Anaesthesia Associates and Physician Associates Order 2024

Debate between Baroness Brinton and Baroness Finlay of Llandaff

Monday 26th February 2024 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare that I am a doctor registered with the General Medical Council, a member of the BMA and a fellow of the Royal College of General Practitioners and the Royal College of Physicians.

We have physician associates and anaesthesia associates seeing patients, examining them and advising them, who are as yet unregulated. All responsibility for their behaviour rests with the doctor who is their supervisor from whom they have delegated responsibility. The professional scope of practice for these associates can vary widely across the country. It is determined at a local level and patients have no idea about the variation.

There is a golden thread in clinical care that the most experienced person delegates down. They delegate down tasks that they know the relevant team member has the skills to undertake. A key skill in medicine, gained with extensive experience, is the integration of all the relevant information, evaluation of risk and prioritisation. Currently a problem in the whole of the NHS is that we expect staff to refer upwards and the boundaries are unclear.

A case of non-accidental injury in a child has been brought to my notice where the expert evidence was provided by a physician associate whose relevant experience is unclear at best. This blurring is misleading to non-medical professionals, including the police, judiciary and legal professionals. Supervision must be mandatory and stipulated in the GMC’s Good Medical Practice.

The junior doctors’ discontent, which we have heard about already from the noble Baroness, Lady Bennett, is boiling over. After training, medical graduates emerge with huge student debts to work a 40-hour week for just over £32,300, only to find that after a two-year postgraduate programme a physician associate typically earns between £3,000 and £11,000 more, for only 37.5 hours a week. All this has inflamed tensions—although I would say that direct verbal attacks on physician associates and anaesthesia associates, who have trained in good faith and with good intent, are not appropriate and I would not condone them.

Doctors are the only healthcare professionals who must undergo extensive, nationally stipulated postgraduate training before being appointed to a permanent senior role. Without long-term job security, these juniors rotate through departments, sometimes commuting many miles. They find that they do not belong and do not feel part of the team or valued, while patients miss out on continuity of care.

Very importantly, patients seen by a physician associate sometimes think that they have seen a doctor. The term “physician associate” gets muddled with the specialty and associate specialist doctor, who often has years of experience. Can the Minister clarify whether the term “physician associate”, which is so misleading, will become a protected title after this order passes? How can the name then be changed to revert to the more accurate “physicians’ assistant”? Currently, no medical titles are protected: “doctor” is not and grades up to and including consultant are not, which is another source of confusion. How is that going to be cleared up?

The cost-efficacy basis for these posts has been questioned in a recent paper, showing how the cost of one consultant anaesthetist supervising two operating theatres with an anaesthesia associate in each—that is, three staff—is more expensive than having two consultants doing one list each. The risk is higher if a problem arises in both theatres, especially in an anaesthetic emergency, when deterioration and brain damage can happen in minutes.

This crisis has been 20 years coming because we failed to expand medical school places or to register these new healthcare roles and define their scope of practice. What is the solution?

I fear this order will not solve all the problems. Yes, physician associates and anaesthesia associates must be regulated. It seems an outrage that people with such responsibility have been around for 20 years, unregulated, and a decade after that was recommended. The General Medical Council, in taking responsibility for regulation, must keep the register completely and clearly separate from that of medically qualified doctors. Can the Minister confirm that this clarity will be a legal requirement?

I tabled my regret amendment because it must be clearly on the record that the concerns exist, that some current regulation around the Medical Act needs updating urgently and that the GMC must be held accountable to Parliament, as has been explained by the Minister. Regulation is essential, but it is not the end of the issue; it is only the beginning.

The GMC must tackle the inappropriate way that some courses are advertised, which state that they train PAs

“to work as a safe and competent medically trained healthcare professional”

or to

“be a medically trained, generalist healthcare professional”

—which sounds awfully like a GP to me. Some courses describe working under a senior physician, but others say nothing about supervision. The anaesthesia associate courses differ slightly. They make it clear that, at present in the UK, only doctors who have specialist training in anaesthesia can administer anaesthetics and that the anaesthesia associate works as part of the anaesthetic team.

Next, the scope of practice must be clearly defined and agreed at national level, so that any employer is aware of what the associates should be doing and how the senior doctors must supervise them on site. Employers must also ensure that all patients know the qualification level of the person seeing them. Seven-day services are essential for patients.

Medical postgraduate training itself is in crisis. The royal medical colleges, the Academy of Royal Medical Colleges and the GMC must get together urgently to address postgraduate training. Perhaps it could be shortened, with post consultant-level fellowships to develop highly specialised skills and bring innovation to healthcare. Lifelong learning is essential; it is the essence of growing a good medical workforce in the long term. Medical schools, as they welcome the increased numbers, must look at how those who might wish to convert to a medical degree can be credited with their prior learning and experience, and tackle regulatory blocks in funding and timing.

Importantly, the title must be reviewed. The terms “physician assistant” and “anaesthesia assistant”, in use until 2014, clearly denoted the role as having delegated responsibilities from a supervisor. If “physician associate” and “anaesthesia associate” are to be protected terms, then we need a designation of medicine that clearly identifies a medical degree—similar to the American MD designation, for example. Patients must know who has seen them.

To summarise: patients must know the level of training of the person whom they have seen. Physician associates and anaesthesia associates must be regulated with appraisal and ongoing learning, including revalidation. The scope of practice of this new workstream must be defined to ensure that they have clear boundaries and supervision must be defined as being closely supervised on site to ensure patient safety. People must not be misled into believing that they are completely independent practitioners.

[Baroness Brinton (LD)]

My Lords, I am grateful to follow both the noble Baronesses, Lady Bennett and Lady Finlay of Llandaff, and I have been crossing out large chunks of what I was going to say, which I hope will be helpful to Members of your Lordships’ House.

As both of the other noble Lords have, I want to start by saying that this is not an attempt to discredit the many PAs and AAs who do an extremely good job. We need to understand that, and we need to understand that our health system must change and modernise. The issue is what is happening in our NHS and how the role of PAs and AAs is impacting not just on patients—I will come to the detail of that in a minute—but on the working of supervising doctors and junior doctors. All of those groups are in crisis, and this just seems to be adding further problems.

I echo the points made by, I think, the noble Baroness, Lady Bennett, about the Secondary Legislation Scrutiny Committee, which the Minister referred to in his introduction. In the committee’s report to us, it says three times that the Explanatory Memorandum assumed understanding and that it was not good enough. I ask the Minister if he will work with his officials to ensure that any more Explanatory Memorandums that come forward, not just on this issue but on others, are very clear and do not assume prior knowledge.

All of us have said that PAs and AAs—I am not going to keep saying physician associate and anaesthesia associate because it takes too much time—are not a replacement for doctors, though not one of us believes that that is the case. I am going to start with the title. The Royal College of Physicians and the Faculty of Physician Associates, which sits within the RCP, has guidance on the associate title and introduction guidance for PAs, supervisors, employers and organisations. What it says is in complete contradiction to what is happening on the ground:

“It is our view that, when a PA introduces themselves to a patient or staff member, they must make it clear at the start of the interaction that they are a physician associate, as well as explain the use of the term ‘PA’ … PAs must correct patients and staff if they refer to them as a … doctor, nurse or other professionally protected role title. This includes verbal, written and other forms of communication”.


Like other noble Lords, I have been inundated with letters from doctors and patients saying that they have been misled—not in the deliberate sense, but that PAs have not been correcting the record when someone has called them a doctor. The BMA, in its very helpful briefing, said that:

“To patients, PAs and AAs and doctors may look the same and appear to be doing a similar job”.


The problem, as the noble Baroness, Lady Finlay, said, is that the title is confusing. “Physician associate” perhaps implies that they have the same level of expertise as doctors. Unfortunately, as the noble Baroness, Lady Bennett, said, this has already led to a tragedy. Emily Chesterton died, aged 30, after two appointments with a PA who she believed was a GP, where mistakes were made.

A further difficulty, particularly in GP practices, is that GPs are beginning to worry that they are going to spend their entire time supervising PAs, as well as seeing patients with chronic diseases, and will not see ordinary people at all. Trainee GPs are worried about how they are going to be supervised. How is the Minister going to ensure that the issues of supervising and training, which are very serious, will be dealt with after the passage of this SI—because I do not think any of us are planning to call a vote today?

We have heard that, across acute trusts and GP surgeries, doctors have reported 70 instances of avoidable patient harm and near misses caused by PAs. That includes fatalities, missed diagnoses resulting in terminal diseases, missed DVTs, sepsis, heart attacks and haemorrhages. Missed cancer diagnoses in primary care has therefore emerged as a significant issue. In England, 74 acute trusts have replaced doctors with PAs on the doctors’ rota. Even if those PAs are supervised, that means that doctors who should be seeing patients are supervising more and more people. It is not a zero-sum game. One trust—I think it was Leeds, from memory—had a paper on how much more beneficial PAs were on the rota because they were much cheaper than doctors.

Doctors at 24 trusts reported witnessing PAs illegally prescribing medications, including controlled drugs. That is a particular worry because they are not permitted, under their current training and qualifications, to prescribe any drugs. That must be done by the doctor. The PA can recommend to the doctor what they think, but it should be signed off by a doctor. In addition, 42 acute trusts in England have witnessed PAs introducing themselves as doctor or failing to correct errors.

We have heard about a number of issues. I conclude by saying that, earlier on today, on the Victims and Prisoners Bill, we were talking about the duty of candour, which the NHS introduced nearly a decade ago. One issue related to this is that every regulated member of staff must report whenever they believe that something has happened that either possibly will cause damage or has caused damage. One of the good things about regulation for PAs and AAs is that they will come under the duty of candour. However, in all the cases that we have been told about where things have gone wrong, there is no evidence that there were reports to the CQC by the supervising doctors about things going wrong. Therefore, yet again I say to the Minister that my real concern is about current practice inside our extremely pressed and busy NHS, to make it safe. Just providing regulation for PAs and AAs will not in itself do that. I hope that he can help your Lordships’ House to understand.

Building Safety Bill

Debate between Baroness Brinton and Baroness Finlay of Llandaff

Committee stage
Wednesday 2nd March 2022 Grand Committee

[Baroness Brinton (LD) [V]]

My Lords, I support all three amendments in this group. Amendment 111, which was laid by my noble friend Lord Foster and to which I have added my name, aims to protect consumers from items purchased online that are non-compliant with rules for purchasing the same products in shops. I thank him for his clear and detailed explanation of why it is needed.

The excellent analysis by Electrical Safety First of the Office for Product Safety and Standards demonstrates that there is a real safety issue. Nearly two-thirds of electrical products bought in an online marketplace are non-compliant and a shocking quarter is actively unsafe. Electrical Contracting News said that in 2020 faulty appliances caused 43 fires per week in England. Everyday household appliances caused 15,000 accidental fires in homes. We know that some serious and fatal fires in high-rise and medium-rise buildings were caused by faulty appliances. Some fires were due to household items being placed too close to the source of heat or to misuse of appliances, but a number were due to appliances that were found to be faulty.

If two-thirds of electrical products bought in online marketplaces are non-compliant and, worse, a quarter is unsafe, that is a recipe for danger. Perhaps it is not surprising that legislation is taking time to catch up with new ways of purchasing goods, yet the focus of this Bill is to ensure that buildings are safe, especially high-rise buildings. This amendment proposes a solution to the problem and I support it.

Briefly, I want also to add my support to Amendment 112 laid by my noble friend Lady Pinnock and Amendment 117 laid by the noble Baroness, Lady Finlay. The amendment of my noble friend Lady Pinnock also responds to evidence given at both the Grenfell inquiry and Dame Judith Hackitt’s review of the appalling habits of too many construction product companies of managing to soften or even blatantly breach the safety regulations. It is evident that the regulations are out of date and I hope that the Minister will be able to respond favourably to this, too.

Finally, the amendment of the noble Baroness, Lady Finlay, highlights the importance of the provision of CO detectors and alarms and seeks for the responsible person to ensure that they are provided. Too many times, people end up with unsafe equipment, whether an old gas fire or, worse, a new exterior gas fire being used inside through ignorance, which has resulted in the deaths of far too many people. We are used to having smoke alarms in buildings, especially high-rise ones. We should also have CO detectors and monitors as a matter of absolute routine for safety. I look forward to hearing the Minister’s response.

[Baroness Finlay of Llandaff (CB)]

My Lords, I would like to speak to my Amendment 117 in this group— I am grateful to the noble Lord, Lord Hunt of Kings heath, for supporting this amendment with me. I should declare my interest, as I co-chair the All-Party Parliamentary Carbon Monoxide Group and I chair the CO Research Trust.

As the noble Baroness, Lady Brinton, said, faulty appliances are often a source of carbon monoxide, but so are wood-burning stoves and oil central heating. Anything that burns a carbon-based fuel can produce carbon monoxide, which is colourless, tasteless and odourless and results from incomplete combustion of the fuel. The problem is that high levels kill you rapidly, within a few minutes, but the symptoms are that you just feel warm and sleepy. You think that you are comfortable and sleepy; the next thing you are dead. However, low levels also produce long-term damage and are thought to damage the developing foetus in pregnant women.

--- Later in debate ---

[Baroness Brinton (LD) [V]]

My Lords, I have signed Amendments 122, 123 and 124 in the name of the noble Lord, Lord Foster, and will come to them in a minute, but I wanted to start by supporting Amendment 120, laid by my noble friend Lady Jolly.

As the noble Baroness, Lady Harris, has said, BS 5395-1 ensures that staircases in new-build homes have the best possible ratios between treads and risers. This is especially important as many new-build homes are built to fewer square metres than recommended, resulting in staircases being squeezed into narrower spaces. There is only one consequence of that: stairs become steeper, and too often even fail to have a handrail all the way up because of the narrowness of the stairs. That is a recipe for falls, whether for children, the elderly, or the disabled.

Let me tell noble Lords, it is extremely scary to have to come slowly and painfully down steep emergency exit stairs, holding a handrail, with a stick in your other hand, while others race past you. On one occasion, someone tripped on my stick as they tried to race past me, resulting in both of us falling—luckily, only a couple of steps. Had it been at the top of a run of 10 steps, not only would we both have hurt ourselves badly but others following would probably have fallen over us too. Building standards are there for a reason and should be a minimum for new builds. Building in safety is part of Hackitt’s golden thread.

Elderly and disabled people using a stick, or sticks, on a narrow and steep staircase, possibly with no handrail, will be at serious risk of falls. Special fracture clinics report that falls in the vulnerable often lead to life-changing injuries, serious muscle loss while they are in hospital, loss of confidence and, sadly, earlier deaths. So it does not just cost lives; it costs quality of life, and it also costs the NHS and social care millions every year in extra treatment and care support.

I now turn to the other three amendments in this group in the name of the noble Lord, Lord Foster, to which I have added my name. One of the worrying aspects of fires in high and medium-rise residential blocks is the number caused by faulty or defective installation. Home Office data shows that this number is growing, whether from the cables themselves or from the shoddy work on party walls that breaches compartmentation, both of which are completely unacceptable. These amendments address that.

Amendment 122 requires leaseholders to ensure the safety of electrical installations in high-rise buildings. Amendment 123 specifies that leaseholders in mixed tenure high rises have to ensure the safety of their electrical installations. Amendment 124 places a specific responsibility on social landlords to do the same. The noble Baroness, Lady Pinnock, spoke eloquently in the first group this afternoon about the problems of breached compartmentation and quoted from Dame Judith Hackitt’s report. The same applies here, but currently the same responsibility does not apply to different types of landlords and leaseholders, and this is an unacceptable loophole. The amendments from the noble Lord, Lord Foster, remedy that.

The requirements in these amendments make it clear that leaseholders and landlords have a duty to ensure that installation works must be safe. Surely, that is not too much to ask. Surely, all these various types of flat should have a current electrical installation condition report, which not only demonstrates that they, the landlords and leaseholders, have taken care to ensure the safety of residents and the buildings they live in but gives them the same protection as those of flats with private tenants. Dame Judith Hackitt’s golden thread does not just apply to the construction industry; it also applies to those with responsibilities for the buildings once they are lived in. Most tenants are not aware of the distinction between different types of landlord and leaseholder in building safety law. Surely, our law should be consistent.

[Baroness Finlay of Llandaff (CB)]

My Lords, I was delighted to see this amendment from the noble Baroness, Lady Jolly. As she pointed out, more than 700 people die each year from falls on the stairs. But in addition to this, 43,000 people are admitted to hospital. Falls are tragic and common, but they do not often make the news. Someone is estimated to fall on stairs every 90 seconds, and falls on stairs account for a quarter of all falls in the home. Obviously, when stairs have an inadequate guardrail, the trauma sustained is even worse, as it is when they are a long flight of stairs.

The most common injury is a fractured hip, but the most costly to the country is a spinal cord injury, which is absolutely devastating. The lifetime average cost of a spinal cord injury is £1.12 million, which works out at a total of £1.43 billion for all the accumulated spinal cord injuries. These are staggering figures, yet the British Standard, which has been referred to, is associated with a 60% reduction in falls. It has existed since 2010 and has been thoroughly tested, evidenced and assessed by industry and government. If we are to have homes that are built as homes for life, we need stairs in them that are safe. If workplaces are to be safe, they must have safe evacuation stairs as well.

As they grow older, many people need to install a stairlift in their home to enable them to go up and down stairs safely, particularly when they have items to carry. Many homes are still being built with stairs too narrow to safely install a stairlift on. In the long term, the British Standard is a very good investment for the nation.

I know that the Minister is aware of all of this and has been working with RoSPA to come to a solution. I look forward to hearing an update from him on this matter, because RoSPA and those of us who signed this amendment honestly believe that this one action could save more lives than anything else in the Bill.

Health and Care Bill

Debate between Baroness Brinton and Baroness Finlay of Llandaff

Committee stage
Friday 4th February 2022 Lords Chamber

[Baroness Brinton (LD) [V]]

My Lords, I support the noble Baroness, Lady Cumberlege, in her Amendment 283, which would include financial and non-pecuniary interests of medical practitioners alongside clinical interests and their recognised and accredited specialisms on a register. I particularly thank her for explaining exactly why this is so important for patients. Currently, the GMC does not require them to hold or publish that data, but it is the obvious place for it to be held—and then linked, as she explained, to local employers, contractors and organisations. Anything that reduces the complex maze for a patient or a member of the public trying to find out whether a doctor is being paid for doing some work or using particular devices, and might therefore have an interest, has to be one of the cornerstones of a truly accessible and accountable register of interests. In today’s data-rich society, patients and the wider community want to understand what interests a doctor may have, but which may not be obvious.

A website called whopaysthisdoctor.org at Sunshine UK—so-called, I presume, because sunlight is always the best disinfectant—was set up by number of doctors, including Ben Goldacre. It is a database where doctors who want to be transparent about their interests can declare and register them, and the public can see whether their doctor is listed. The problem, of course, is that those who do not want to make these declarations voluntarily may be those we most want to see. That is why the amendment would make it compulsory.

I thank the GMC for its helpful brief, in which it recognises that the

“current arrangements to register conflicts of interest fall short of delivering adequate transparency and assurance for patients.”

However, the GMC would prefer this register to be maintained just at a local level and

“published by a doctor’s employer, contractor or organisation”.

The noble Baroness, Lady Cumberlege, has already referred to the recommendations in the First Do No Harm review and the Government’s response, in which they said that it was proposed that information would be published locally at an employer level. However, I believe that there is also a golden thread from the obvious place to go, where doctors already have a duty to register other information, and that is the GMC.

Like the noble Baroness, Lady Cumberlege, I am keen to see action on this. Personally, I believe that the registration body is a good place to hold that data and, as she said, we need to start somewhere. But, frankly, we need to see progress on a register of interests. I hope the Minister can give your Lordships’ House some encouraging news on this.

[Baroness Finlay of Llandaff (CB)]

My Lords, I was—it is fair to say—flattered when the noble Baroness, Lady Cumberlege, asked me to co-sign her amendment, because I have admired all the work she has done, and I think her report, First Do No Harm, has had influence way beyond the group of patients she was looking at. Indeed, I was vice-chair of a NICE review, and we referred to it in terms of helping to empower the voice of the patients we had in that review process, which was, first, very important and, secondly, particularly helpful because they were very clear in their thinking, and they worked extremely hard.

I am also grateful to the noble Baroness, Lady Brinton, for referring to the General Medical Council’s briefing, because the GMC agrees that a solution to this needs to be

“Accurate, up-to-date, accessible and presented in a way that is useful for patients, so that they can have confidence in it”.

It also said that it must be “Enforceable”, and the GMC also wants it to be “Multi-professional”. However, I agree that we have to start somewhere. Your Lordships may think that the advantage of a local register is that it is more accessible, but the disadvantage is that doctors move around in different jobs, particularly trainees—but even consultants’ time in one post is now relatively short; it used to be a lifetime appointment.

It is important that, as a doctor, I am prompted to be completely open so that there can be no subliminal influence on my decision-making. The most dangerous influences are the subliminal ones—not the ones where you are completely open about what is going on. There has been a great clamp-down over recent decades on the pharmaceutical industry because of sponsorship and so on, and that has decreased influences on prescribing. But when it comes to using other products in medicine, the same can apply. I think that a register would help the profession itself in making clinical decisions. I do not see this in any way as inhibiting research; on the contrary, it would display who is research active and who is achieving results through their research.

A register would support the development of innovative healthcare and support novel thinking because it would be declared and open. It would also support the move that people should always publish their results, whatever they are.