NHS Grapples with Deepening Dispute Over Physician and Anaesthesia Associate Roles

For Julia, her initial four years as a physician associate (PA) fulfilled her expectations. Having spent almost ten years in a non-patient-facing capacity within the NHS, she found satisfaction working on hospital wards, assisting doctors and other healthcare professionals. She stated, “I loved the contact I had with patients, assessing them and playing a part in their care. I felt supported and part of a team.” Approximately a year ago, this positive experience shifted. Julia recounted, “Suddenly we came under attack. Doctors in the radiology department started refusing to talk to me about scans and others have been saying we don’t deserve to get paid what we do.“The atmosphere has totally changed. We’ve even stopped going into the canteen as we were being made to feel uncomfortable.” Julia’s situation is not unique. United Medical Associate Professionals (UMAPs), an organization representing physician associates (PAs) and anaesthesia associates (AAs), reports numerous comparable cases where staff encounter bullying and are marginalized. The Academy of Medical Royal Colleges, representing senior doctors within the NHS, has issued a warning that the overall situation has grown so “destructive” it is impairing teamwork in hospitals and general practitioner surgeries employing PAs and AAs. The Academy pointed to the especially contentious debate occurring on social media, characterized by frequent criticisms regarding the remuneration and professional conduct of PAs and AAs, alongside conversations about strategies to diminish their roles in professional settings. This week, Health Secretary Wes Streeting determined that intervention was necessary, commissioning a review of PAs and AAs in England to address what he described as a “toxic” dispute. This raises the question of how the situation escalated to doctors opposing the very individuals introduced to assist them. The role of a PA is not recent within the NHS, having been established for two decades, assisting doctors with duties such as compiling medical histories and conducting examinations. The significant change lies in the accelerated pace of their recruitment; over the past seven years, their numbers have increased from a few hundred to 3,500 currently, with an objective of reaching 12,000, encompassing AAs, by 2036. With the rise in their numbers, doctors have expressed apprehension that the distinctions between professional roles are becoming indistinct. Sam, who is five years into his medical training, works alongside PAs at a hospital in the South West. He stated, “They are more of a hindrance than a help,” adding, “They’re being placed on rotas instead of doctors – but there are things they cannot do so doctors end up having to double up.“And for those doctors at the very start of training having PAs on a ward can actually limit their exposure to some of the medical tasks that should be part of their learning. We’ve had enough.” The British Medical Association (BMA), the doctors’ union, is sufficiently concerned to advocate for a halt in the rollout of these roles pending the outcome of the review. The BMA asserts that PAs and AAs, who undertake a two-year master’s degree after an initial degree typically in a bioscience field, are being assigned responsibilities outside their intended scope and are deputizing for doctors. This, the union contends, jeopardizes patient safety. To substantiate its assertions, the BMA references two prominent cases: the deaths of patients Emily Chesterton and Susan Pollitt, following consultations with PAs. Additionally, the BMA refers to a survey from last year involving 18,000 of its members, which revealed that almost nine out of ten respondents believed the current operational model for AAs and PAs in the NHS consistently or occasionally presented a risk to patient safety. Dr Emma Runswick, deputy council leader for the BMA, stated: “We’re seeing PAs doing things, such as ordering scans they are not qualified to order and prescribing drugs that they aren’t qualified to prescribe. “And when they see patients it’s not always clear to the patient that they are not being seen by a doctor. It’s dangerous and has got to stop.” The union is advocating for the establishment of stringent guidelines that would delineate the permissible and impermissible actions for PAs and AAs. The BMA’s proposal would fundamentally confine their responsibilities to those of assistants, involving tasks such as assisting with ward rounds, drawing blood, following up on scan results, and coordinating discharge procedures. Conversely, Stephen Nash, chief of UMAPs, asserted: “It’s not about patient safety, but about protecting their interests. They want us to be subservient.” Nash characterized the reported fatalities as “absolute tragedies” but expressed apprehension regarding their deployment to discredit an entire profession. He added, “There is meant to be a no-blame approach to learning the lessons from failures.” Nash explained that errors typically stem from numerous contributing factors, yet the campaign targeting PAs and AAs has resulted in their role being unfairly isolated. He concluded, “It misleads the public.” Ultimately, the independent review, headed by Royal Society of Medicine president Prof Gillian Leng, will be tasked with ascertaining the facts of the matter. A crucial resource for this will be the NHS England database, which compiles patient safety incidents reported by healthcare services nationwide. While data for the previous year is not publicly accessible, a senior NHS source commented: “The key here is not whether PAs are making mistakes – everyone in the NHS does, doctors included – but whether they are making more mistakes and causing more safety incidents than you would expect. “The reports are complex and nuanced quite often, but there’s nothing in there that immediately rings alarm bells.” This contention is not confined to hospital wards and general practitioner consulting rooms but has permeated the highest levels of the medical profession. Although the Academy of Medical Royal Colleges has largely endorsed the introduction of PAs and AAs, several of the 23 constituent colleges it represents have been embroiled in internal disputes regarding the matter, resulting in resignations. The Royal College of Physicians, the Royal College of GPs (RCGP), and the Royal College of Anaesthetists have all recently shifted their stance towards opposition. An individual familiar with the developments within the royal colleges commented: “There have been some huge rows – I fear relationships have been damaged permanently. As royal colleges we were always traditionally above the politics of trade unionism.“There is a group of doctors that see PAs and AAs as a threat – we saw the same when nurses took on extra responsibility years ago.” Legal professionals have also become involved, with UMAPs contemplating legal action against the RCGP, based on the belief that the latter’s opposition has resulted in job losses for some PAs. Furthermore, the BMA has initiated a legal challenge against the General Medical Council, which is scheduled to commence regulating PAs and AAs next month. The union objects to the same regulatory body overseeing both doctors and PAs/AAs, arguing that this would further obscure professional boundaries. It is evident that this disagreement will not be easily resolved. Meanwhile, frontline staff are left to navigate the ongoing challenges. Mr Nash stated, “PAs and AAs are worried every time they go into work,” adding, “A very powerful lobby within the medical profession has turned against them. It’s a really horrible time.”