Anaesthesia Associates and Physician Associates Order 2024

Debate between Baroness Bennett of Manor Castle and Lord Young of Cookham

Monday 26th February 2024 Lords Chamber

[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.

Domestic Abuse Bill

Debate between Baroness Bennett of Manor Castle and Lord Young of Cookham

Report stage
Monday 15th March 2021 Lords Chamber

[Baroness Bennett of Manor Castle (GP) [V]]

My Lords, it is a pleasure to follow the noble Baroness, Lady Warwick of Undercliffe, who added powerful examples to the already clear and strong examples from the noble Baroness, Lady Deech, and the noble Lord, Lord Randall, as to why we should agree both these amendments. I will not detain the House for long, but I want to strongly express the Green group’s support for these two amendments.

The logical way to take them is in the opposite order to that in which they are numbered. Amendment 87C, in the name of the noble Baroness, Lady Deech, and with strong cross-party support, expresses the ideal situation which, we have been told, is already being created in Scotland, with even stronger support for victims of domestic abuse. It is for people to stay in their own homes and communities and, very often, for children to stay in the schools that they are used to, with their friends. This is obviously the right thing to do to support victims of domestic abuse and to ensure that abusers do not profit from the situation, as they are often left with the home, tenancy, control and their place in the community.

Amendment 66B, moved by the noble Lord, Lord Randall of Uxbridge, acknowledges that that is simply not always possible. Victims of domestic abuse, having fled to refuges, may have started to establish themselves in a new place, possibly on the other side of the country, and have started to make friends, and children have become used to schools. The amendments make an excellent package—in this case, the grouping works—to provide a bit more wraparound and support for the victims of domestic abuse, for whom we are all spending so many hours in your Lordships’ House trying to make this the best Bill it can be. These two amendments, or something very like them, are needed to make this the Bill that it should be, so I commend them to your Lordships’ House.

[Lord Young of Cookham (Con)]

My Lords, I begin by commending my noble friend Lord Randall for the case he made for Amendment 66B. I look forward to the Minister’s reply on that. The case for Amendment 87C was capably made in Committee by a number of noble Lords and reinforced today by the noble Baronesses, Lady Deech, Lady Warwick and Lady Bennett. I will not repeat it, except to gently remind the Minister that in Scotland they have gone further than our modest amendment in giving security to victims of domestic abuse, even when they are not a joint tenant.

I want to focus on what has happened since Committee, and begin by thanking my noble friend Lord Parkinson for his patient and sympathetic approach in seeking to find a way forward. In his wind-up speech in Committee, he recognised that our amendment would simplify the current complex and uncertain legal mechanism available to victims, and would prevent perpetrators from exerting control over a victim. That was enormously helpful.

In our letter dated 15 February, we sought to address the concerns that he expressed on five separate issues. In particular, we amended the section on responsibility for arrears to clarify that the perpetrator remains liable for arrears before the joint tenancy is terminated. Then we added subsection (11) to the new clause proposed by the amendment, to give the Government time to assess progress in Scotland. We had a meeting with my noble friend earlier this month, for which again I am grateful, and he replied to our letter last week, in which he repeated his sympathy for the motives behind the amendment.

So where do we go from here? If there are defects in our drafting, we know that the Bill will go back to the other place, so there will be an opportunity for the Government to tidy it up. My preferred solution would be for the Government to accept the amendment, tidy it up in the other place and implement it as soon as it is successfully rolled out in Scotland.

I would understand the disappointment if the Government were to resist but, if they do, with some reluctance I would consider the more cautious approach suggested in my noble friend’s letter and referred to by the noble Baroness, Lady Deech, in her opening speech—namely consultation. I am not entirely convinced that this is necessary but, subject to some strict conditions—an early start date, a reasonable but not protracted time for consultation and a decision by the Government by the autumn—the proposition is worth reflecting on. The option would be even more attractive if there was also a commitment to include the necessary measures in the first relevant piece of legislation, be it on rights for renters or leasehold reform, both of which are likely to feature in the next Session. I will listen with more than usual attention to my noble friend’s response at the end of this debate, before deciding how best to proceed.