Physician Associates

Debate between Dan Poulter and Rachael Maskell

Wednesday 7th February 2024 Commons Chamber

[Dr Poulter]

I completely agree with the hon. Member. He advocates strongly for his constituents, as always, and for the need to better retain our medical workforce in general, our junior doctors in particular. The Government will have heard his comments. I am sure that things can be done to improve the current offer to junior doctors in England. Indeed, things can be looked at in Northern Ireland, too, with the restoration of political arrangements.

An agreement could be put in place that will properly renumerate junior doctors, and also look at the other terms and conditions of employment that are important in respect of retaining the medical and healthcare workforce. These situations are not always about pay; it is also about wider terms and conditions. The Government could certainly look in more detail at student debt, for example, as the Times Health Commission outlined this week, which may incentivise people to stay in medicine for longer.

We have diverged slightly into the broader healthcare challenges, so I will return to physician associates, which was the point of this evening’s debate. There are concerns about the regulation and training of this particular group in the medical workforce. Physician associates and anaesthesia associates are not currently regulated. There have been a number of recent high-profile cases of patient harm as a result of being seen by medical associate professionals, including, sadly, some deaths. We know, for example, of the tragic case of Emily Chesterton from Salford who died of a pulmonary embolism having been seen twice and had her deep vein thrombosis misdiagnosed as a musculoskeletal problem by a physician associate at her local GP practice.

Anybody who watches the TV programme “24 Hours in A&E” may have seen some fairly enlightening scenes in respect of the clinical skills of some medical associate professionals, including physician associates. There are many examples of poor clinical diagnosis and judgment, including, for example, making initial decisions to send patients with compound fractures home without an X-ray when the patient actually required surgery.

In my own clinical practice, I have worked alongside some very competent physician associates, but there is a high degree of variability in their training and skills. Only last year, I was forced to directly intervene to prevent patient harm following a paracetamol overdose by a patient who attended A&E. The physician associate incorrectly informed me that they did not require N-acetylcysteine treatment because their liver function test was normal, in spite of the fact that they were over the treatment line as a result of their paracetamol overdose. Of course, at that time, the patient’s liver function tests were normal, but they would not have been for very long. The consequences of that diagnostic decision by the physician associate could have been fatal. The key issue for me is that many physician associates do not know or have the self-awareness to understand the limits of their knowledge and practice, but this is perhaps understandable in a health system that fails to adequately regulate and indeed define its scope of practice.

There are many other areas of concern that have been highlighted in a recent British Medical Association survey of 18,000 doctors, an overwhelming majority of whom work with physician associates. In November 2023, due to severe concerns around patient safety, the BMA called a halt to the recruitment of medical associate professionals to allow proper time for the extent of patient safety claims to be investigated and the scope of the role to be considered.

When the physician associate role was introduced, it was clearly seen as part of the solution to a shortage of doctors, which currently stands at in excess of 8,500. By freeing up doctors from administrative tasks and minor clinical roles, it allowed them to see more complex patients and get the training required to become excellent consultants or GPs.

Unfortunately, physician associates and anaesthesia assistants have been employed in the NHS in roles that stretch far beyond that original remit, and in many cases that were reported in the recent BMA survey that I mentioned, they appear to be working well beyond their competence. That has raised serious patient safety concerns—I gave some examples earlier—and led to calls to review the role, limit the scope of practice, and protect training for the doctors that the NHS desperately needs. When consultant time is taken by supervising physician associates, that is to the detriment of training and supervising junior doctors. That has not yet been addressed or even considered in the NHS England workforce plan.

[Rachael Maskell (York Central) (Lab/Co-op)]

I am grateful to the hon. Member for introducing this evening’s debate. I sat on the Committee that considered the Anaesthesia Associates and Physician Associates Order 2024. He is drawing out several issues. One is competency; another is patient literacy. A lot of new roles are emerging—technicians, assistants, associates, and advanced practitioners—and to the public this is now becoming a blurred space. People do not understand the competences that individuals possess, their scope of practice, and where they fit into the medical family, or indeed professions allied to health. Does he agree that we need to define those roles clearly, and that associate roles should be around professions allied to health, rather than associated directly with the medical profession?

[Dr Poulter]

I fully agree with the hon. Lady, and I will expand on that a little later. There is certainly confusion among the public about what a physician associate is. Many members of the public assume them to be doctors or other healthcare professionals. They therefore lack a much greater degree of competence. Given that it is envisaged that the role will be significantly expanded, the public understanding and awareness of it, and people’s expectations when being treated by somebody in that role, are really important. That needs to be better addressed through the current proposals for regulation, which I will come to in a moment.

I will talk briefly about general practice and the additional roles reimbursement scheme. Through the ARRS, the Government have provided funding to GP practices that can be used to pay for physician associates and other clinical staff, but not for hiring additional doctors and nurses. That is quite extraordinary, and results in GP practices having physician associates rather than fully qualified GPs. Currently, most physician associates in general practice are funded through the additional roles reimbursement scheme: an NHS scheme that funds primary care networks to support recruitment across a very limited set of eligible roles. The current rules for ARRS funding are causing inefficiencies as they are not flexible enough to respond to locality needs for healthcare staff. In particular, the rules do not allow practices to hire primary care nurses, practice nurses, or indeed GPs, as I mentioned.

Over the past year, there have been many developments in how the Government and the profession view the roles of physician and anaesthesia associates, but it seems extraordinary that when we are talking about supporting general practice in developing the right skills and competences, and delivering the right service for patients, one of the key funding schemes does not allow for the hiring of the GPs and practice nurses that are needed, and is skewed towards physician associates. I wonder whether the Minister might take that away, look at the scheme, and help to provide additional flexibility, which general practice would like and which seems eminently sensible, to allow recruitment at a local level, in line with patient need.

There are significant concerns connected with the roll-out of the anaesthesia associates project. While the GMC addressed some of those issues in its recent letter to NHS England, a number of concerns remain. In particular, the NHS long-term workforce plan suddenly projected a huge expansion in the number of anaesthesia associates, but no expansion in the number of doctors in anaesthesia—or, as we are talking about position assessments, in the number of doctors in other specialities. To many, that looks like a replacement of doctors with anaesthesia associates, rather than anaesthesia associates being employed to complement the anaesthesia team, which was the idea previously portrayed.

There are many examples of medical associate professionals in the wider sense working in ways that have caused concern, as we have discussed in this debate, particularly with regard to their scope of practice. Anaesthesia provision in the UK must continue to be led and delivered by doctors, who are properly trained and properly regulated. Anaesthesia associates are valuable members of the anaesthesia team in addition to doctors, but they are not a solution to the challenges of low workforce numbers in anaesthesia and growing waiting lists.

The answer is to expand consultant numbers, an expansion in training scheme places for doctors in anaesthesia, and the development of the large number of speciality doctors and locally employed doctors already in post. Creation of speciality and specialist doctors and consultants via the General Medical Council’s new portfolio pathway could result in our having many more independent doctors in anaesthesia and other medical disciplines. It seems extraordinary that we are not looking at that first, given that we have a properly regulated and properly trained profession, rather than at expanding a workforce that is not subject to proper regulation to date, does not have a certified training pathway, and has been associated with a significant number of adverse patient outcomes and incidents.

Regulation ensures consistent standards for training, and for the practice of physician associates and anaesthesia associates. It maintains standards and, critically, contributes to patient safety. As per the recent Anaesthesia Associates and Physician Associates Order 2024 laid before the UK and Scottish Parliaments, those associates will be registered with the General Medical Council. However, there are increasing concerns that that could further blur the distinction between doctors and anaesthesia associates.

In response to those concerns, the GMC has said that physician associates and anaesthesia associates will be issued with a registration number format that distinguishes them from doctors. That is to be welcomed. However, it must go further and present doctors on a separate register from physician associates and anaesthesia associates, whether we are talking about a register online or in print—that aligns with the point that the hon. Member for York Central (Rachael Maskell) made—so that it is very clear that the different professions are regulated under separate registers. That is important for both accountability and transparency, and it is important that patients understand that.

There should be a clear distinction between the register of doctors and other registers. That is necessary to provide absolute clarity for patients and others who wish to access the registers, and it is essential to protect everyone from accidental or deliberate misrepresentation. With modern information technology systems, there is no legitimate reason why that cannot be done. It would be simple, and it is about transparency, openness and patients better understanding the difference between the responsibilities of doctors, and those of physician associates and anaesthesia associates. I hope the GMC is listening to this debate and will ensure properly separate registers. That does not cost much, but is very important.

Perhaps the crucial point in this debate is the scope of practice. There should be a national scope of practice for physician associates and anaesthesia associates, both on qualification and after any post-qualification extension of practice. Any future changes to scope of practice should be developed in conjunction with the regulator and should be agreed at national level. I understand that currently the GMC will not regulate extended scopes of practice, which is very regrettable. For example, we are aware of whether a doctor is on the GP register or a specialist register, or just has a licence to practise. Those levels of expertise are part of the regulatory framework. It seems extraordinary that although the GMC has been asked to look at regulating physician associates, there is no understanding of the scope of a physician associate’s practice. That needs to be properly mapped out and explored.

[Rachael Maskell]

I am grateful to the hon. Gentleman for making those points. It is particularly concerning that a prescribing nurse, say, could become a physician associate, but perhaps without the ability to prescribe. That would create even greater confusion. Does he agree that we need clarity and distinctions to be drawn on those kinds of issues?

[Dr Poulter]

I fully agree; the hon. Lady is absolutely right. I was going to address that very point about prescribers a little later. There is clear agreement on the challenges. Those issues should be thought through before a workforce plan is brought forward, and before there is a significant expansion of the workforce, for reasons of patient safety, particularly as concerns have consistently been raised about the scope of practice and adverse incidents. It is rather putting the cart before the horse to say, “We want to expand the workforce without dealing with the important issues of how that workforce is trained, how it can properly be regulated, and what its scope of practice is.” That is unfortunately a regrettable failing of NHS England’s plan, which I hope it will consider.

If the GMC cannot regulate extended scopes of practice, they should be devised according to a national framework. There needs to be an understanding of what that should be. It is unacceptable for employing organisations in the NHS to devise their own extended scopes of practice without reference to at least some national framework—one that has the confidence of regulators and standard setters—so that we know and understand what good practice looks like.

Doctors should be directly involved in devising any changes to the scope of physician associate and anaesthesia associate practice, whether on qualification or at extended level. There should be no extension of roles beyond the scope of practice on qualification until national guidance is issued. Where organisations are planning such an extension, it should be paused for reasons of patient safety. Where physician associates or anaesthesia associates are already working in an extended role, it should be recorded on the healthcare organisation’s risk register, and the organisation should ensure that it has full confidence in its standards of supervision, access to support, indemnity of the anaesthesia or physician associate and the supervising doctor, and patient information and consent. Anaesthesia associates have a role to play as part of the wider anaesthesia team, but it is important to ensure that it is a complementary role as an addition to the workforce, not as a replacement for doctors and nurses, as the hon. Lady rightly underlined. Expansion in the number of anaesthesia and physician associates should not be at the expense of expansion in the number of doctors in specialist posts.

Let me come briefly to assessment, which is another area that has not been well thought through. It is important that assessment for anaesthesia associate roles is standardised at national level. The Royal College of Physicians does a national exam for physician associates, but a national body needs to be established to undertake the assessment process for anaesthesia associates if we are to ensure confidence in their competencies. It may be possible for that to be delivered locally, if there are stringent controls in place to ensure consistency. However, before the anaesthesia associate workforce is expanded, there needs to be some process for assessing competency.

On indemnity, which was also addressed by the hon. Lady, further information is needed around indemnity cover for both physician associates and anaesthesia associates, as well as for any doctors supervising them. “Good medical practice” expects all doctors to ensure that they are fully indemnified. The same standard should apply to physician associates and anaesthesia associates. Many doctors in anaesthesia, in general practice and in emergency departments are already worried about medicolegal liability when working with physician associates, and clear guidance is urgently needed. Although reference is made to accountability, more information is required in this area, given the challenges that we know have arisen.

The hon. Lady mentioned prescribing rights. Some physician and anaesthesia associates—for example, those with a nursing background—may already have those rights from their parent profession. The Commission on Human Medicines is responsible for deciding which professions are able to prescribe, and it is important that it is clear in its guidance and reasoning in respect of physician and anaesthesia associates before there is a wider roll-out of those roles.

I draw the Minister’s attention to key findings from the British Medical Association’s recent survey, which sought the views of over 18,000 doctors about the role of the medical associate professions. Almost 80% of respondents—that is well in excess of 15,000 doctors—had worked with or trained medical associate professionals, which means that contact with those professionals is widespread throughout the NHS. Medical associate professionals are currently unregulated and have a poorly defined scope of practice. The BMA survey respondents were very concerned about that, as well as about the fact that MAPs have been employed in the NHS in a variety of roles, which go well beyond what was originally envisioned as an assistant role. A staggering 87% of doctors surveyed believed that the way that physician and anaesthesia associates work in the NHS is a risk to patient safety. For the Minister’s benefit, that is the best part of 18,000 doctors who work with this workforce raising concerns about working practice and patient safety.

[Rachael Maskell]

Once again, I am grateful to the hon. Member for giving way. Doctors in training need a very clear career pathway, but because of the rise in anaesthesia associates in particular, but also in physician associates, the pathway to many more senior roles will be blocked. As a result, people will stagnate as doctors in training, as opposed to getting a consultancy. Does he agree that that is highly problematic, and that the career pathway needs working through before there is any increase in the number of physician and anaesthesia associates?

[Dr Poulter]

That is absolutely essential. At the moment, the prerequisite appears to be a biomedical science degree, which is incredibly variable—depending on whether a person went to Hull, Newcastle or a London university, a biomedical science degree could be very different—and then two years of study. A physician associate would then have to pass an exam set by the Royal College of Physicians, but when a person passes that exam, it does not necessarily mean that they had standardised or good training; potentially, it just means that they prepared well to pass their exam. The difference with doctors in medical school—and indeed the difference with nurses going through nursing school—is that they are consistently assessed, all the way through their undergraduate training. When they graduate at the end of that training, they are consistently assessed as they progress.

None of that exists in the training pathway for physician or anaesthesia associates; in fact, as we have discussed, there is not even an exam for anaesthesia associates at the end of the process. It is absolutely essential that those issues are addressed as a priority, and it is little wonder that patient deaths and adverse incidents are occurring on such a scale. Perhaps when the Minister is suffering from insomnia late at night, he may wish to watch old episodes of “24 Hours in A&E”. He will see the huge variability in the expertise of physician associates. Some are very good, but some are not, and we should not be dealing with variability in the British health system. That is what we are trying to address, so the hon. Member for York Central is absolutely right in everything she has said.

That highlights the last point I am going to draw to the House’s attention from the BMA survey of 18,000 doctors. Some 75% of respondents said that the quality of training among medical associate professions—physician and anaesthesia associates—was woefully inadequate; 84% said that the quality of their supervision when they are at work was inadequate; 91% outlined the fact that they work outside their competence; and 86% of respondents confirmed that the public would confuse them with doctors, as the hon. Lady outlined. This is not just a few hundred doctors; this is 18,000 doctors saying in a survey that they have serious patient safety concerns due to the variability in training of anaesthesia associates. There have been far too many adverse incidents where things have gone wrong, and it is time for the Government to give NHS England some clear direction that this area needs to be looked at, and some proper planning and consideration of the expansion of this workforce put in place.

These are the asks I have of my right hon. Friend the Minister. First, we should ensure there is a standardised and quality assured training programme for physician associates, anaesthesia associates, surgical care practitioners and all other medical associate professionals, and indeed that there is ongoing training and supervision to a nationally standardised level when that group is in the workplace post qualification. Secondly, we should ensure that the General Medical Council sets up a register for the regulation of medical associate professionals, separate from the register for doctors. Thirdly, as is the case with all other healthcare professionals, we should ensure that the scope of practice of physician associates is clearly set out to make sure that we can develop appropriate training pathways and supervisory pathways, but, more importantly, to ensure patient safety. Finally, the Government should support the introduction of a system with greater flexibility to hire GPs and general practice nurses using the ARRS funding. I thank the House, and I look forward to the Minister’s response.

Support for New Adoptive Parents

Debate between Dan Poulter and Rachael Maskell

Monday 21st March 2022 Westminster Hall

[Rachael Maskell]

I thank my hon. Friend for raising that issue, on which she is probably more of an expert than I am. We have recognised the role of digital and the fact that many children in adoptive settings can be traced or can trace their birth parents without having support around them. We have to recognise the digital age in which children are growing up in order to keep them safe and to protect them. I am sure we will talk more about this subject.

The Minister for Children and Families, the hon. Member for Colchester (Will Quince), is committed to building stable families and providing the care and support that young people and their parents need. He has a sizeable task. Over 80,000 children are in care. I trust that, with the imminent publication of the review by Josh MacAlister, he will simultaneously fix the gaps in the adoption journey. We welcome the commitment of £144 million for the adoption support fund and £19.5 million for the implementation of the adoption strategy over the next three years. It is a sound investment, on which we will see a return.

We need a workforce plan to support children in the care system and their families. There is a deficit in timely support for families, and the scars of trauma emerge in various expressions. Three quarters of children experience abuse or neglect prior to adoption. They need support to be in place at the right time. In our APPG’s “Strengthening Families” report published last year, we identified the importance of aiding parents in the matching process. It has been more challenging through the pandemic, but we cannot let a recovery period delay the process of family building. We are particularly concerned about black and minoritised children in the care system, as well as older children and young people who have been in care the longest. As an APPG, we have more work to do, but so do the Government.

Self-employed parents need help, too. The crucial period of bonding as a family forms is vital in forming attachments and a new rhythm in a child’s life. The self-employed need the same opportunities as other parents to dedicate time to this. Denying statutory adoption pay is nonsensical. I trust that the Minister agrees. We await the legislative response to the Taylor review. I ask that the Minister ensures that the voice of adoptive parents is not lost in that process.

The right hon. Member for Basingstoke (Mrs Miller) made a powerful plea for other parental rights to emerge in such a Bill. I ask that adoptive parents do not suffer any detriment either. If we, as a society, value parenting and recognise its importance, there is no excuse for exclusion. I hope the Minister will forgive me, but I am impatient. Self-employed parents need support now. We know how hard self-employed people work to make their businesses a success.

We heard from the hon. Member for Carshalton and Wallington (Elliot Colburn) about the challenges of the pandemic and how hard people worked to make their businesses thrive. They cannot juggle work around bonding with their child. Ensuring that the right attachments are made is a full-time task. That is why we need to ensure that the self-employed get the financial underpinning to not have to worry about paying their bills, not least at a time when the cost of living is such a challenge to all families.

Adoptive parents should not have to go cap in hand to their local authority either. Special guardians, kinship carers and adoptive parents need recognition that they, even more than birth parents, need to be 100% focused on family building. There is time for the Government to carry out a consultation on the Taylor review prior to their promised employment Bill. I ask the Minister to commit to that consultation today.

The 2013 statutory guidance on adoption states in paragraph 9.38 that

“The local authority should consider making a payment of financial support equivalent to the Maternity Allowance to adoptive parents who are ineligible to receive”

statutory adoption pay. Why is it that adoptive parents continually have to chase everything, and dedicate their time to feeding into the bureaucracy and trying to get it to work for them, as opposed to the Government addressing the issue?

Statutory pay will aid the recruitment of potential adopters and will assist in the success and stability of others. We know that 3,000 children are in need of a family. A full consultation was committed to by the Under-Secretary of State for Business, Energy and Industrial Strategy, the hon. Member for Sutton and Cheam (Paul Scully), who has responsibility for parental pay and leave, during his evidence to the Petitions Committee in 2020, but we must include adoption pay, too. The Government have committed to improving adoption, so this is yet another opportunity for them to do so, and I hope the consultation will therefore be inclusive. He said,

“it is crucial to the success of an adoption placement that an adopter takes time off work to care for and bond with their child.”

That must apply to the self-employed as much as to the employed. There is no difference in the eyes of that child, or in that child’s needs.

[Dr Poulter]

I am sure the Minister will find it difficult to disagree with the hon. Lady. She rightly mentions the barriers to adoption more generally. The coalition Government did a lot with my hon. Friend the Member for Eddisbury (Edward Timpson), in a previous guise, to reduce some of those barriers. He also highlighted the failure of previous Governments to have joined-up thinking, such as joining up the fiscal and financial incentives to support people in adoption. I hope the take-home message for the Minister is that it is time to do that. I hope he will commit to doing so at the Dispatch Box, and I hope the hon. Lady agrees.

[Rachael Maskell]

The hon. Gentleman is absolutely right. Normally it is the parent who does the joining up, and that is clearly not right. The Government need to make sure that the adoption strategy looks at every aspect of an adoptive parent’s journey and ensures that the facilities, support and services are in place to give the child the best possible start in life. It is exhausting for parents, who find themselves having to negotiate—this is where the law stands at the moment—with a local authority to see if they fit any of the criteria, on which there is no guidance. We know that cash-strapped local authorities may not be minded to pay specific attention to what is a very small cohort of parents.

The Government recognise how necessary statutory maternity entitlements are for parents to bond with their child, and they must recognise how much more important such support is for a child who has experienced multiple forms of trauma and who could have complex needs that need addressing. Life is often exhausting for an adoptive parent who is trying to form a new family and working to give their child the safest home possible. The services need to be there in a timely way to support and nurture that child, and to ensure they have the best start in life when perhaps their first start was not the right one.

The “Good Work” review does not accept that there should be a differentiation in the support received. On statutory adoption pay for the self-employed, we are not talking about a lot of people. It is not a high cost to the Government in the scale of things and, as well as the savings to the Government from ensuring that self-employed parents have the support around them, statutory adoption pay would be immeasurable for parents and for the child. Now is the time to act, and I trust that the Minister agrees.