Thereâs a fierce debate going on at the moment about Physician Associates in the NHS, and so I thought it was time to examine whatâs going on.
Physician associates arenât a new concept; there have been a small group within the NHS since the early 2000s. However, they used to be referred to as âphysician assistantsâ, and there werenât very many at that time. The Conservative government, however, has decided to rapidly expand the numbers of physician associates (PAs), and anaesthetic associates (AAs), and theyâre aiming to build a workforce of 10,000 PAs and 2000 AAs by 2036/2037, causing a huge amount of concern.
In order to explain why people are so worried, itâs important to understand the role theyâre now expected to perform in the NHS, and the differences between a PA and a doctor. Doctors go to medical school; this takes a minimum of four years (if youâre already a graduate and are being fast-tracked), but most people complete a medical degree in five. All medical degrees involve the same type of learning - lots of lectures and textbook learning, and also hundreds of hours of learning within clinical environments, where students are attached to different medical teams to learn about each speciality in turn. This learning continues once medical school ends and you qualify as a doctor. There is a structured training programme for foundation doctors - the first two years after you qualify as a doctor, when you rotate around many different specialities - and then you can apply competitively to a speciality training programme. All doctors - surgeons, GPs, hospital medics, the lot - have to undergo a rigorous specialist training programme involving postgraduate exams in order to train to become a fully qualified specialist in any givenarea of medicine.
The course, the training and the apprenticeships have been honed over decades. Medical training is gruelling and all-consuming, but it is consistent. If you move from one NHS hospital to another, or one area of the UK to another, you could walk into a hospital as a doctor, declare your level of training, and the team around you would have a pretty accurate idea of your level of expertise, and your need for supervision. This, incidentally, was really important during the pandemic. Teams were rapidly assembled and moved from one ward to another, and this ability to identify the level of experience of every member of the team was really important. In full PPE, it was difficult for staff members to see each othersâ faces, and so many teams wrote their role â essentially their rank - on their faceguards with a pen in big letters (CONSULTANT, SHO, REGISTRAR) to enable a swift flow of decisions up and down the chain of command.
This hierarchy of decision-making is absolutely crucial in understanding the debate around physician associates. Medicine has a strict hierarchy of supervision, learning and decision-making, and that makes patients safe.
Physician associates are not doctors. They do not go to medical school. They aregraduates who have a degree (âin a health, biomedical science or life-sciences subjectâ) and they then complete 2 years of postgraduate study to become a PA. They are trained with the âmedical modelâ which means that they are taught to perform some of the tasks that doctors do; for example talking to a patient about their symptoms (which is called âtaking a historyâ, or âclerkingâ), or examining a patient. They do not, however, have the grounding of medical knowledge that doctors have, and so it is often difficult for doctors to understand their professional limits. They might understand what an allergic rash looks like, for example, but do they understand the physiological mechanism taking place? They might understand when a blood test shows poor kidney function, but do they understand the anatomy of the kidneys? How much do they know about anaemia? The clotting cascade? Thyroid function? This is why, for so many of the doctors Iâve spoken to, they arenât sure at what level to pitch their discussions with their PA colleagues. They donât want to patronise their new PA colleagues, but they donât want to assume a level of understanding either. All of this is highly stressful in busy clinical environments because, atthe moment, NHS doctors donât have much time to stop and discuss the basis of disease. Theyâre rushed off their feet.
Because PAs are not doctors, they are also not allowed to prescribe medications, and so doctors are meant to supervise them. But this is causing problems too. After all, if things are extremely busy, doctors often donât have time to supervise PAs all the time, and are now being put in compromising positions. Should they sign the prescription that a PA says is necessary for a patient? Can they trust the physical examination that has been performed? How accurate was the information that came from the PAâs clerking of the patients they have seen, and are they willing to put their signature to the decisions made off the back of this work?
From what I have heard, the situation varies wildly across the UK at the moment. There are NHS departments where PAs are receiving excellent supervision, and where they are a valued addition to a busy and well-functioning team where everyone understands their role. There are other places, however, where, due to chronic understaffing, it is difficult to offer PAs the supervision required. On top of this, many members of the public are extremely confused about their role.