There is a role for physician associates in the NHS – GWC Mag

We are in the midst of a political and professional storm over the role of the Royal College of Physicians (RCP) in supporting physician associates (PAs).1 Concerns around the profession’s scope of practice, supervision, and regulation have come to the fore in recent months. The NHS has changed beyond recognition since I qualified as a doctor almost 40 years ago and I genuinely believe that the development of multidisciplinary team (MDT) working has improved access to services, evidence-based care, and continuity of care. On 13 March 2024, the RCP will hold an extraordinary general meeting (EGM) to discuss these concerns and, whatever its outcome, we must use it as an important opportunity to further the conversation about how these multidisciplinary teams—including PAs—can work together safely to provide the best care possible for patients.

PAs have worked in the NHS for over 20 years, and since 2015 the RCP has supported the profession’s governance and leadership by hosting the Faculty of Physician Associates (FPA). Our aim has been, and continues to be, to help the profession develop in a way that is distinct and supplementary to doctors. Looking back, our communications from that time are optimistic about MDT working.2 I worry this has been lost in recent months, as the NHS struggles to balance huge patient demand with a workforce crisis and unresolved industrial action.

There are over 370 000 doctors on the UK medical register held by the General Medical Council (GMC) and the NHS England long term workforce plan commits to an extra 60 000 to 74 000 doctors and a total of 10 000 PAs in the NHS by 2036/37, with PAs making up just a small fraction of the workforce.34

We are clear that PAs are not doctors, cannot and must not replace doctors. However, we recognise that there is still some ambiguity around their scope of practice and about their role for patients.5 Employers must ensure that the supervision of PAs is never to the detriment of the training, education, and supervision of doctors—and must give those with supervision responsibilities adequate time for this role. We are clear that PAs must always explain their role accurately to patients.

There have been missteps along the way that have contributed to the current issues, including the commitment in the long term workforce plan to expand the PA profession before regulation, disagreement around who should be the regulator, the unfair difference in pay between newly qualified doctors and PAs, and the potentially inappropriate use of PAs in some short-staffed NHS environments.6 The combined impact of these has led us to where we are today.

Last week, the BMA issued a document outlining scope of practice for MAPs.7 We have long said more guidance on PA scope needs to be developed. Unfortunately, the RCP was offered no involvement in shaping the document and, in our view, patient safety is better served by collaboration. Different sets of guidance are unlikely to improve patient safety—the best approach is for the profession to come together to provide shared clarity for patients.

In 2023, RCP Council’s consensus statement acknowledged the debate and our commitment to providing additional guidance on scope of practice and supervision for PAs this year.8 Following a request from RCP fellows, Council will hold an extraordinary general meeting (EGM) on 13 March to discuss the concerns held by some fellows and members.910

Our historic byelaws allow only RCP fellows to participate in the meeting, but there are mixed views among our wider physician membership, so we have also surveyed subscribing UK doctor members (not fellows) ahead of the meeting. In the past the RCP has been criticised for a perceived lack of transparency. We have listened and acknowledged there were things we could have done better. We must now face the issues circulating about PAs head on.

Advocates for a pause in regulation and recruitment of medical associate professions argue that this is a patient safety issue.11 They tell us that errors have been made, scope and competencies ignored, and qualifications misrepresented. Unfortunately, there will always be staff who behave unprofessionally and jeopardise patient care, regardless of their role. This is why regulation is important: to establish reporting mechanisms that protect patients from harm. Now that the necessary legislation has passed, I’m hopeful that regulation will be in place by the end of 2024.12 We have made it clear to the GMC that once PAs are regulated, the difference between a doctor and PA must be clarified on the register. Last week, the GMC confirmed this will be the case.13

Living with uncertainty has been exhausting and demoralising for people working in healthcare, including PAs. I have met both doctors and PAs on my trust and health board visits, many of whom feel let down by the system. Doctors are understandably becoming more unsettled by a lack of clarity, while a growing number of PAs say they face hostility at work.

The RCP must be at the heart of open and honest debate around the role of PAs. We need a culture of learning where people feel safe and empowered to speak up without fear of being targeted online. The upcoming RCP EGM is an opportunity for our fellows and members to move this conversation forward in a positive way so that doctors, physician associates and patients can have clarity and feel assured that the best care can be delivered.