Physician and Anaesthetist Associate Roles: Review

Lord Kamall Excerpts

Thursday 5th December 2024 Lords Chamber

[Lord Kamall (Con)]

My Lords, I refer noble Lords to my interests as set out in the register. As a precaution, I will say that I work for a university that has just applied to open a medical school. I also used to be a research director at a think tank that wrote about medical issues, including physician associates.

I thank the noble Baroness, Lady Bennett, for securing this important debate, and other noble Lords who spoke. I am also grateful to the House of Lords Library and others who sent their briefings, the health professionals I spoke to, and the journalists who wrote the articles I read in preparing for the debate.

From this reading and from listening to the arguments, it is sad to see that the debate on physician associates and anaesthetist associates has descended into one that is polarised. Some have described it as toxic. We now read about lawyers being consulted and legal cases being launched. On one side, we hear from some doctors and their trade union, the BMA, that PAs and AAs are performing tasks for which they are not trained, that there is mission creep—indeed, that they are sometimes substituted for doctors—that patients are not always told that they are seeing a PA or an AA, not a fully qualified doctor or nurse, and that having PAs and AAs affects the training of some doctors. We also hear that PAs and AAs are blamed for poor medical treatment and even patient deaths. We heard about the sad case of Emily Chesterton from the noble Baroness, Lady Keeley.

On the other hand, I have heard and read about doctors praising these associates; PAs and AAs being bullied or shunned by doctors and health professionals, as the noble Lord, Lord Scriven, referred to; and, in some cases of medical accidents or deaths, that it is not always clear who is at fault and that it is unfair to pick on PAs and AAs when qualified nurses and doctors have also caused deaths and put patients at risk. Others have called for a no-blame culture if we really want to get to the bottom of these incidents.

I have also heard from managers who agree that PAs and AAs should perform only tasks for which they are trained, but who feel that opposition to PAs and AAs is based on doctors and nurses protecting their interests. After all, maybe that is their job. I read a letter from a retired doctor who wrote:

“Physician associates can be a huge asset to the NHS if trained, regulated and supervised appropriately … some of the antagonism from the medical establishment seems protectionist rather than in the best interests of patients”.


In another letter, a cardiac consultant wrote:

“The dispute about the role of physician associates in the NHS is rooted in dogma. Whether the person delivering treatment is a medical doctor is not the issue. What matters is that anyone delivering healthcare is trained and qualified to do so, practises within the correct guidelines and has access to support and guidance whenever a situation arises that falls outside the routine. This should apply to PAs, resident doctors and experienced consultants alike”.


At the same time, though, another consultant wrote that he was

“puzzled by the need for physician associates”

when there are already

“well-trained nurses in speciality roles”.

With that great British understatement, I acknowledge that opinion is divided. But on delving deeper into this debate, there is some hope and some consensus. After all, it seems common sense that physician associates and anaesthetist associates should perform only tasks for which they are trained, but our system of health and care has to continue to evolve, as it has done since the founding of the NHS in 1948. Where appropriate, we may see more tasks delegated from doctors to other medical professionals, but with clear regulations and delineation, as the right reverend Prelate the Bishop of London said.

When I went to a GP surgery as a child, I always saw a GP, but these days, as a patient, I do not always need to see a GP. I may sometimes see a nurse, a physiotherapist or a pharmacist at the surgery instead. It seems reasonable for PAs and AAs to be trained to perform more tasks on the job, under the supervision of qualified doctors.

I am also sure that there is consensus on the need for total transparency when patients see PAs and AAs, and on what they are qualified to do. I have heard from former hospital employees who stress the importance of a clear delineation of what PAs and AAs can and should be allowed to do in a clinical setting. One gave the example of an ECG. A nurse or a healthcare support worker will perform the ECG, but they then need sign-off from a clinician. I was told by that former employee that not all nurses or healthcare support workers know who is authorised to sign that off. So there must be absolute clarity of responsibility for clinical duties, such as the guidance issued by the Royal College of General Practitioners, which states that PAs should explain that they are not doctors when they introduce themselves to patients, and wear clear name badges.

In some ways, what noble Lords have said today will be superseded by the independent review announced by the Government last month to be led by Professor Gillian Leng. We acknowledge that she is a respected expert in evidence-based healthcare, something the noble Lord, Lord Scriven, called for, and a former chief executive of NICE.

I hope the Minister will acknowledge that, since I was appointed as a Lords shadow Health Minister, I have sought to get away from point-scoring on health and social care. I hope to build some sort of consensus on modernising our system of health and care. In this spirit, these Benches welcome the independent review. In fact, I worked with Professor Leng when I was a Health Minister and look forward to her report. I understand it will be published in the spring. As the noble Baroness, Lady Bennett, said, we may need some definition of “spring”, but, as I said in a debate last night, at least it is better than “in due course”.

While it is reassuring to have a definite timeframe for the publication of the report, in the spirit of co-operation, I have a few questions about what happens between now and then. What interim measures have the NHS or the Government announced to address the concerns of the BMA and its supporters over the use of AAs and PAs, as well as the concerns of United Medical Associate Professionals, which represents PAs and AAs, about the treatment and bullying that some of them have faced from doctors, nurses and other medical professionals? What guidance will the NHS give on the responsibilities of PAs and AAs?

I understand that the Minister cannot comment on legal cases, but does she know whether there are any discussions with the various plaintiffs about suspending legal action until after the publication of Professor Leng’s review? Will these legal cases be complete by the time of its publication in spring next year? How do the Government plan to take account of any legal cases that may be resolved after Professor Leng’s report? Will the NHS and the Government have to wait for the legal cases to be resolved before issuing any clear guidance that might be recommended by the report? I acknowledge that there are a lot of questions there. I hope that the Minister can answer them, either today or in writing to all noble Lords who took part in this debate.

Whatever our view on PAs and AAs and the toxicity of the debate, I am sure that we all want to see a system of healthcare that continues to modernise and evolve, in which associates, doctors and nurses offer the best medical care and in which patients feel safe.