Physician Associates

Motion made, and Question proposed, That this House do now adjourn.—(Mark Jenkinson.)

I draw the attention of the House to my entry in the Register of Members’ Financial Interests as a practising NHS consultant psychiatrist.

The UK has a severe shortage of healthcare professionals, amounting to more than 110,000 in England alone, coupled with a growing ageing population with an ever-increasing need for a strong and responsive health service. To address the shortage, the Government in England have introduced the NHS long-term workforce plan, with additional proposals also set out in the devolved nations.

NHS England’s plan sets out a wide range of mostly unfunded workforce measures, including doubling the current number of medical student places to potentially add 60,000 doctors to the workforce by 2036-37. Controversially, it also includes plans to increase the number of physician associates from approximately 3,250 to 10,000, an increase of over 300%, and anaesthesia associates from approximately 180 to 2,000. That is not to say that physician and anaesthesia associates should not have an important role in the future NHS workplace. However, at this time, serious regulatory and safety concerns relating to associates need to be addressed before the NHS seeks to expand their numbers and roles. Furthermore, standardised high-quality training pathways and a properly defined scope of practice are essential.

Physician associates, anaesthesia associates and surgical care practitioners are collectively known as the medical associate professions, and I may use the terms interchangeably. Physician associates and anaesthesia associates currently complete a two year postgraduate course and are employed in a variety of settings in the NHS, including GP surgeries, emergency departments, and medical and surgical settings, and they have also been introduced to mental health settings.

I commend the hon. Gentleman for securing the debate. The issue is massive—it is massive for me back home, as well—so I thank him for his reasoned and knowledgeable speech, as well as his contribution to the NHS over the years. Without an increase in the number of GPs and doctors, does he agree that the healthcare crisis we face will become an abyss? In small countries such as Northern Ireland, students cannot get places in our small medical schools and are training, working and living in other countries, which is a real loss to future stability. Does he agree we need to do more to keep our young medical staff rather than let them head to greener grass in far off fields?

I completely agree with the hon. Member. He advocates strongly for his constituents, as always, and for the need to better retain our medical workforce in general, our junior doctors in particular. The Government will have heard his comments. I am sure that things can be done to improve the current offer to junior doctors in England. Indeed, things can be looked at in Northern Ireland, too, with the restoration of political arrangements.

An agreement could be put in place that will properly renumerate junior doctors, and also look at the other terms and conditions of employment that are important in respect of retaining the medical and healthcare workforce. These situations are not always about pay; it is also about wider terms and conditions. The Government could certainly look in more detail at student debt, for example, as the Times Health Commission outlined this week, which may incentivise people to stay in medicine for longer.

We have diverged slightly into the broader healthcare challenges, so I will return to physician associates, which was the point of this evening’s debate. There are concerns about the regulation and training of this particular group in the medical workforce. Physician associates and anaesthesia associates are not currently regulated. There have been a number of recent high-profile cases of patient harm as a result of being seen by medical associate professionals, including, sadly, some deaths. We know, for example, of the tragic case of Emily Chesterton from Salford who died of a pulmonary embolism having been seen twice and had her deep vein thrombosis misdiagnosed as a musculoskeletal problem by a physician associate at her local GP practice.

Anybody who watches the TV programme “24 Hours in A&E” may have seen some fairly enlightening scenes in respect of the clinical skills of some medical associate professionals, including physician associates. There are many examples of poor clinical diagnosis and judgment, including, for example, making initial decisions to send patients with compound fractures home without an X-ray when the patient actually required surgery.

In my own clinical practice, I have worked alongside some very competent physician associates, but there is a high degree of variability in their training and skills. Only last year, I was forced to directly intervene to prevent patient harm following a paracetamol overdose by a patient who attended A&E. The physician associate incorrectly informed me that they did not require N-acetylcysteine treatment because their liver function test was normal, in spite of the fact that they were over the treatment line as a result of their paracetamol overdose. Of course, at that time, the patient’s liver function tests were normal, but they would not have been for very long. The consequences of that diagnostic decision by the physician associate could have been fatal. The key issue for me is that many physician associates do not know or have the self-awareness to understand the limits of their knowledge and practice, but this is perhaps understandable in a health system that fails to adequately regulate and indeed define its scope of practice.

I am grateful to the hon. Member for introducing this evening’s debate. I sat on the Committee that considered the Anaesthesia Associates and Physician Associates Order 2024. He is drawing out several issues. One is competency; another is patient literacy. A lot of new roles are emerging—technicians, assistants, associates, and advanced practitioners—and to the public this is now becoming a blurred space. People do not understand the competences that individuals possess, their scope of practice, and where they fit into the medical family, or indeed professions allied to health. Does he agree that we need to define those roles clearly, and that associate roles should be around professions allied to health, rather than associated directly with the medical profession?

I fully agree with the hon. Lady, and I will expand on that a little later. There is certainly confusion among the public about what a physician associate is. Many members of the public assume them to be doctors or other healthcare professionals. They therefore lack a much greater degree of competence. Given that it is envisaged that the role will be significantly expanded, the public understanding and awareness of it, and people’s expectations when being treated by somebody in that role, are really important. That needs to be better addressed through the current proposals for regulation, which I will come to in a moment.

I will talk briefly about general practice and the additional roles reimbursement scheme. Through the ARRS, the Government have provided funding to GP practices that can be used to pay for physician associates and other clinical staff, but not for hiring additional doctors and nurses. That is quite extraordinary, and results in GP practices having physician associates rather than fully qualified GPs. Currently, most physician associates in general practice are funded through the additional roles reimbursement scheme: an NHS scheme that funds primary care networks to support recruitment across a very limited set of eligible roles. The current rules for ARRS funding are causing inefficiencies as they are not flexible enough to respond to locality needs for healthcare staff. In particular, the rules do not allow practices to hire primary care nurses, practice nurses, or indeed GPs, as I mentioned.

Over the past year, there have been many developments in how the Government and the profession view the roles of physician and anaesthesia associates, but it seems extraordinary that when we are talking about supporting general practice in developing the right skills and competences, and delivering the right service for patients, one of the key funding schemes does not allow for the hiring of the GPs and practice nurses that are needed, and is skewed towards physician associates. I wonder whether the Minister might take that away, look at the scheme, and help to provide additional flexibility, which general practice would like and which seems eminently sensible, to allow recruitment at a local level, in line with patient need.

There are significant concerns connected with the roll-out of the anaesthesia associates project. While the GMC addressed some of those issues in its recent letter to NHS England, a number of concerns remain. In particular, the NHS long-term workforce plan suddenly projected a huge expansion in the number of anaesthesia associates, but no expansion in the number of doctors in anaesthesia—or, as we are talking about position assessments, in the number of doctors in other specialities. To many, that looks like a replacement of doctors with anaesthesia associates, rather than anaesthesia associates being employed to complement the anaesthesia team, which was the idea previously portrayed.

I am grateful to the hon. Gentleman for making those points. It is particularly concerning that a prescribing nurse, say, could become a physician associate, but perhaps without the ability to prescribe. That would create even greater confusion. Does he agree that we need clarity and distinctions to be drawn on those kinds of issues?

I fully agree; the hon. Lady is absolutely right. I was going to address that very point about prescribers a little later. There is clear agreement on the challenges. Those issues should be thought through before a workforce plan is brought forward, and before there is a significant expansion of the workforce, for reasons of patient safety, particularly as concerns have consistently been raised about the scope of practice and adverse incidents. It is rather putting the cart before the horse to say, “We want to expand the workforce without dealing with the important issues of how that workforce is trained, how it can properly be regulated, and what its scope of practice is.” That is unfortunately a regrettable failing of NHS England’s plan, which I hope it will consider.

If the GMC cannot regulate extended scopes of practice, they should be devised according to a national framework. There needs to be an understanding of what that should be. It is unacceptable for employing organisations in the NHS to devise their own extended scopes of practice without reference to at least some national framework—one that has the confidence of regulators and standard setters—so that we know and understand what good practice looks like.

Doctors should be directly involved in devising any changes to the scope of physician associate and anaesthesia associate practice, whether on qualification or at extended level. There should be no extension of roles beyond the scope of practice on qualification until national guidance is issued. Where organisations are planning such an extension, it should be paused for reasons of patient safety. Where physician associates or anaesthesia associates are already working in an extended role, it should be recorded on the healthcare organisation’s risk register, and the organisation should ensure that it has full confidence in its standards of supervision, access to support, indemnity of the anaesthesia or physician associate and the supervising doctor, and patient information and consent. Anaesthesia associates have a role to play as part of the wider anaesthesia team, but it is important to ensure that it is a complementary role as an addition to the workforce, not as a replacement for doctors and nurses, as the hon. Lady rightly underlined. Expansion in the number of anaesthesia and physician associates should not be at the expense of expansion in the number of doctors in specialist posts.

Let me come briefly to assessment, which is another area that has not been well thought through. It is important that assessment for anaesthesia associate roles is standardised at national level. The Royal College of Physicians does a national exam for physician associates, but a national body needs to be established to undertake the assessment process for anaesthesia associates if we are to ensure confidence in their competencies. It may be possible for that to be delivered locally, if there are stringent controls in place to ensure consistency. However, before the anaesthesia associate workforce is expanded, there needs to be some process for assessing competency.

Once again, I am grateful to the hon. Member for giving way. Doctors in training need a very clear career pathway, but because of the rise in anaesthesia associates in particular, but also in physician associates, the pathway to many more senior roles will be blocked. As a result, people will stagnate as doctors in training, as opposed to getting a consultancy. Does he agree that that is highly problematic, and that the career pathway needs working through before there is any increase in the number of physician and anaesthesia associates?

That is absolutely essential. At the moment, the prerequisite appears to be a biomedical science degree, which is incredibly variable—depending on whether a person went to Hull, Newcastle or a London university, a biomedical science degree could be very different—and then two years of study. A physician associate would then have to pass an exam set by the Royal College of Physicians, but when a person passes that exam, it does not necessarily mean that they had standardised or good training; potentially, it just means that they prepared well to pass their exam. The difference with doctors in medical school—and indeed the difference with nurses going through nursing school—is that they are consistently assessed, all the way through their undergraduate training. When they graduate at the end of that training, they are consistently assessed as they progress.

None of that exists in the training pathway for physician or anaesthesia associates; in fact, as we have discussed, there is not even an exam for anaesthesia associates at the end of the process. It is absolutely essential that those issues are addressed as a priority, and it is little wonder that patient deaths and adverse incidents are occurring on such a scale. Perhaps when the Minister is suffering from insomnia late at night, he may wish to watch old episodes of “24 Hours in A&E”. He will see the huge variability in the expertise of physician associates. Some are very good, but some are not, and we should not be dealing with variability in the British health system. That is what we are trying to address, so the hon. Member for York Central is absolutely right in everything she has said.

That highlights the last point I am going to draw to the House’s attention from the BMA survey of 18,000 doctors. Some 75% of respondents said that the quality of training among medical associate professions—physician and anaesthesia associates—was woefully inadequate; 84% said that the quality of their supervision when they are at work was inadequate; 91% outlined the fact that they work outside their competence; and 86% of respondents confirmed that the public would confuse them with doctors, as the hon. Lady outlined. This is not just a few hundred doctors; this is 18,000 doctors saying in a survey that they have serious patient safety concerns due to the variability in training of anaesthesia associates. There have been far too many adverse incidents where things have gone wrong, and it is time for the Government to give NHS England some clear direction that this area needs to be looked at, and some proper planning and consideration of the expansion of this workforce put in place.

These are the asks I have of my right hon. Friend the Minister. First, we should ensure there is a standardised and quality assured training programme for physician associates, anaesthesia associates, surgical care practitioners and all other medical associate professionals, and indeed that there is ongoing training and supervision to a nationally standardised level when that group is in the workplace post qualification. Secondly, we should ensure that the General Medical Council sets up a register for the regulation of medical associate professionals, separate from the register for doctors. Thirdly, as is the case with all other healthcare professionals, we should ensure that the scope of practice of physician associates is clearly set out to make sure that we can develop appropriate training pathways and supervisory pathways, but, more importantly, to ensure patient safety. Finally, the Government should support the introduction of a system with greater flexibility to hire GPs and general practice nurses using the ARRS funding. I thank the House, and I look forward to the Minister’s response.

I congratulate my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) on securing this debate. He spoke knowledgeably, both as a serving NHS medic and as a former Health Minister.

Let me begin by making a very important point. I addressed it in the Delegated Legislation Committee on 17 January, but it is worth repeating. The role of a physician associate is to work with doctors, not to replace them. Improved patient safety and care is at the heart of the NHS long-term workforce plan, which, backed by significant Government investment, shows our determination to support and grow the workforce. As set out in the plan, roles such as physician associates, who remain supervised by doctors, play an important part in NHS provision, and it is therefore right that we include a range of roles and skills in our multi-disciplinary teams that can offer personalised, responsive care to patients.

It is important to note that the NHS long-term workforce plan commits to doubling medical school degree places to 15,000 a year by 2031-32. That compares with 1,500 physician associate places. In turn, this will mean a major expansion of specialty training, on which we are committed to working with the royal colleges. 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 reaffirms that we absolutely do not see physician associates as replacements for doctors. There are currently 139,200 full-time equivalent doctors working in the NHS in England, which is over 42,100, or 43.4%, more than in 2010. Patient safety remains of the utmost importance, and regulation will help bring further clarity to patients and healthcare professionals on the nature of these roles and their remits.

Earlier, in response to the hon. Member for York Central (Rachael Maskell), I made the point about the variability of biomedical science degrees from different institutions. The GMC would not recognise a biomedical science degree as being adequate for a doctor in training as part of their preclinical studies, because of that variability. Will my right hon. Friend raise that issue directly with NHS England, with regard to putting in place a standardised training pathway for physician assistants?

My hon. Friend makes a valid point, and that is one reason why regulation is so important. The GMC has assured me that although draft regulations are out there, it will be consulting further on them later this year, so my hon. Friend, the BMA and various others can make strong representations about how the training framework should be provided. With that introductory regulation, the GMC will be responsible for setting, owning and maintaining a shared outcomes framework for physician associates, which will set a combination of professional and clinical outcomes. The outcomes framework will help to establish and maintain consistency, embed flexibility, and establish principles and expectations to support career development and lifelong learning. While at the moment there is significant variability in the system, I hope that the regulations we passed in this House on 17 January will help to provide that clarity and give the GMC the powers it needs to ensure that the training provided to physician associates is of the appropriate quality for the roles we are expecting them to undertake in our NHS.

Physician associates can work autonomously with appropriate support, but always under the supervision of a fully trained and experienced doctor. As with any regulated profession, an individual’s scope of practice is determined by their experience and training, and will normally expand as they spend longer in the role. That must be coupled with appropriate local governance arrangements to ensure that healthcare professionals only carry out tasks that they have received the necessary training to perform. Statutory regulation is an important part of ensuring patient safety, but that is also achieved through robust clinical governance processes within healthcare organisations, which are required to have systems of oversight and supervision for their staff.

NHS England is working with the relevant professional colleges and regulators, to ensure that the use of associate roles is expanded safely and effectively. That includes working with the GMC, royal colleges and other stakeholders to develop appropriate curriculums, core capabilities and career frameworks, standards for continual professional development, assessment and appraisal, and supervision guidance for anaesthetist and physician associates. NHS England will also work with colleges, doctors’ representative organisations, AAs and PAs to identify areas of concern. Specifically, the NHS has committed to working with the Academy of Medical Royal Colleges and individual professional bodies to develop and implement recommendations as a result.

On that point, can the Minister clarify where the liability will sit if error does occur? Will it sit with the clinician or the consultant who is supervising them? I am not clear on that particular issue.

In many ways, it will be the same as with many medical professionals. Once we have the situation clarified in regulation, it will not be any different from the personal liability of a doctor or others working in an organisation. Those are the kind of things that the GMC will be consulting on and discussing with stakeholders in the coming months, and is important that all these points are clarified. The hon. Lady was in the debate we had in January, where the tragic case of Emily Chesterton was raised. In that case, unfortunately we saw a PA move from one practice to work in another, and we need to ensure that there is a proper, robust fitness-to-practice regime so that any medical professional can be held to account in such cases for what has happened and, if necessary, struck off the register and no longer able to practice.

The Minister is being generous in giving, and we are taking advantage of the slightly extended time we have for this Adjournment debate, but it is an important issue, because it is about patient safety. On that point, he is putting a lot of faith in the GMC doing things quickly, when we know there are existing patient safety issues. Would it not be more sensible to wait for the GMC to put in place the proper regulatory framework, the proper scope of practice and the other pieces of work that are being done before we commit to an expansion of a workforce when we know there is variability and patient safety concerns?

I feel that I am being criticised from both angles on this point. Some people are saying we are going too fast, and other people are saying we are going far too slow. A number of years ago, we consulted on regulating these professions. We are now moving forward. Those regulations have passed through the UK Parliament and the Scottish Parliament. The GMC has had a long time to prepare. In my meetings with the GMC, it has reassured me that it is ready to go. It will want to consult to ensure that any further concerns that people wish to raise are reflected in the regulations. It wants to ensure that it gets the regulations right, but it has known that they have been coming for some time. We consulted on who was best placed to regulate physician associates and anaesthetist associates back in 2019, so the GMC has had some time to lay the groundwork.

Under the long-term workforce plan, there is a much more significant expansion of doctors, as opposed to physician associates or anaesthetist associates. The number of extra doctors we are bringing in to the health service, as compared with physician associates, is of a magnitude of five to one. I hope I can reassure hon. Members that this is not in any way about replacing doctors. Doctors are still absolutely pivotal to patient care and will be heavily involved in overseeing physician associates, who are not doctors and need to be overseen in clinical practice.

The role of physician associates is in no way a replacement for that of any other member of the general practice team. They work in conjunction with and are complementary to an existing team. Physician associates can help to broaden the capacity and skills mix within a practice team by helping to address the needs of patients in response to the growing and ageing population, but let me be clear that the employment of PAs does not mitigate the need for more GPs, nor does it remove the need for other practice staff.