Physician and Anaesthetist Associate Roles: Review

Baroness Bennett of Manor Castle Excerpts

Thursday 5th December 2024 Lords Chamber

Asked by

[Baroness Bennett of Manor Castle]

To ask His Majesty’s Government what the review, announced by the Secretary of State for Health and Social Care on 20 November, of the physician associate and anaesthetist associate roles will cover; and what actions they plan to take in advance of the outcome.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I thank noble Lords for staying with us late on a Thursday for this debate. I know there are many noble Lords, among them the noble Baronesses, Lady Finlay and Lady Brinton, who moved regret Motions about the statutory instrument passed under the previous Government that is behind the mess we are discussing today and who would have very much liked to take part.

I will not go over the same ground as I did in February, when I begged the then Government to pause their action, but the concerns expressed then have only grown, reflecting many of the reasons why Professor Gillian Leng has been asked to conduct the review of PA and AA roles. In the words of consultant Partha Kar, the Government’s national adviser on diabetes, we have seen

“months of heated debates, social media uproar, royal colleges in turmoil, and the reputation of many national organisations being questioned”.

Professor Kar has described this as

“the worst example of a policy implementation in the NHS I’ve seen”.

I note that just this week the Irish Medical Council concluded that it was not the appropriate body to regulate PAs, and referred to

“the potential for emerging patient safety risks arising … as observed recently because of regulation of PAs by the GMC in the UK”.

I shall ask a large number of questions. To be fair to the Minister, and to ensure that this debate is as constructive as possible, I have shared my questions with her in advance. I begin with the first part of my question, about the review itself. I have heard only respect and hopeful feelings about Professor Leng being appointed as lead, but many concerns have been expressed to me about the level of co-operation that the review will receive and the quality of information available to it. Just yesterday, the GMC wrote to medical bodies, nine days before it is due to begin registering PAs and AAs, saying that it would

“soon publish a report on the outcome of the consultation and the research; along with the final drafts of the rules, standards, and guidance”.

That report was published just two hours ago, before this debate started.

Does the Minister consider that to be an appropriate timetable and level of transparency? Is the Minister happy with the response of the GMC to requests for information over this difficult year? Can the Minister assure me that Professor Leng will have the necessary resources and that the Government will do everything necessary to ensure that she receives full co-operation and transparency?

We have seen many different, often disturbing, localised reports about the ways in which PAs in both hospital settings and general practice have been deployed. Knowledge and concern about the deployment of PAs and AAs is growing among patients and the general population. I note that the Fire Brigades Union conference in May voted to oppose the growing use of PAs. Will Professor Leng have the resources to access those public views?

The review’s remit seems quite narrow. An obvious omission is the ask from the Royal College of Physicians that it should consider the impact of the PA role on training opportunities for resident doctors. Will the review do that? Further, will it consider the fundamental issue that the “taskification” of medicine is a massive change from previous practice and a reversal of the recent growing understanding of the need to consider the whole human, and their environment, in supporting health and tackling disease?

Our debate in February heard considerable concerns about the impact of PAs on doctors’ training. There were suggestions from all sides of the House that a major revamp of training arrangements for doctors needs to be put in place. Can the Minister write to me about what plans the Government might have in that area? I want mostly to focus what interim measures the Government plan to deal with what is clearly an untenable current situation. In February, the then Minister, the noble Lord, Lord Markham, said that PAs and AAs are

“very much a supplemental role rather than a substitute”.—[Official Report, 26/2/24; col. 912.]

Of course, that is not what has been happening, as demonstrated by a letter sent in March from NHS England to ICBs and trusts. It said that PAs

“should not be used as replacements for doctors”

on rotas, yet a detailed investigation by “Channel 4 News” in October found widespread subsequent use of such substitutions. A number of trusts indicated that they did not even keep any records of such substitutions. Does the Minister stand by that NHS England guidance? What will the Government do to ensure that it is implemented?

The Government’s announcement of the review said that it is to report in spring 2025. Your Lordships’ House knows that government definitions of seasons means that that could extend well into the year. By the time report is absorbed and action decided, realistically, we are talking about a year of a clearly untenable situation. Does the Minister agree that interim action is surely needed?

In September, the governing council of the Royal College of General Practitioners voted to oppose a role for physician associates working in general practice. Reports suggest that, as a result, PAs are being made redundant—they have my sympathy—and general practices face the risk of legal action. How will the Government deal with this situation and prevent it escalating, at great cost to NHS services?

The council of the Royal College of Physicians has agreed that there is a limited role for physician associates working in secondary care in the medical specialties, as long as they are supported by clear supervision arrangements, professional regulation and a nationally agreed scope of practice. Do the Government agree? Will they take action immediately to deliver this, at least in an interim way? Do they agree that such supervision urgently needs to be defined?

I turn to caring for our children, and highly vulnerable patients at risk of rapid deterioration in condition, an area of particular concern. The Royal College of Paediatrics and Child Health has called for an immediate pause in the recruitment of PAs. Given the very disturbing situation that arose at Alder Hey hospital, does the Minister agree that there should be such a pause?

The House may well ask where guidelines across disciplines for national scope—a ceiling of practice—for PAs and AAs might come from. I was at the launch of a detailed, carefully prepared British Medical Association outline of a PA/AA scope document. I did not hear anyone express serious concerns about the activities of PAs and AAs being safe, if they were working to that outline. Does the Minister agree?

Later this month—very soon, I think—it is expected that the Royal College of Physicians will publish draft “safe and effective practice” guidance on the supervision of PAs, alongside a definition of the PA role drafted by the RCP resident doctor committee and agreed by both the PA oversight group and the RCP council. Does the Minister agree that this should be applied?

To back to our debate in February, I suggest that the Minister misspoke in saying that the GMC is regulating. What is due to come into practice on 13 December is a registration process for which there is a two-year lead-in period, so it will in effect remain voluntary until December 2026. I respectfully suggest that, without a national scope and clear guidelines for supervision, this cannot in any way be described as “regulation”. It is purely registration. Does the Minister agree?

I turn to AAs specifically, and an issue of grave concern—including legal concern—that was recently raised with me. In the current regulations, AAs and PAs are not allowed to prescribe or order ionising radiation. How can someone acting as an anaesthetist not do so? Expert advice that I have received suggests that the tool of patient-specific directive, which are meant to allow a doctor to direct another professional in making a limited choice of drugs under very specific circumstances, is being used and possibly misused. I am told that PSDs are being used to provide an extensive list of drugs for AAs to choose from; in essence, that means that they are prescribing. Can the Minister comment on that?

Finally, I turn to a couple of broader “What now?” questions. The NHS careers website’s PA/AA page, which I consulted yesterday, lists 39 universities offering courses for these roles. I have heard that several are pausing these courses. Does the Minister think it is fair to encourage students to start new PA and AA courses, given the uncertainty while the review is conducted?

I conclude by stressing that my questions to the Minister, my concerns and the mess that we are in now are not the fault of PAs and AAs who, in good faith, have signed up for service, studied and got the debt to show for it. Can the Minister assure me that the Government are committed to ensuring that a way forward will be found for them, whatever the review’s conclusions and future steps?