Physician and Anaesthetist Associate Roles: Review
(1 month, 1 week ago)
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Baroness Bennett of Manor Castle
To ask His Majesty’s Government what the review, announced by the Secretary of State for Health and Social Care on 20 November, of the physician associate and anaesthetist associate roles will cover; and what actions they plan to take in advance of the outcome.
Baroness Bennett of Manor Castle (GP)
My Lords, I thank noble Lords for staying with us late on a Thursday for this debate. I know there are many noble Lords, among them the noble Baronesses, Lady Finlay and Lady Brinton, who moved regret Motions about the statutory instrument passed under the previous Government that is behind the mess we are discussing today and who would have very much liked to take part.
I will not go over the same ground as I did in February, when I begged the then Government to pause their action, but the concerns expressed then have only grown, reflecting many of the reasons why Professor Gillian Leng has been asked to conduct the review of PA and AA roles. In the words of consultant Partha Kar, the Government’s national adviser on diabetes, we have seen
“months of heated debates, social media uproar, royal colleges in turmoil, and the reputation of many national organisations being questioned”.
Professor Kar has described this as
“the worst example of a policy implementation in the NHS I’ve seen”.
I note that just this week the Irish Medical Council concluded that it was not the appropriate body to regulate PAs, and referred to
“the potential for emerging patient safety risks arising … as observed recently because of regulation of PAs by the GMC in the UK”.
I shall ask a large number of questions. To be fair to the Minister, and to ensure that this debate is as constructive as possible, I have shared my questions with her in advance. I begin with the first part of my question, about the review itself. I have heard only respect and hopeful feelings about Professor Leng being appointed as lead, but many concerns have been expressed to me about the level of co-operation that the review will receive and the quality of information available to it. Just yesterday, the GMC wrote to medical bodies, nine days before it is due to begin registering PAs and AAs, saying that it would
“soon publish a report on the outcome of the consultation and the research; along with the final drafts of the rules, standards, and guidance”.
That report was published just two hours ago, before this debate started.
Does the Minister consider that to be an appropriate timetable and level of transparency? Is the Minister happy with the response of the GMC to requests for information over this difficult year? Can the Minister assure me that Professor Leng will have the necessary resources and that the Government will do everything necessary to ensure that she receives full co-operation and transparency?
We have seen many different, often disturbing, localised reports about the ways in which PAs in both hospital settings and general practice have been deployed. Knowledge and concern about the deployment of PAs and AAs is growing among patients and the general population. I note that the Fire Brigades Union conference in May voted to oppose the growing use of PAs. Will Professor Leng have the resources to access those public views?
The review’s remit seems quite narrow. An obvious omission is the ask from the Royal College of Physicians that it should consider the impact of the PA role on training opportunities for resident doctors. Will the review do that? Further, will it consider the fundamental issue that the “taskification” of medicine is a massive change from previous practice and a reversal of the recent growing understanding of the need to consider the whole human, and their environment, in supporting health and tackling disease?
Our debate in February heard considerable concerns about the impact of PAs on doctors’ training. There were suggestions from all sides of the House that a major revamp of training arrangements for doctors needs to be put in place. Can the Minister write to me about what plans the Government might have in that area? I want mostly to focus what interim measures the Government plan to deal with what is clearly an untenable current situation. In February, the then Minister, the noble Lord, Lord Markham, said that PAs and AAs are
“very much a supplemental role rather than a substitute”.—[Official Report, 26/2/24; col. 912.]
Of course, that is not what has been happening, as demonstrated by a letter sent in March from NHS England to ICBs and trusts. It said that PAs
“should not be used as replacements for doctors”
on rotas, yet a detailed investigation by “Channel 4 News” in October found widespread subsequent use of such substitutions. A number of trusts indicated that they did not even keep any records of such substitutions. Does the Minister stand by that NHS England guidance? What will the Government do to ensure that it is implemented?
The Government’s announcement of the review said that it is to report in spring 2025. Your Lordships’ House knows that government definitions of seasons means that that could extend well into the year. By the time report is absorbed and action decided, realistically, we are talking about a year of a clearly untenable situation. Does the Minister agree that interim action is surely needed?
In September, the governing council of the Royal College of General Practitioners voted to oppose a role for physician associates working in general practice. Reports suggest that, as a result, PAs are being made redundant—they have my sympathy—and general practices face the risk of legal action. How will the Government deal with this situation and prevent it escalating, at great cost to NHS services?
The council of the Royal College of Physicians has agreed that there is a limited role for physician associates working in secondary care in the medical specialties, as long as they are supported by clear supervision arrangements, professional regulation and a nationally agreed scope of practice. Do the Government agree? Will they take action immediately to deliver this, at least in an interim way? Do they agree that such supervision urgently needs to be defined?
I turn to caring for our children, and highly vulnerable patients at risk of rapid deterioration in condition, an area of particular concern. The Royal College of Paediatrics and Child Health has called for an immediate pause in the recruitment of PAs. Given the very disturbing situation that arose at Alder Hey hospital, does the Minister agree that there should be such a pause?
The House may well ask where guidelines across disciplines for national scope—a ceiling of practice—for PAs and AAs might come from. I was at the launch of a detailed, carefully prepared British Medical Association outline of a PA/AA scope document. I did not hear anyone express serious concerns about the activities of PAs and AAs being safe, if they were working to that outline. Does the Minister agree?
Later this month—very soon, I think—it is expected that the Royal College of Physicians will publish draft “safe and effective practice” guidance on the supervision of PAs, alongside a definition of the PA role drafted by the RCP resident doctor committee and agreed by both the PA oversight group and the RCP council. Does the Minister agree that this should be applied?
To back to our debate in February, I suggest that the Minister misspoke in saying that the GMC is regulating. What is due to come into practice on 13 December is a registration process for which there is a two-year lead-in period, so it will in effect remain voluntary until December 2026. I respectfully suggest that, without a national scope and clear guidelines for supervision, this cannot in any way be described as “regulation”. It is purely registration. Does the Minister agree?
I turn to AAs specifically, and an issue of grave concern—including legal concern—that was recently raised with me. In the current regulations, AAs and PAs are not allowed to prescribe or order ionising radiation. How can someone acting as an anaesthetist not do so? Expert advice that I have received suggests that the tool of patient-specific directive, which are meant to allow a doctor to direct another professional in making a limited choice of drugs under very specific circumstances, is being used and possibly misused. I am told that PSDs are being used to provide an extensive list of drugs for AAs to choose from; in essence, that means that they are prescribing. Can the Minister comment on that?
Finally, I turn to a couple of broader “What now?” questions. The NHS careers website’s PA/AA page, which I consulted yesterday, lists 39 universities offering courses for these roles. I have heard that several are pausing these courses. Does the Minister think it is fair to encourage students to start new PA and AA courses, given the uncertainty while the review is conducted?
I conclude by stressing that my questions to the Minister, my concerns and the mess that we are in now are not the fault of PAs and AAs who, in good faith, have signed up for service, studied and got the debt to show for it. Can the Minister assure me that the Government are committed to ensuring that a way forward will be found for them, whatever the review’s conclusions and future steps?
Baroness Keeley (Lab)
My Lords, I welcome the opportunity to speak in this short debate on the review of the physician associate and anaesthetist associate roles and what actions the Government plan. I congratulate the noble Baroness, Lady Bennett of Manor Castle, on the debate and her opening speech. I will start by focusing on the way in which physician associates are used in the NHS and some of the consequences this has had.
In July 2023 I led an Adjournment debate in the Commons on the use of physician associates in the NHS. I did so to raise issues in the case of Emily Chesterton, the daughter of my former constituents Marion and Brendan Chesterton. Emily tragically died of a pulmonary embolism, aged 30, after seeing the same physician associate twice at her GP practice and being misdiagnosed.
The circumstances of Emily’s death were investigated by a coroner in March 2023. Messages from Emily examined at the inquest evidence Emily’s belief that she was seeing a doctor, that the appointments with the physician associate were short and that Emily was not examined fully. The conclusion of the coroner was:
“Emily Chesterton … attended her general practitioner surgery … with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived”.
Crucially, the physician associate did not seek medical advice after seeing a patient who had presented twice in one week with significant risk factors for pulmonary embolism, and she sent Emily home without consulting a doctor about her symptoms.
I said in that Commons debate that Emily’s case raises serious questions about the wider use of physician associates in the NHS. In particular, it raises questions about allowing physician associates to carry out unsupervised one-to-one consultations with undifferentiated patients in general practice. PAs are a dependent role; they are meant to be under the supervision of a designated medical practitioner, but that does not appear to have been the case with the lack of supervision that occurred in the case of Emily Chesterton.
The GP practice later raised concerns about the physician associate’s knowledge and understanding of what investigations she should perform on a patient presenting with those symptoms, about her ability to recognise an unwell patient and escalate those concerns to a doctor, and about her overconfidence and lack of insight into the limitations of her own clinical knowledge and practice.
Since I raised Emily Chesterton’s case, my fears about these roles have increased. There have been other deaths involving PAs. Susan Pollitt died after a drain was mistakenly left in her abdomen for 21 hours by a PA. The inquest concluded that her death in Royal Oldham Hospital in July 2023 had been caused by an
“unnecessary medical procedure contributed to by neglect”.
The Northern Care Alliance NHS Foundation Trust, which runs the Royal Oldham, found that Mrs Pollitt would have survived had the drain been removed earlier.
As we have heard, there are also examples of PAs taking on roles that are far too complex for their experience and knowledge. Alder Hey Children’s Hospital has now admitted that, from 2019 to 2023, a PA worked in a role that involved child sexual abuse medicals. Alder Hey had originally denied that PAs were being used in its paediatric sexual referral centre, which is for children under 16 who have experienced sexual abuse.
Dr Matt Kneale, former chair of the Doctors’ Association, said
“This is flagrantly unsafe. I have no confidence that those cases have been assessed to the same competence of a senior paediatric doctor. Children deserve better”.
Alder Hey later admitted that it stopped deploying a PA within its safeguarding team after concerns were raised by the Crown Prosecution Service and the police about relying on the evidence of a PA in court cases.
The Royal College of Paediatrics and Child Health has just published a survey of the experience of paediatricians working with PAs, with 2,200 responses. The survey reported the following safety issues in the work of PAs: misdiagnosis, 63%; miscommunication, 58%; failure to escalate deterioration, 48%; undetected deterioration, 23%; and ordering ionising radiation—which PAs are not allowed to do—9%. The RCPCH survey also reported that 72% of paediatricians with experience of working with a PA believe that their recruitment should be halted.
There are many more examples where patient safety is seen to be endangered by the way in which PAs and AAs are being used in the NHS. This is not helped by seeing a number of posts on social media with PAs videoing themselves, their patients and their clinical settings just to make posts on TikTok or other social media. Concerned consultants who highlighted these inappropriate videos to the press have said that PAs are coming very close to the line of professional misconduct by making these videos.
The new Government have inherited what is effectively a Wild West in medical care, because a new medical role was brought in without regulation, with only voluntary registration and no national scope of practice for PAs and AAs. GP members of the BMA have voted in favour of stopping hiring PAs in general practice and phasing out the PA role. They also stated that the role of PA is inadequately trained to manage undifferentiated patients and that there should be an immediate moratorium on such consultations. The medical royal colleges, as we have heard in this debate, are making their strength of feeling heard on these safety issues. This was recently summarised by Professor Martin McKee in an article in the BMJ.
As I mentioned, the Royal College of Paediatrics and Child Health found substantial safety concerns with PAs working in paediatric settings. The Royal College of GPs has agreed to oppose the role of PAs working in general practice, following a consultation of its members.
The Royal College of Physicians of London is now advocating for a limit to the rollout of the PA role, following a survey of its members. Its sister royal college in Edinburgh has called for a delay in implementation
“until clear nationally agreed scope and ceiling of practice protocols are in place and clear plans regarding post-registration training and assessment of PAs are defined”.
The Royal College of Surgeons has also expressed concerns, including the risk that the expansion of these roles could undermine the roles of surgical care practitioners, surgical first assistants and advanced nurse practitioners. As we have heard, the Royal College of Anaesthetists, after noting concerns about the current use of AAs, has called for a pause in their recruitment.
The Royal College of Radiologists says it has
“no plans to bring PAs into the College and we do not anticipate a significant expansion of the role within our specialties”.
The Royal College of Emergency Medicine also
“does not currently support the expansion of the Physician Associate workforce in Emergency Medicine”,
again supported by a member survey expressing widespread concern. Now, as we have heard, the Universities of Chester and Portsmouth have halted recruitment to their PA courses for 2025, and the University of Leeds no longer lists the course on its website.
On announcing the Leng review, Secretary of State Wes Streeting said that
“there are legitimate concerns over transparency for patients, scope of practice and the substituting of doctors”.
I agree.
I believe the issues that need to be tackled are these. We need to focus on the unsafe substitution of physician associates in what should be doctor-only roles and rotas, and we should put a stop to that substitution while the Leng review is in progress. We need to accept that it is time to pause the recruitment of PA and AA roles and to halt the expansion of their numbers, particularly until after the Leng review reports, and we should take action, as we have heard, so that PAs and AAs in existing roles are now given the opportunity to retrain into other roles.
In the interim, I hope we can accept that there must be proper regulation of PAs and AAs. They must work within a national scope of practice agreed with the royal colleges. As a first step, as we have heard, the BMA’s safe scope of practice could be adopted.
After the tragic deaths, such as those of Emily Chesterton and Susan Pollitt, we must also hear the voices of patients and the public. Do people want these roles, or would they rather see a doctor?
I end with a quote that Emily’s mother, Marion Chesterton, sent to me. She said:
“We hope that, for all our sakes, precise, thorough and true regulation of PAs will end the chaos, confusion, vagueness and potential danger to patients. We pray for clarity, honesty and co-operation. If our daughter’s life means anything, please, sort out this sorry mess. No more Emilys”.
The Lord Bishop of London
My Lords, it is good to participate in this important debate and I am grateful to the noble Baroness, Lady Bennett, for having secured it. I declare my entry in the register of interests, specifically that I was formerly the Government’s Chief Nursing Officer.
This is clearly a complex issue, and I join other noble Lords in welcoming the Government’s recently announced review of the physician associates and anaesthetist associates. In building an NHS fit for the future, it is right that the right people with the right training and the right competence undertake the right roles. Over the last 20 years, we have seen an expanding of roles to release medical staff to do what only they can do; for example, the development of nurse-led assessment, advanced nurse practitioners and nurse prescribing, and the expansion of the role of pharmacists. In some sense, the development of physician associates and anaesthetist associates is part of this change. However, any change in role and the healthcare workforce needs to be carefully implemented and regulated. Therefore, I welcome the regulation of physician associates and anaesthetist associates, but I too question whether their regulation should take into account the outcome of this review, rather than moving ahead at present.
The main points I will make are around clarity and trust. Noble Lords will often hear me speak in this place about the essential commodity of trust in healthcare and the health of the nation. Research carried out by Healthwatch found that the public awareness of physician associate roles is mixed, particularly among older people, who are less likely to know the difference between a PA and a GP. Clear information needs to be given to people about the healthcare worker they are seeing, and they need to be reassured that they are competent and working to clear standards.
I am encouraged to hear that both roles and standards will be examined in the review, but can the Minister tell us whether what and how information is given to the public will be part of the scope? I also wonder whether we can learn from past changes, such as the introduction of nurse prescribing, to help us understand how we bring about this type of change.
Giving clarity is a vital step towards ensuring trust, particularly in primary care. We must ensure that we are transparent and that we focus on building trust as a priority. I also speak from a London perspective, where the memory is fresh of the great losses during Covid that were disproportionate in some communities, especially those that still struggle to reach the health service—their trust in primary care is low. Will the Government assess the distribution of physician associates as part of the review and examine how patients might have greater clarity about who they are seeing at an appointment? This is especially important where communication might be difficult, such as when English is a second language. According to the Royal College of General Practitioners, GPs in more deprived areas are responsible for caring for more patients than those in affluent areas. It would be helpful to know how physician associates fit into that picture.
Looking more generally at the workforce and the long-term workforce plan, which accelerates the expansion of physician associate and anaesthetist associate roles, do the Government plan to change the projections of this expansion based on the outcome of the review? What impact will this have not just on the plan but on the wider workforce?
The issue of supervision has already been raised in the debate. While I welcome the diversification of roles in the multidisciplinary team to ease pressure where it is appropriate, it is absolutely clear that the supervision of those roles is important. Who is supervising them? Who are they accountable to? That is particularly the case when there is pressure already on our health service.
When the long-term workforce plan was first published, I am not sure that it answered the question related to supervision. On apprenticeship schemes for roles such as this, what progress has been made to ensure that in hospital settings and primary care, funding is given for backfilling? When apprentices are paid and have time for study, is the hospital or the primary care setting able to backfill with staff? If the Minister has any insight into how this has progressed since the plan was published, I would be grateful to know.
The role of the physician associate is a controversial topic, as has been highlighted in this debate. It is having a very clear impact on team dynamics. Within some of those teams, staff are reporting bullying. Staff morale is low, including that of the physician associates and anaesthetist associates. I wonder whether this should be a high priority for the Government and a dimension of the review.
Finally, I hope that the Government will learn from this review and that the learning they undertake will be transferred to other areas of health. As the Government shift from sickness to prevention, from hospital to community, as part of their 10-year plan, it is likely that diversification—in primary care but also elsewhere—will be required and will need to grow. Therefore, there is an opportunity to learn from this review and to roll that learning out. I look forward to hearing from other noble Lords on this important issue and from the Minister when she responds.
Lord Scriven (LD)
My Lords, this has been a short but useful debate introduced by the noble Baroness, Lady Bennett. The Question that she laid before the House underlines the lack of balance that she opened with. She asked
“what the review, announced by the Secretary of State for Health and Social Care on 20 November, of the physician associate and anaesthetist associate roles will cover, and what actions they plan to take in advance of the outcome”.
I would hope that if a review of this controversial issue was taking place, it would be considered wise to wait for the evidence and recommendations, not just do something on instinct or limited evidence. Therefore, it is welcome that the Government have opened the Leng review into how physician associates and anaesthetic associates are deployed as part of a team to improve patient outcomes working under the supervision of doctors to support the delivery of medical care.
I thank the approximately 5,000 physician associates and 300 anaesthetist associates who are registered or practising for the professional and dedicated work they do, and the thousands of doctors, nurses and other allied medical professionals of all levels who quietly but professionally and supportively work alongside PAs and AAs as part of the medical team to improve the health of patients.
If I were to think back to when other health professional roles were introduced into healthcare settings when I was managing in the NHS, the issues raised about the work that these healthcare professionals do, and the potential issues that arise, are no different. This is not anything new. What is new is the level of unprofessionalism and hostility that has been shown to these roles.
The lack of respect and the bullying behaviour that some medical leaders within the BMA have decided to adopt when dealing with the issues around the use and deployment of these professionals are not only unacceptable but go against the very GMC regulations that govern you as a doctor. On collaborative working, the regulations say:
“Work effectively … with colleagues in the multidisciplinary team”
and
“respect the skills and contributions”
of all healthcare professionals. Some of the examples of ostracisation, making false claims and bullying at work fall far below what doctors are expected to do and the standards that they are expected to uphold. To that small minority of doctors, I say, “Stop”.
It is clear that PAs and AAs have not had the introduction or supervision that has led to some care being optimal. However, to quote individual cases and then equate the lack of patient safety with all PAs or AAs is neither useful nor correct. The very nature of healthcare is that risk is there and can and does lead to problems. This happens across all professional groups involved in healthcare provision. The issue at hand is whether PAs and AAs have more never events or near misses than other medical and healthcare professionals. Surely, that should be a key line of inquiry to work out the safety of these professions.
Physician associates are mid-level healthcare professionals trained under a medical model to support doctors in diagnosis, treatment planning and patient care. They have a science degree, predominantly, and two years of postgraduate training. PAs can enter the workforce sooner than fully qualified doctors, and, as some evidence suggests, they can make a real difference in relieving pressure on overstretched health services.
The NHS has been using a model of PAs since 2003, and their role has expanded over the years. Yet, despite 20 years of valuable contributions, their integration remains controversial. Some doctors have rightly voiced concerns about their short training period, lack of regulatory authority and potential competition for roles. These concerns deserve thoughtful consideration, which is why the investigation will take place, but they should not overshadow the evidence demonstrating the benefits that PAs and AAs can bring to our healthcare system.
Research led by Professor Vari Drennan and colleagues has provided compelling insights into the effectiveness of PAs across various settings. For instance, an observational study comparing PAs and GPs in primary care found that consultations with PAs resulted in no significant differences in re-consultation rates, diagnostic testing, referrals or patient satisfaction, while maintaining comparable patient outcomes. In secondary care, a BMJ Open study evaluated PAs working in emergency departments alongside doctors in training. It concluded that PAs were equally effective and safe, with no significant differences in clinical adequacy or unplanned re-attendances. What is more, PAs were praised for improving team continuity and efficiency, allowing doctors to focus on more complex cases. These findings demonstrate that PAs can provide high-quality care while addressing staffing mix issues in primary and secondary care settings.
To address the concerns, the new GMC regulation regime will help to deal with some of the genuine issues raised around the scope of practice. I need to be clear, as people keep talking about a national scope of practice. The scope of practice—that people are working within their competence—is down to the individual. That is exactly what the GMC does now with individual doctors. Individuals have to work within their scope of practice, and standards will be laid down by the GMC, which then allows the scope of practice and revalidation to take place. We need to be clear what we are talking about. Along with this new regulatory scheme, there will be professional accountability for education, training and conduct, and it will ensure that individuals undertaking these roles are safe to practise.
Secondly, it would be useful for the NHS to undertake a refreshed national public campaign to raise awareness of PAs and what they do. Some patients still mistake PAs for doctors or nurses, which can lead to confusion and undermine trust and satisfaction. Research conducted in 2021 revealed that a simple information leaflet, co-designed with patients, significantly improved patient understanding of and confidence in PAs. Expanding such initiatives across the NHS would enhance public confidence and empower patients to make informed decisions about their care.
As we move forward, and when the Leng review reports, we must ensure that PAs and AAs are regulated to the highest standards and adequately equipped to perform their roles. Furthermore, improving public understanding of PAs will help their role to be understood more widely by the public.
With these measures in place and other recommendations that will emanate from the review, PAs and AAs will not only help, as part of a modern medical team, to address the future demands of patients but, if the review identifies the key changes required and the Government act on them, become a vital part of a resilient NHS. I hope we can all embrace the opportunity to support our health service and improve patient care.
Lord Kamall (Con)
My Lords, I refer noble Lords to my interests as set out in the register. As a precaution, I will say that I work for a university that has just applied to open a medical school. I also used to be a research director at a think tank that wrote about medical issues, including physician associates.
I thank the noble Baroness, Lady Bennett, for securing this important debate, and other noble Lords who spoke. I am also grateful to the House of Lords Library and others who sent their briefings, the health professionals I spoke to, and the journalists who wrote the articles I read in preparing for the debate.
From this reading and from listening to the arguments, it is sad to see that the debate on physician associates and anaesthetist associates has descended into one that is polarised. Some have described it as toxic. We now read about lawyers being consulted and legal cases being launched. On one side, we hear from some doctors and their trade union, the BMA, that PAs and AAs are performing tasks for which they are not trained, that there is mission creep—indeed, that they are sometimes substituted for doctors—that patients are not always told that they are seeing a PA or an AA, not a fully qualified doctor or nurse, and that having PAs and AAs affects the training of some doctors. We also hear that PAs and AAs are blamed for poor medical treatment and even patient deaths. We heard about the sad case of Emily Chesterton from the noble Baroness, Lady Keeley.
On the other hand, I have heard and read about doctors praising these associates; PAs and AAs being bullied or shunned by doctors and health professionals, as the noble Lord, Lord Scriven, referred to; and, in some cases of medical accidents or deaths, that it is not always clear who is at fault and that it is unfair to pick on PAs and AAs when qualified nurses and doctors have also caused deaths and put patients at risk. Others have called for a no-blame culture if we really want to get to the bottom of these incidents.
I have also heard from managers who agree that PAs and AAs should perform only tasks for which they are trained, but who feel that opposition to PAs and AAs is based on doctors and nurses protecting their interests. After all, maybe that is their job. I read a letter from a retired doctor who wrote:
“Physician associates can be a huge asset to the NHS if trained, regulated and supervised appropriately … some of the antagonism from the medical establishment seems protectionist rather than in the best interests of patients”.
In another letter, a cardiac consultant wrote:
“The dispute about the role of physician associates in the NHS is rooted in dogma. Whether the person delivering treatment is a medical doctor is not the issue. What matters is that anyone delivering healthcare is trained and qualified to do so, practises within the correct guidelines and has access to support and guidance whenever a situation arises that falls outside the routine. This should apply to PAs, resident doctors and experienced consultants alike”.
At the same time, though, another consultant wrote that he was
“puzzled by the need for physician associates”
when there are already
“well-trained nurses in speciality roles”.
With that great British understatement, I acknowledge that opinion is divided. But on delving deeper into this debate, there is some hope and some consensus. After all, it seems common sense that physician associates and anaesthetist associates should perform only tasks for which they are trained, but our system of health and care has to continue to evolve, as it has done since the founding of the NHS in 1948. Where appropriate, we may see more tasks delegated from doctors to other medical professionals, but with clear regulations and delineation, as the right reverend Prelate the Bishop of London said.
When I went to a GP surgery as a child, I always saw a GP, but these days, as a patient, I do not always need to see a GP. I may sometimes see a nurse, a physiotherapist or a pharmacist at the surgery instead. It seems reasonable for PAs and AAs to be trained to perform more tasks on the job, under the supervision of qualified doctors.
I am also sure that there is consensus on the need for total transparency when patients see PAs and AAs, and on what they are qualified to do. I have heard from former hospital employees who stress the importance of a clear delineation of what PAs and AAs can and should be allowed to do in a clinical setting. One gave the example of an ECG. A nurse or a healthcare support worker will perform the ECG, but they then need sign-off from a clinician. I was told by that former employee that not all nurses or healthcare support workers know who is authorised to sign that off. So there must be absolute clarity of responsibility for clinical duties, such as the guidance issued by the Royal College of General Practitioners, which states that PAs should explain that they are not doctors when they introduce themselves to patients, and wear clear name badges.
In some ways, what noble Lords have said today will be superseded by the independent review announced by the Government last month to be led by Professor Gillian Leng. We acknowledge that she is a respected expert in evidence-based healthcare, something the noble Lord, Lord Scriven, called for, and a former chief executive of NICE.
I hope the Minister will acknowledge that, since I was appointed as a Lords shadow Health Minister, I have sought to get away from point-scoring on health and social care. I hope to build some sort of consensus on modernising our system of health and care. In this spirit, these Benches welcome the independent review. In fact, I worked with Professor Leng when I was a Health Minister and look forward to her report. I understand it will be published in the spring. As the noble Baroness, Lady Bennett, said, we may need some definition of “spring”, but, as I said in a debate last night, at least it is better than “in due course”.
While it is reassuring to have a definite timeframe for the publication of the report, in the spirit of co-operation, I have a few questions about what happens between now and then. What interim measures have the NHS or the Government announced to address the concerns of the BMA and its supporters over the use of AAs and PAs, as well as the concerns of United Medical Associate Professionals, which represents PAs and AAs, about the treatment and bullying that some of them have faced from doctors, nurses and other medical professionals? What guidance will the NHS give on the responsibilities of PAs and AAs?
I understand that the Minister cannot comment on legal cases, but does she know whether there are any discussions with the various plaintiffs about suspending legal action until after the publication of Professor Leng’s review? Will these legal cases be complete by the time of its publication in spring next year? How do the Government plan to take account of any legal cases that may be resolved after Professor Leng’s report? Will the NHS and the Government have to wait for the legal cases to be resolved before issuing any clear guidance that might be recommended by the report? I acknowledge that there are a lot of questions there. I hope that the Minister can answer them, either today or in writing to all noble Lords who took part in this debate.
Whatever our view on PAs and AAs and the toxicity of the debate, I am sure that we all want to see a system of healthcare that continues to modernise and evolve, in which associates, doctors and nurses offer the best medical care and in which patients feel safe.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I congratulate the noble Baroness, Lady Bennett, on securing this debate. This is an important issue, as we have heard today. I thank all noble Lords for their invaluable and varied contributions.
I shall start with the toxicity of the debate. I emphasise this Government’s support of and gratitude to all staff. That absolutely includes physician and anaesthetist associates who work hard to treat and care for patients in the NHS. As the noble Lord, Lord Kamall, said, the debate has been not just toxic but polarised. As the noble Lord, Lord Scriven, acknowledged, we have seen bullying, which is unacceptable; as the noble Lord, Lord Kamall, said, we need to look at the toxic culture as well as the toxic debate. I absolutely associate myself with the comments made by the noble Lords from their respective Front Benches. At times, not just the debate but the activity around the subject has been deeply abusive, not just in words or on social media, and has been aimed at PAs and AAs. There is no excuse for this and it will not be tolerated. They are valued team members, as is everybody who works in the National Health Service, and deserve our respect and support.
Let me assure noble Lords that this review—I am glad that it has been welcomed—will be an independent, end-to-end review. It will cover training, recruitment, day-to-day work, oversight, supervision and professional regulation. It will assess the safety of the PA and AA roles relative to existing professions, the contribution that the roles can make to more productive use of professional time in multidisciplinary teams and whether the roles deliver good-quality and efficient patient care in a range of settings. All these matters, among others that noble Lords have rightly flagged today, will be considered.
The noble Baroness, Lady Bennett, asked about resources, support and co-operation for the review. I can assure her that this review is properly resourced and, importantly, that stakeholders across the health and social care system have already indicated that they will actively support its work. I agree that this is vital to Professor Leng’s work. As the noble Lord, Lord Kamall, identified, Professor Leng is a champion for patient safety who brings a thorough understanding of healthcare in this country. She is one of the UK’s most experienced leaders in it and I am most grateful to her for her work. I will draw key points from this debate to her attention, including the matter that the right reverend Prelate and the noble Lord, Lord Scriven, raised about getting information to the public. I take that point and will draw these aspects of the debate to the attention of my ministerial colleagues and Professor Leng.
As the Secretary of State highlighted when he announced it on 20 November, the review will gather available evidence and data on the PA and AA professions. It will also engage with relevant professions, the public, employers and researchers. In response to a number of questions raised today, I am committed to ensuring that noble Lords are kept informed as the review progresses. As has been identified, it will report in spring 2025 and we will publish our findings and update your Lordships’ House on the next steps.
I will address the concerns of the noble Baroness, Lady Bennett, and other noble Lords on interim action. NHS guidance remains in place on PA and AA deployment while the review is ongoing. Furthermore, NHS England continues to engage with NHS organisations to ensure that this guidance is adhered to. On the pace of the review, we are committed to it moving quickly to provide clarity, while ensuring that it has sufficient time to consider all available evidence.
The right reverend Prelate spoke of the value of a skills mix and the need for it in providing the kind of healthcare that we need into the future. My belief is that it is recognised—the noble Lord, Lord Scriven, also spoke to this—that the mix of professions required to deliver the right kind of care has evolved continually since the birth of the NHS. As the right reverend Prelate said, on previous occasions there have been many other criticisms and concerns; it is the nature of change. However, I want to be clear that the premise behind the use of PAs and AAs as part of the multidisciplinary team is absolutely sound. To give some context, PAs and AAs have been practising in the NHS for over 20 years, as the noble Lord, Lord Scriven, said. It is not a recent development.
The numbers we are speaking about are small. I will give some context to your Lordships’ House. There are 14,000 full-time equivalent doctors in anaesthetics in England and 170 AAs in the whole of the UK. There are 146,000 full-time equivalent doctors in England and 1,600 PAs. There are 38,420 full-time equivalent GPs and 2,105 PAs. I would not want your Lordships’ House to labour under any misunderstandings.
PAs support doctors to diagnose and manage patients —“support” is the operative word. They are not and should never be used to replace doctors. Similarly, AAs are qualified to administer anaesthesia but only under the supervision of a medically qualified anaesthetist. These roles always have to work under the right supervision. Concerns have been raised by medical professionals about blurred lines of responsibility and whether, in some cases, PAs and AAs are being used to replace doctors. So I understand the need for a comprehensive view of how these roles are being deployed and how effectively. I am confident that the review will address this.
I am acutely aware of the rare but deeply tragic incidences where patients have lost their lives following treatment by an associate. I offer sincere condolences—I know other noble Lords will too—to family and friends. They deserve answers and the assurance that we are listening—and indeed we are. My noble friend Lady Keeley spoke so movingly about the cases of Emily Chesterton and Susan Pollitt, which are deeply tragic. As the noble Lord, Lord Scriven, said, it is so important not to lump every PA and AA together, just as it is not right to do that for any other group. The noble Lord, Lord Kamall, rightly observed that tragic death happens when care is provided by other health professionals. Our job is to reduce that as far as we possibly can, which is what we are working to do.
The noble Baroness, Lady Bennett, highlighted a reference to legal action and redundancies, as well as the systematic impact that uncertainty has created for employers, GP practices, NHS services and individuals. That is why this review is so vital. It enables us to take stock of the evidence, establish the facts and provide absolute clarity for patients, professionals and employers.
As the noble Baroness, Lady Bennett, acknowledged, there has been significant debate on the scope of practice, especially for PAs. The review will cover all aspects of PA and AA roles, including their deployment and scope of practice. The issue will therefore be considered as part of the review, and I will not pre-empt its outcome on this or any other aspect. Many questions were rightly asked about what happens in the meantime. NHS England’s guidance on the deployment of PAs and AAs should continue to be followed.
On the important points about patient confusion, the GMC has published interim standards for AAs and PAs in advance of regulation. That will make clear that professionals should always introduce their roles to patients and set out their responsibilities in the team. The Faculty of Physician Associates has produced guidance, which includes an example of what a good initial introduction should look like. The review will also consider the professional regulation of these roles, which, as was set out, the GMC will commence next week.
The noble Lord, Lord Kamall, and the noble Baroness, Lady Bennett, asked about the action that will be taken in advance of the review concluding. It is important to note, as the noble Lord, Lord Scriven, did, that regulation by the GMC will begin in a very short while. As the noble Baroness, Lady Bennett, set out, I am aware that concerns have been raised about the GMC as the regulatory body for the roles. But we can be assured of the benefit of statutory regulation in helping to ensure that all PAs and AAs meet the very high standards expected of—and I emphasise this—every healthcare professional. Where these standards are not met, action can be taken.
This has been a challenging period for the PA and AA workforce, and it is vital that, like all NHS staff, they are treated with respect. It is therefore incumbent on all to do this. I look forward to the review, and I wish Professor Leng well. I thank noble Lords for their valued contributions to this debate. I look forward to PAs and AAs playing their part in providing improved healthcare in this country.