Anaesthesia Associates and Physician Associates Order 2024

Baroness Bennett of Manor Castle Excerpts

Monday 26th February 2024 Lords Chamber

Moved by

[Baroness Bennett of Manor Castle]

As an amendment to the above Motion, to leave out from “that” to end and to insert “this House declines to approve the draft Anaesthesia Associates and Physician Associates Order 2024 because it represents a significant constitutional change in regulation of healthcare professionals by omitting parliamentary oversight and approval for regulating anaesthesia associates and physician associates; and fails to address concerns within the medical profession about the supervision and titles of the roles.”

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise to move what the Minister has correctly identified as a fatal amendment that the House do not approve this order. This is on two primary grounds: the lack of democratic oversight and the concerns of the medical profession.

Before I begin, I want to make it clear that I am not opposed to the existence of physician associates or assistants, or their anaesthetist colleagues. I am not opposed to their regulation—indeed, I am keen to see them regulated—and I respect the efforts of current and future PAs and AAs who complete their studies and have the student debt to prove it.

I also want to be clear that, unless I get an indication from the House that it wishes me to do so, it is not my intention to put this amendment to the vote. My intention in tabling it was to ensure that the many hundreds of voices of concern that have reached me personally and the more than 21,000 doctors and patients who wrote to their MPs opposing this order are heard, and that the Government consider—seriously, I hope—whether they should go forward to regulate PAs and AAs in this manner, with this order.

I will first address the second part of my fatal amendment, about the views of doctors and patients. Sir Robert Peel invented the concept of policing by consent. I want to adapt that for these circumstances by saying that we must have regulation by consent. I am sure that all noble Lords engaged tonight are aware that the British Medical Association, the Doctors’ Association UK and the EveryDoctor group are opposed to this statutory instrument, for reasons on which I am sure we will hear much more from the noble Baronesses, Lady Finlay and Lady Brinton, with their regret amendments.

One of the very serious concerns is about clarity for patients and the confusion introduced by the title “associate”. On that I turn to a report from the BBC, an interview with Marion Chesterton, the mother of Emily, who tragically died after being seen twice by a PA and misdiagnosed. Marion said that her daughter

“didn’t know she hadn’t seen a doctor”.

Marion added—and this is something that I think people should focus on:

“Physician associate sounds grander than a GP”.


I pick up a point made by the Minister about PAs and AAs having been around for 20 years, an often-cited statistic. If we look back to 2014 and 2015, there were fewer than 50 PA and AA graduates. There were literally handfuls in the system. It is only when you get to 2018 that you start to see the figures leaping up to 400 graduates, and the Government’s aim is to head towards the figures that the Minister cited. So we may not have seen much confusion, but there were few people to be confused about within the system. This is a situation that is arising now, and that demands a reconsideration.

However, I will largely leave the arguments about titles, and the General Medical Council as regulator, to the regret amendments. What I want to focus on is the word “consent” and the concerns of doctors and patients in the context of the state of our medical system.

We debate as junior doctors are in the middle of their 10th strike action. We debate as one in seven British-trained doctors is working overseas. We debate after a BMA poll found last year that around 40% of junior doctors plan to leave the NHS as soon as they can find another job.

We need to make changes to the system. That is something on which the Minister and I, and I think pretty well everyone, are agreed, but we can make changes to the system only with the consent of all those involved. There is a moral argument for that, but also a very powerful practical argument. The Government need to work co-operatively and sensitively, and to listen to our medical professionals rather than ride roughshod over their serious concerns—concerns that are shared by many patients and that have filled my social media feed in recent days.

The first part of my amendment is about democracy. The order got virtually no scrutiny or consideration in the other place. We, of course, have no opportunity to amend it to tackle the issues that the noble Baronesses will focus on in their regret amendments. We have only the extraordinarily rarely used option of rejecting it. I have not had any indication from the Labour Party that it would support that, and I assume that its silence on the Order Paper means that it supports the Government’s path, but I ask the Labour Front Bench to consider whether we have to take this back to the drawing board. That is a question I put to it directly.

The Minister raised the report of our hard-working and, I fear, underappreciated Secondary Legislation Scrutiny Committee, which makes it very clear that this is not just about PAs and AAs but is meant to be the model for broad and widespread changes to medical regulation in the future. The committee’s report says that this is

“the first use of powers inserted into the parent Act by the Health and Care Act 2022 to give the GMC direct powers to make and amend standards and procedures for these associates”,

while, as it says in bold,

“removing the process from Parliamentary oversight”.

It is interesting that the Committee says:

“The Explanatory Memorandum should have been more explicit on this point and on what safeguards remain”.


In testimony, under questioning from the committee of your Lordships’ House, the department confirmed that

“changes in registration processes etc will no longer be laid before Parliament in any form, they will just be posted on the GMC’s website … however members of either House can respond to consultations if they wish”.

I am glad about that.

This has really not been made clear through the process, as the committee highlights. I think it is worth focusing on the fact that had it not been for the amendments from the noble Baronesses and me we would not even be doing this in the main Chamber. We would be in the secondary Chamber, getting, as we all well know, very little attention at all.

I particularly want to highlight, in case noble Lords did not receive it, the briefing from the Professional Standards Authority, which has responsibility for overseeing the GMC’s activities. It said, in what I think one would describe in bureaucratic terms as a carefully worded briefing, that we

“need to keep under review as the reforms are rolled out the accountability framework proposed to balance the increased autonomy for regulators with greater accountability”.

I wish to make a final point to address the fear and concerns of many patient groups and communities—which the Minister alluded to—that their communities and their families will lose ready or perhaps any access to doctors and be relegated to a second tier of NHS services, with PAs with two years of medical training versus GPs with 10. In the letter following up the very useful briefing that he arranged last week—and I think him very much for that and for the letter—the Minister makes reference, as he did in his speech, to the Government’s aim of doubling the number of medical places in England to 15,000 by 2031-32.

The Minister gave, I believe, the same figures as were reported in the Observer on Sunday. These were in a leaked letter from the Health Minister and the Minister for Skills, Apprenticeships and Higher Education to the independent regulator, the Office for Students. The figures in that letter have been interpreted as significant back-pedalling on the Government’s final aim and total. I ask the Minister whether he remains confident and can guarantee to the House that we are on target to achieve that final figure, given that we do not seem to be taking very strong steps in that direction.

The way those figures came out can only amplify the fears of many communities that those who can pay can go private, as increasing numbers of Britons feel they are forced to do. Patients at the centre of well-serviced areas where doctors can supplement their NHS pay with private work will keep access to a service like that now available, while other areas—the kinds of areas that are often talked about as being in need of levelling up—will get a second-class service.

We have to think about the context of this. Our NHS is battered by privatisation, with nearly 10% of services, including more than half of under-18 inpatient psychiatric services, now provided by for-profit providers. We have seen the disaster of PFI schemes, now set to cost £80 billion for the original £13 billion investment—the equivalent of £1,200 for everyone in the UK. We have seen this jewel in the British crown worn away by austerity—a decade in which investment in infrastructure and new technology collapsed and the pay of junior doctors and midwives in particular plummeted in real terms.

Please let us not deliver another blow. Please withdraw this order either tonight or afterwards. Take the path of consensus. Take the path of democratic oversight. Bring this forward as legislation that can be debated, amended and properly scrutinised. Please listen to the fear of communities. I ask everyone in this debate but particularly the Labour Front Bench to consider that approach and the wisdom of it. I beg to move.

[The Deputy Speaker (Lord Young of Cookham) (Con)]

I should inform the House that if this amendment is agreed to, I will be unable to call the amendments in the names of the noble Baronesses, Lady Finlay of Llandaff and Lady Brinton, by reason of pre-emption.

--- Later in debate ---

[Lord Scriven (LD)]

My Lords, I have listened to the debate very carefully. My professional experience as a former health service manager over many years is that we have had this debate about people taking on different roles in health and always the same arguments come. Whether it be physiotherapists taking on roles, nurses becoming nurse practitioners or pharmacists coming into this, the same argument always happens: that somehow this dilutes patient care and safety. The answer is that it does not if it is properly regulated, there is proper training and there is proper monitoring of what happens to patients.

I understand that there is some anxiety, but I have to say to the BMA, in particular, that its language in the briefings it has given has driven the bullying and ostracisation of colleagues in hospitals who are valued members of a clinical team. That is the word: “team”. It needs to be led by a senior doctor, normally the consultant, without ostracising people within that team. I gently say to the noble Baroness, Lady—I have forgotten.

[Baroness Bennett of Manor Castle (GP)]

Bennett.

[Lord Scriven (LD)]

The noble Baroness, Lady Bennett of Manor Castle—I remembered the Manor Castle because of Sheffield, but I could not remember the Bennett bit—that, twice during her contribution, she used the term “a second-rate service”. These people do not provide a second-rate service; they provide and augment the team service, to ensure that patient outcomes are as good as they can be.

On the whole, I support the fact that these orders are being laid, although there is one issue that I think needs to be thought through carefully: if the GMC is going to regulate, there is an issue about the way that the distinguishing of the registers is dealt with. I see that as a potential trip-up point if not thought through very carefully; I hope the Minister can give the House some assurance on that.

On the whole, I support the regulations. This is just a continuation of many years of different people in the team taking roles. With the correct regulation and the correct training and supervision, this will improve patient outcomes and service.

--- Later in debate ---

[Baroness Bennett of Manor Castle (GP)]

My Lords, I am acutely aware of the hour, but I am also aware there are a great many people—so social media tells me—watching this debate. There are a couple of things I need to say.

First, I thank everyone who has taken part in the debate, especially the noble Lords, Lord Patel and Lord Winston, for bravely telling us about the detail of their rich experience.

I will pick up on the comments made by the noble Lord, Lord Hunt, and the noble Baroness, Lady Merron. If you look back at my speech—I have handed over my notes now—I used the word “respect” talking about the PAs and AAs, and I talked about their study and student debt. I make it clear to the noble Lord, Lord Hunt, that I have not made any listing of incidents where things have gone wrong. I cited one case relating to the issue raised by the noble Lord, Lord Allan, of the difficulty patients have in understanding what the term “physician associate” actually means.

I highlight the words of the noble Lord, Lord Patel: using an SI to do a major piece of legislation is inappropriate. That is the whole reason I put down this fatal amendment. The noble Lord, Lord Hunt, and others said we cannot get the parliamentary time for it. Well, we have talked about reform a lot tonight, so maybe we ought to look at reform in Parliament as well. I will refrain from suggesting some of the Bills that we could not be doing so we could be doing this as a Bill instead.

There are a couple of points that need to be answered. The noble Baroness, Lady Bloomfield, questioned part-time GPs. If GPs are working, say, theoretically four days a week, it is more than a full-time job in terms of the stress, pressure and time involved. If we are going to keep people in the profession, we have got to allow them to contribute as much as they can. That is an issue of sustainability.

The noble Lord, Lord Scriven, referred to me talking about a second-rate service. I was talking about a possible experience a few years in the future; if there is the situation of whole regions, areas and practices—like the noble Lord, Lord Allan, said—having only PAs, effectively that would be a second-rate service. That was the future context I was talking about.

Given the time, I will make one final point. The noble Lord, Lord Bethell, said the Government are looking for the number of PAs and AAs to be 8% of the total of doctors. The question, of course, is not just about the total but about the distribution. There is the point about private hedge fund owners of GP surgeries and what they might choose to do. There is also the point which I have been driving at all the way through, having for more than a decade been visiting northern cities and towns in particular, where people really feel that they are struggling to get a decent NHS service and struggling to get the staff, and they fear that they might not get enough doctors.

Again, I thank everyone. I thank the noble Baroness, Lady Fox, for stressing how vulnerable patients are. My final point is that in making sure that patients understand they are being seen and treated by a PA or an AA, there has to be an attempt to understand that when people are ill, vulnerable and desperate, they may not absorb something just being done to them by rote. That is really important.

With that brief summing up, and in the circumstances, I beg leave to withdraw my amendment.

Amendment to the Motion withdrawn.