Draft Anaesthesia Associates and Physician Associates Order 2024

Baroness Keeley Excerpts

Wednesday 17th January 2024 General Committees

[Barbara Keeley (Worsley and Eccles South) (Lab)]

It is a pleasure to serve on this Committee with you in the Chair, Dame Caroline. I am pleased to be able to speak in our discussion of this very important area of legislation, as the right hon. Member for Suffolk Coastal just called it. In my view, this issue is so important that we should be debating it in the Chamber; perhaps we could have found a way to do that.

Schedule 1(3)(a) to the order states that the regulator

“has the objective of promoting and maintaining—

(i) public confidence in, and

(ii) proper professional standards and conduct for members of, the anaesthesia associate and physician associate professions”.

I hope that the regulator takes those duties very seriously, because public trust in physician associates has already been damaged by the very sad death of Emily Chesterton, who died after being seen twice and diagnosed by a physician associate at a local GP practice. Emily was the daughter of my constituents, Marion and Brendan Chesterton, and I raised her case at an Adjournment debate on 6 July 2023. I would like to give details of Emily’s case, because it illustrates the need for the greatest clarity in the distinction between doctors and staff in the medical associate professions.

Emily Chesterton died in November 2022 after suffering a pulmonary embolism, after being seen twice by a physician associate, rather than a GP. She was just 30 years old when she died. Emily was a budding actor in musical theatre. She and her partner had moved to London from Boothstown, in my constituency, to pursue their careers in the arts. They registered with their local GP surgery, the Vale Practice in Crouch End, north London. Emily had been diagnosed with polycystic ovary syndrome and had also contracted covid-19 in late summer 2022. Marion Chesterton, her mother and my constituent, said that Emily had been feeling unwell for a few weeks before she made an appointment at the Vale Practice on 31 October 2022, as she had calf pain and was breathless. Emily believed that this appointment was to see a GP, but the person she was booked to see at the practice was a physician associate.

Physician associates and doctors have a very different depth of expertise. Physician associates have to complete just two years of clinical training, following a biosciences undergraduate degree. Doctors, on the other hand, must complete a five-year medical degree, as well as several years of foundation training and specialism training, interspersed with national exams. As both the Minister and my hon. Friend the Member for Bristol South on the Opposition Front Bench have said, physician associates are intended to support and assist more medically qualified staff, not replace them.

In Emily’s case, after a short appointment, the physician associate diagnosed Emily with a sprain and possibly long covid. Emily was told to rest and take paracetamol. At no point during the appointment at the GP surgery was Emily made aware that the person who had diagnosed her was not a doctor.

A week later, on 7 November, Emily began to feel very unwell. Her leg was swollen and hot, and she struggled to walk a few steps without becoming out of breath. She made another appointment at the Vale Practice and saw the same physician associate. It appears that this was a short appointment, and that Emily’s legs were not examined. The physician associate suggested that Emily’s breathlessness was due to anxiety and long covid. She prescribed propranolol. In messages that Emily sent to her family on that day, it appears that she described seeing “the doctor”, and that she was never told that the person she was consulting for medical assistance was not a fully qualified GP.

In its serious incident report after Emily’s death, the Vale Practice stated that patients should not see a physician associate twice for the same condition. The guidelines make it clear that physician associates cannot prescribe; any prescriptions need to be signed off by a supervising GP. It appears that the oversight of prescribing medication was missing, and the system failed in Emily’s case.

Later in the evening of that same day, 7 November, Emily’s health deteriorated, so she took a propranolol tablet, as advised by the physician associate. She then became drowsy, and then very ill. Her partner Keoni recalled to the inquest that she lost her pulse, and he had to perform CPR on her, which recovered the pulse. He then called an ambulance.

Emily suffered a cardiac arrest on the way to the hospital. Her family had to say their goodbyes to her while she was still on the machine that was pumping her heart for her. Keoni recalled that staff at the A&E department at Whittington Hospital, where Emily died, told him that the propranolol tablet “definitely would not have helped” Emily’s condition, and staff had to give her an antidote to the drug.

The circumstances that led to Emily Chesterton’s death were investigated by a coroner, and there was a hearing at St Pancras coroner’s court on 20 March 2023. Messages from Emily to her partner and family at the time of her appointments were shared at the inquest. These messages provide evidence that Emily believed that she was seeing a doctor. They also provide evidence that the appointments with the physician associate were short, and that Emily was not examined fully.

The coroner’s conclusion was as follows:

“Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 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.”

That heartbreaking statement lays out clearly the failings in the health system, which should have supported Emily with appropriate care.

Sadly, further failings were evidenced in the incident report that the Vale Practice provided to the coroner. In particular, it was noted that the physician associate who saw Emily did not introduce herself and her role to Emily during the appointment. The practice said that the physician associate had failed to explore the causes of Emily’s symptoms, failed to refer Emily for clinical investigations, and failed to consult a doctor after seeing a patient who had presented twice in one week with significant risk factors for pulmonary embolism. The practice also raised concerns about the physician associate’s overconfidence and lack of insight into the limitations of her clinical knowledge and practice. Although the physician associate’s contract at that practice was later terminated, Mrs Chesterton was upset to learn that she was still practising in the NHS in London, but I understand that that changed after I raised concerns in the Adjournment debate.

I must add that Emily’s is not the only case like this. Sadly, Ben Peters, a previously healthy 25-year-old, died from a heart haemorrhage after being diagnosed with a panic attack by a physician associate. A freedom of information request sent to Scottish health boards found that there have been at least 12 “never events” linked to physician associates in Scottish health authority areas.

These cases demonstrate the urgent need for this profession to be regulated in a way that avoids further confusion among patients, their families and medical staff. To patients, associates and doctors may look the same—they appear to be doing a similar job—but the fact is that the associates do not have the same qualifications or expertise as doctors. I understand that it was originally envisaged that physician assistants would be vital members of multidisciplinary teams, assisting with the workload and contributing to a high quality of care, but the regulator must ensure that there are now clear guidelines for associates to make their role clear to patients when they introduce themselves. As I have described, that did not happen in the case of Emily Chesterton.

There is a bigger question around the titles of associate. At the time of my Adjournment debate, Marion Chesterton raised with me the point that the title sounds

“extremely grand, even grander than a General Practitioner”.

Some have suggested changing the title back to the original title of physician assistants and anaesthesia assistants to avoid that confusion. There may be other solutions that the Minister could consider.

Getting the approach to associates right will become even more urgent as the profession grows in line with the proposals set out in the NHS long-term workforce plan. There is certainly a need to tackle workforce shortages in the NHS, as my hon. Friend the Member for Bristol South said. A lack of qualified professionals is the root cause of many of the challenges that our health service faces. We must be careful that any adaptations to the workforce to fix those issues do not push existing professionals out.

I had many GPs write to me after my Adjournment debate about Emily’s case. One told me,

“There is much talk amongst GP locums of work drying up, possibly due to the increasing use of Additional Roles Reimbursement Scheme staff (including the associate roles) to fill vacancies (and these are much cheaper than employing locum GPs), and last week there was considerable disquiet about the Surrey practice that made its salaried GPs redundant due to ‘new ways of working’.”

He wrote on,

“For GPs—salarieds, locums, and trainees—who have been working in an over-stretched, high-stress system, and [who have] been told that there is a national shortage of GPs—this leaves many wondering about the security of their career and exploring other options. I am seriously concerned that the many intelligent, enthusiastic and valuable people in training and working as GPs are looking at options outside the NHS, outside medicine, and outside the country.”

I am sure the Minister would agree that this is deeply concerning when the UK already faces intense competition from other countries to retain our doctors. While multidisciplinary teams with a diversity of roles are vital, doctors must still be valued. Most importantly, patients and clinicians must have a clear understanding of the skills, qualifications and limitations of those providing care.

I want to acknowledge that there have been many tragic cases leading to avoidable deaths of patients that have involved other roles. We could look at the case of Connor Sparrowhawk, an epileptic teenager who had a seizure and drowned in a bath at a hospital unit run by Southern Health. Connor was just 18. Dame Caroline, you will know well the case of Oliver McGowan, who died in Southmead Hospital at the age of 18. Oliver was prescribed the anti-psychotic medication olanzapine by a consultant in the hospital, despite his notes saying that he had reacted badly to it previously. Oliver died as a result of the brain injury caused by the medication.

Those are tragic cases, but in neither of them was it the role and the limitations of an NHS professional that caused the problem. The issues I have raised are about the safety of patients and the accepted standards of knowledge, training and experience that we should expect from our medical professionals in order for them to provide a high quality of care. I hope that the Minister notes the points raised in this debate, and takes steps to ensure that the NHS workforce delivers for patient safety.

--- Later in debate ---

[Andrew Stephenson]

I thank my right hon. Friend the Member for Suffolk Coastal and the hon. Members for Bristol South, for Leicester East, for Worsley and Eccles South, for York Central, and for Wirral West for their contributions to today’s debate.

I would like to turn first to the contribution by the hon. Member for Worsley and Eccles South, who spoke movingly on behalf of her constituents Marion and Brendan Chesterton about the death of their daughter, Emily. I know that the hon. Lady also did so in a very moving fashion during an Adjournment debate, which was responded to by my predecessor, my hon. Friend the Member for Colchester (Will Quince). Ahead of today’s debate, I was very keen to listen to that debate, so I watched it back and I am keen to see what more we can do to learn lessons.

No family should ever have to endure the loss of a child, and no words from me will assuage the family’s grief. However, I hope that by passing this order we are helping to ensure that some lessons have been learned and that we can deliver improved patient safety through better regulation of these roles. I recognise that there have been delays to the previously published timescale for the regulation of AAs and PAs. Although that is in part due to the pandemic, it is important to reiterate that this work is being taken forward as part of a broader package of reforms of regulators, governing a whole range of medical professions. That work is significant and complex. On that basis, a huge amount of work and input from all the regulators and a range of stakeholders has contributed to the draft legislation for AAs and PAs, which will be used as a template for reforms to other regulatory bodies.

Throughout this process, officials from my Department have met the BMA and other stakeholders to develop the policy behind this legislation. On the basis of feedback received through public consultation and additional targeted engagement, officials have made a number of amendments to the draft order to ensure that the legislation is fit for purpose and delivers the flexibility and autonomy required to empower regulators to be able to introduce new regulatory processes that would better serve patients and their registrants. That engagement has been crucial in shaping both our policy intention and the resultant legislation to ensure that it remains a practical piece of legislation that can be used by regulators.

The forthcoming GMC rules consultation, which will follow the passage of this order, represents a further opportunity for the BMA and others to have input into the regulation of these roles. When I met the GMC, I was assured that they were confident that they could bring forward this consultation quickly so that there are no further delays to the timetable of implementing these regulations.

Turning to the AA and PA titles, which quite a few Members have raised today, the physician associate title has been well established in the UK since 2014, and the Government have no plans to change the titles of PAs or AAs. As set out in the National Institute for Health and Care Excellence guidelines, all healthcare professionals directly involved in patient care should introduce themselves and explain their role to the patient. AAs and PAs are not and should never be referred to as medical practitioners, doctors or consultants.

The GMC has published interim standards for AAs and PAs in advance of regulation that make it clear that professionals should always introduce their role to patients and set out their responsibilities in the team. Ahead of regulation by the GMC, the Faculty of Physician Associates has issued guidance for PAs, supervisors, employers and organisations that helps to provide a structured and standardised way of using the title. In addition, NHS England has produced patient-facing materials that have been shared widely with GP practices to support patient awareness and understanding of the PA role.

[Barbara Keeley]

I thank the Minister for his words of sympathy; I will pass them on to Mr and Mrs Chesterton. On patient-facing advertising, I think a couple of months ago, I raised with the previous Secretary of State for Health, the right hon. Member for North East Cambridgeshire (Steve Barclay), a post from Norfolk and Waveney integrated care system that read, “Got abdominal pain that isn’t going away? A Physician Associate based in your GP practice can help…They are highly skilled at diagnosing conditions”. That was marketing material related to the role, which does not help. We have had tragic cases like Emily’s, and it does not help to have over-egged advertising like that. Can the Minister can say anything about that?

[Andrew Stephenson]

I completely agree. Things like that do not help, and that is why bringing forward these regulations will help. The GMC is obviously very keen to start its consultation and have the regulations introduced. As soon as this is set out in statute, it will be very helpful, not just for PAs but everybody, particularly employers and others, in ensuring that they never oversell the abilities of a PA and are clear about the role of a PA or AA in an integrated health team.

Turning to the shadow Minister, the hon. Member for Bristol South, I thank her for her contribution and join her in paying tribute to the PAs and AAs already working in our NHS. She asked about the impact on training opportunities for junior doctors, which leads me on to addressing quite a few of the points about why we have decided to go with the GMC as the regulator. The assessment of the most appropriate regulatory body for AAs and PAs was completed in 2019 following a public consultation. The majority of respondents were in favour of the GMC taking on regulation, including the professional bodies representing the two roles and the medical royal colleges. For the record, from a total of over 3,000 responses, 59% of respondents felt that the GMC was the most appropriate, while 20% thought it should be the HCPC.

Regulation of the associate roles by the GMC will allow it to take a holistic approach to the education, training and standards of associate and doctor roles. That will enable a more coherent and co-ordinated approach to regulation, hopefully ensuring that concerns around training places for junior doctors, for example, are addressed appropriately. I am happy to reassure the shadow Minister that I will continue to work with all stakeholders to ensure that we get the regulations right.

I thank the hon. Member for York Central, who spoke knowledgeably about these roles. We would all agree that it has been long recognised that we need to reform the legislative framework for the regulation of healthcare professionals to make things faster and more flexible. The current UK model needs to change to better protect patients, support our health service and help the workforce to meet future challenges.

Successive Governments have considered such reforms, but they have never come to fruition until now. While it is our intention to work as swiftly as possible to deliver reform for each regulator and profession, we will prioritise delivery based on criteria including the size of the registrant base, the need for reform, and our assessment of regulators’ readiness to implement the changes. Based on those criteria, we intend to start working with the regulators to develop reform legislation for their professions over the next couple of years.

The hon. Lady asked about fee levels. I believe the GMC’s current plan is to charge AAs and PAs a fee of £221 per annum, adjusted for inflation. That is what PAs are currently paying the FPA—of course, AAs do not currently pay a fee. The GMC, like the NMC and other regulators, works on the basis of their activities being funded by the fees from registrants, which is an important way of keeping them independent from Government.

This draft order represents a vital step forward to improve patient safety by ensuring that PAs and AAs meet the standards that we expect of all regulated professionals and that they can be held to account if serious concerns are raised. I hope that I have addressed as many of the points raised by the Committee as I can, but I am more than happy to continue dialogue with the Opposition Front-Bench team and others to ensure we get the changes right. I commend the draft order to the Committee.