Physician and Anaesthetist Associate Roles: Review

Baroness Keeley Excerpts

Thursday 5th December 2024 Lords Chamber

[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”.