NHS physician associates should be banned from diagnosing patients who have not already been seen by a doctor, a government review has concluded.
The review calls for the government to overhaul the role of physician associates (PAs), who it says have been substituted in for doctors to fill staffing gaps despite having significantly less training.
The health secretary, Wes Streeting, ordered the review of the more than 3,500 PAs and 100 anaesthesia associates (AAs) working in the NHS after six high-profile deaths of patients who were misdiagnosed by PAs.
Prof Gillian Leng, the president of the Royal Society of Medicine, spoke to more than 1,000 people for the review and concluded there were “no convincing reasons to abolish the roles of AA or PA” but there was also no case “for continuing with the roles unchanged”.
She wrote in the report: “Despite the significantly shorter training, PAs and to a lesser extent AAs have sometimes been used to fill roles designed for doctors. The rationale for doing this is unclear, and was probably one of pragmatism and practicality, relying on medical staff to provide the additional expertise when required.
“This lack of planning may have been responsible for driving the resentment felt by some resident [doctors] and potentially exposed patients to unnecessary risk.”
One of her main recommendations is that PAs should not see “undifferentiated or untriaged patients”, meaning those who have not yet been diagnosed by a doctor. Leng recommended further work to establish which patients they should be able to see and to set clinical protocols that would enable PAs to diagnose patients with mild ailments.
“Let’s be clear, [the role of PAs] is working well in some places, but there indeed has been some substitution and any substitution is clearly risky and confusing for patients,” she said.
Leng recommended PAs should be renamed “physician assistants” and AAs “physician assistants in anaesthesia” to ensure that patients and their families are clear on whether they have been seen by a doctor. She observed that this confusion was the core concern voiced by the bereaved families she had spoken to, who believed it was a contributing factor in their loved ones’ death.
She noted in her report that despite the role’s rapid expansion since it was introduced in the early 2000s, there was limited data and evidence on whether PAs were safe or unsafe. Most concerns related to PAs being the first clinician to see patients unsupervised. “Making the wrong initial diagnosis and putting patients on an inappropriate pathway can be catastrophic,” she said.
The report found that “relatively few doctors felt it was appropriate for PAs to diagnose illness” and it identified disparities between the tasks PAs considered right for them to carry out and what doctors thought.
Leng recommended that newly qualified PAs work in hospitals for two years before they are allowed to work in GP surgeries or mental health trusts, enabling them to start their careers where there are more training opportunities and supervision.
She also recommended more leadership training for doctors, who shared concerns about the lack of preparation for supervision duties, and better career development for PAs and AAs. She suggested a named doctor supervise each PA, while uniforms, lanyards, badges and staff information should be standardised to “distinguish physician assistants from doctors”.
Dr Tom Dolphin, the chair of the British Medical Association, said the report “laid bare the catastrophic failures in NHS leadership that have put patients at serious risk of harm”, but he argued the recommendations did not go far enough on national patient safety standards.
“Prof Leng has succeeded in exposing how NHS England introduced these roles and encouraged their expansion without any robust evidence of their safety,” he said. “The report reveals inadequate national leadership, no accountability and no attempt to listen to the concerns raised by doctors, patients and coroners.
“The blurring of lines between doctors and non-doctors, aided and abetted by the GMC [General Medical Council], has been an unfolding disaster for all to see, and many doctors today will be relieved to see that they were right to raise the alarm,” Dolphin said.
Dr Naru Narayanan, the president of the hospital doctors’ union, the HSCA, said: “Safety concerns will continue until a properly defined national scope is established. The review acknowledges this by calling for standardised job descriptions and clinical protocols. This work needs to be fast-tracked.
“Given how poorly these roles have been defined, and the fact physician assistants earn more after a couple of years of clinical training than resident doctors do after nearly a decade in medicine, it’s not surprising there’s been tension. We’ve got a shortage of medical training places and a limited supply of trainers. Additional support and time for senior doctors, as recommended by Prof Leng, are essential.”
