NHS reins in physician associates

A new name and scope of practice have been imposed on physician associates (PAs) working in primary care in the United Kingdom, following a review of their safety and effectiveness within the health system.
 
The PA role has come under scrutiny in recent years, including among Australian GPs, with concerns over a lack of training, their use as a workforce fix, and patient confusion over whether they are doctors.
 
The UK’s use of PAs is something Australian GPs have been watching closely, leading to fears from many that the role will expand locally – with the RACGP previously warning that the role’s scrutiny should serve as a ‘cautionary tale’.
 
In a bid to ‘inform a refreshed workforce plan’, the UK Government commissioned an independent review, led by Royal Society of Medicine president Professor Gillian Leng, which examined whether PAs and anaesthesia associates (AAs) are safe and effective as members of a multidisciplinary team.
 
Its findings were handed down on Wednesday followed by a National Health Service (NHS) announcement of ‘immediate actions’ required.
 
This included a name change for PAs from ‘physician associates’ to ‘physician assistants’ to reflect the role as a supportive, complementary member of the medical team.
 
In her review, Professor Leng recommends standardised measures, including clothing, badges, lanyards and staff information, be used to distinguish physician assistants from doctors.
 
The NHS also enforced the review’s recommendation that PAs not be allowed to triage patients in any setting, or see undifferentiated patients ‘unless triaged into adult patients with minor ailments and within clearly defined clinical protocols’.
 
‘Safety concerns raised in relation to PAs were almost always about making a diagnosis and deciding the initial treatment, particularly in primary care or the emergency department, where patients first present with new symptoms,’ Professor Leng wrote.
 
‘It is here that the risk of missing an unusual disease or condition is highest, and where the more extensive training of doctors across a breadth of specialties is important.
 
‘Making the wrong initial diagnosis and putting patients on an inappropriate pathway can be catastrophic. This was frequently flagged as the principal risk of PAs seeing undifferentiated patients.’
 
All new PAs entering primary care will now be required to have completed a minimum of two years’ employment in secondary care settings, while current PAs’ roles will need to align to the review’s job descriptions.
 
The NHS said while ‘short-term uncertainty’ is understandable, it expects employers to ‘continue to support their PA and AA workforce and to accept and implement the recommendations of the review’.
 
‘As the NHS faces ongoing pressure, the review marks a pivotal moment – a reset of the national conversation around these roles, and we must now work together to implement the recommendations and move forward constructively,’ it said.
 
RACGP President Dr Michael Wright says the UK’s situation highlights the dangers of introducing, and fragmenting care, with new health professionals with unclear scope.
 
‘Substituting other people for the important work that GPs do leads to bad health outcomes,’ he told newsGP.
 
‘The other important message is that patients didn’t know who they were seeing, and that was, frankly, dangerous.
 
‘When patients come to a general practice, they should know if they’re seeing a GP, or if they’re not. And that was one of the messages that came through in the review.’
 
The UK Government announced in 2015 that a thousand PAs would be introduced into general practice in England to assist in tackling GP workload pressures.

It has also been flagged in Australia, with the Queensland Government recently announcing the model is still being considered.
 
The RACGP maintains its position that implementing PAs in Australia is not a solution to health workforce shortages.
 
GP Dr Michael Bonning, who sits on the RACGP Expert Committee – Funding and Health System Reform, says he believes the UK’s changes do not go far enough in addressing patient safety and confidence.
 
‘This is an impotent, cosmetic approach to fixing a real problem, which is needing to properly fund the NHS so that they can have doctors alongside teams with nurses and allied health professionals who are properly trained look after patients,’ he told newsGP.
 
‘The idea that new PAs must have a minimum of two years employment in secondary care is farcical – it’s bringing in someone with very little educational basis in clinical care into often quite complex environments.
 
‘For a population in an OECD country, ours or theirs, people have a right to expect a consummate quality of clinical services, which someone with one- or two-years’ worth of on-the-job training just can’t deliver.’
 
Dr Bonning also questioned whether preventing PAs from being involved in undifferentiated patient assessment is adequate given the evolving nature of many patient conditions.
 
‘Doctors, especially in leading the diagnostic efforts for a patient’s care, have a broad basis of understanding what’s going on, and therefore are able to think laterally,’ he said.
 
‘Considering the Australian system, we have to recognise that involvement in clinical care that is beyond the scope of training that has been core to your clinical specialty is likely to result in poorer patient outcomes.'
 
Log in below to join the conversation.

general practice reform medical workforce NHS physician assistants role substitution scope of practice