approach and the wisdom of it. I beg to move.
Doctors are the only healthcare professionals who must undergo extensive, nationally stipulated postgraduate training before being appointed to a permanent senior role. Without long-term job security, these juniors rotate through departments, sometimes commuting many miles. They find that they do not belong and do not feel part of the team or valued, while patients miss out on continuity of care.
Very importantly, patients seen by a physician associate sometimes think that they have seen a doctor. The term “physician associate” gets muddled with the specialty and associate specialist doctor, who often has years of experience. Can the Minister clarify whether the term “physician associate”, which is so misleading, will become a protected title after this order passes? How can the name then be changed to revert to the more accurate “physicians’ assistant”? Currently, no medical titles are protected: “doctor” is not and grades up to and including consultant are not, which is another source of confusion. How is that going to be cleared up?
The cost-efficacy basis for these posts has been questioned in a recent paper, showing how the cost of one consultant anaesthetist supervising two operating theatres with an anaesthesia associate in each—that is, three staff—is more expensive than having two consultants doing one list each. The risk is higher if a problem arises in both theatres, especially in an anaesthetic emergency, when deterioration and brain damage can happen in minutes.
This crisis has been 20 years coming because we failed to expand medical school places or to register these new healthcare roles and define their scope of practice. What is the solution?
I fear this order will not solve all the problems. Yes, physician associates and anaesthesia associates must be regulated. It seems an outrage that people with such responsibility have been around for 20 years, unregulated, and a decade after that was recommended. The General Medical Council, in taking responsibility for regulation, must keep the register completely and clearly separate from that of medically qualified doctors. Can the Minister confirm that this clarity will be a legal requirement?
I tabled my regret amendment because it must be clearly on the record that the concerns exist, that some current regulation around the Medical Act needs updating urgently and that the GMC must be held accountable to Parliament, as has been explained by the Minister. Regulation is essential, but it is not the end of the issue; it is only the beginning.
The GMC must tackle the inappropriate way that some courses are advertised, which state that they train PAs
“to work as a safe and competent medically trained healthcare professional”
or to
“be a medically trained, generalist healthcare professional”
—which sounds awfully like a GP to me. Some courses describe working under a senior physician, but others say nothing about supervision. The anaesthesia associate courses differ slightly. They make it clear that, at present in the UK, only doctors who have specialist training in anaesthesia can administer anaesthetics and that the anaesthesia associate works as part of the anaesthetic team.
Next, the scope of practice must be clearly defined and agreed at national level, so that any employer is aware of what the associates should be doing and how the senior doctors must supervise them on site. Employers must also ensure that all patients know the qualification level of the person seeing them. Seven-day services are essential for patients.
Medical postgraduate training itself is in crisis. The royal medical colleges, the Academy of Royal Medical Colleges and the GMC must get together urgently to address postgraduate training. Perhaps it could be shortened, with post consultant-level fellowships to develop highly specialised skills and bring innovation to healthcare. Lifelong learning is essential; it is the essence of growing a good medical workforce in the long term. Medical schools, as they welcome the increased numbers, must look at how those who might wish to convert to a medical degree can be credited with their prior learning and experience, and tackle regulatory blocks in funding and timing.
Importantly, the title must be reviewed. The terms “physician assistant” and “anaesthesia assistant”, in use until 2014, clearly denoted the role as having delegated responsibilities from a supervisor. If “physician associate” and “anaesthesia associate” are to be protected terms, then we need a designation of medicine that clearly identifies a medical degree—similar to the American MD designation, for example. Patients must know who has seen them.
To summarise: patients must know the level of training of the person whom they have seen. Physician associates and anaesthesia associates must be regulated with appraisal and ongoing learning, including revalidation. The scope of practice of this new workstream must be defined to ensure that they have clear boundaries and supervision must be defined as being closely supervised on site to ensure patient safety. People must not be misled into believing that they are completely independent practitioners.
“It is our view that, when a PA introduces themselves to a patient or staff member, they must make it clear at the start of the interaction that they are a physician associate, as well as explain the use of the term ‘PA’ … PAs must correct patients and staff if they refer to them as a … doctor, nurse or other professionally protected role title. This includes verbal, written and other forms of communication”.
Like other noble Lords, I have been inundated with letters from doctors and patients saying that they have been misled—not in the deliberate sense, but that PAs have not been correcting the record when someone has called them a doctor. The BMA, in its very helpful briefing, said that:
“To patients, PAs and AAs and doctors may look the same and appear to be doing a similar job”.
The problem, as the noble Baroness, Lady Finlay, said, is that the title is confusing. “Physician associate” perhaps implies that they have the same level of expertise as doctors. Unfortunately, as the noble Baroness, Lady Bennett, said, this has already led to a tragedy. Emily Chesterton died, aged 30, after two appointments with a PA who she believed was a GP, where mistakes were made.
A further difficulty, particularly in GP practices, is that GPs are beginning to worry that they are going to spend their entire time supervising PAs, as well as seeing patients with chronic diseases, and will not see ordinary people at all. Trainee GPs are worried about how they are going to be supervised. How is the Minister going to ensure that the issues of supervising and training, which are very serious, will be dealt with after the passage of this SI—because I do not think any of us are planning to call a vote today?
We have heard that, across acute trusts and GP surgeries, doctors have reported 70 instances of avoidable patient harm and near misses caused by PAs. That includes fatalities, missed diagnoses resulting in terminal diseases, missed DVTs, sepsis, heart attacks and haemorrhages. Missed cancer diagnoses in primary care has therefore emerged as a significant issue. In England, 74 acute trusts have replaced doctors with PAs on the doctors’ rota. Even if those PAs are supervised, that means that doctors who should be seeing patients are supervising more and more people. It is not a zero-sum game. One trust—I think it was Leeds, from memory—had a paper on how much more beneficial PAs were on the rota because they were much cheaper than doctors.
Doctors at 24 trusts reported witnessing PAs illegally prescribing medications, including controlled drugs. That is a particular worry because they are not permitted, under their current training and qualifications, to prescribe any drugs. That must be done by the doctor. The PA can recommend to the doctor what they think, but it should be signed off by a doctor. In addition, 42 acute trusts in England have witnessed PAs introducing themselves as doctor or failing to correct errors.
We have heard about a number of issues. I conclude by saying that, earlier on today, on the Victims and Prisoners Bill, we were talking about the duty of candour, which the NHS introduced nearly a decade ago. One issue related to this is that every regulated member of staff must report whenever they believe that something has happened that either possibly will cause damage or has caused damage. One of the good things about regulation for PAs and AAs is that they will come under the duty of candour. However, in all the cases that we have been told about where things have gone wrong, there is no evidence that there were reports to the CQC by the supervising doctors about things going wrong. Therefore, yet again I say to the Minister that my real concern is about current practice inside our extremely pressed and busy NHS, to make it safe. Just providing regulation for PAs and AAs will not in itself do that. I hope that he can help your Lordships’ House to understand.
My third point is about the noble Baronesses saying that they do not like the campaign of what is essentially vilification that has been going on over the last few months against the physician and anaesthetist associates. I wish they had paid a little more tribute to the members of those professions and the fantastic work they do. I have met physician and anaesthetist associates, and they are going through a torrid experience. They have been subjected to a nasty campaign and, even in their own employing body, there have been reports of bullying at work and they have been subjected to rude and antagonistic comments from colleagues.
What is the context in which we are to judge this litany of mistakes that they have made? They seem to be isolated examples and, to my knowledge, there is no comparative data on errors by consultants, principal GPs or postgraduate medical trainees. I would not like to see a list of all their mistakes. What would happen if we asked people to report mistakes made by F1 medics each August? The BMA is playing with fire in the campaign it has adopted of putting these poor professionals, who are doing their best, in this frame. I protest about this and the general lack of medical leadership from the profession when it should have been defending the associates. The way it has run away from this issue has been a disgrace. It will find that its lack of leadership and strength will bite it in future. I have not been impressed by the way in which employing authorities have dealt with this either; they have left individual AAs and PAs to withstand the pressure and bullying without the support they need.
The Minister needs to reflect on some of the points raised. First, in addition to declaring his confidence in physician and anaesthesia associates, he needs to set out a long-term plan for their contribution to the NHS, ensuring that the voices of those professions are heard. The Government’s ambitions on the numbers of AAs and PAs seem very modest. Why? Does he think we need to revisit that? Secondly, he needs to make it clear to NHS England and to employing authorities that bullying and intimidation of any healthcare professional in their employment must not be tolerated.
Thirdly, in response to the noble Baronesses, Lady Brinton and Lady Finlay, the Minister needs to ensure that each employing body adopts an appropriate local governance framework to deal with some of the issues that they have legitimately raised. Fourthly, we need research on the clinical outcomes of physician and anaesthesia associates and, frankly, comparative data with other health professionals. That is the only way to deal with the toxicity of these lists of mistakes that have been circulated. Finally—here I agree with the noble Baronesses, Lady Finlay and Lady Brinton—there clearly needs to be a plan of communication to the public to explain the role of the associates and the contribution they can make in future.
The order is important. Some legitimate issues have been raised, but equally we need to defend the associates, uphold the work they do and give them confidence about the future.