Anaesthesia Associates and Physician Associates Order 2024

Lord Patel Excerpts

Monday 26th February 2024 Lords Chamber

Lastly, can the Minister give an estimate of when we can expect to see a draft order covering dental professionals? That is urgent because the GDC is essentially using 40 year-old mechanisms and procedures that are no longer fit for purpose, and it is in a context where more and more new models of dental practice and cosmetic dentistry are emerging—for example, remote orthodontics, where professional oversight is ostensibly being provided remotely, or non-UK providers of services offering “initial consultations” in hotel rooms. Such practices are affecting patient safety now, but the regulatory tools to address them do not yet exist. Flexibility is needed, and we cannot wait indefinitely for regulations to be brought forward.

[Lord Patel (CB)]

My Lords, I begin with a slight disagreement with the noble Lord, Lord Harris. I take his point about how dental professionals, not just dentists, are regulated by the GDC, but I agree with the comment from the noble Lord, Lord Lansley, about the impression it would give if other professions apart from doctors were regulated by the General Medical Council. Hitherto, the GMC has regulated only doctors, so it would have to be clear in the register how these people were differentiated. I am afraid that the solution of having a prefix on a register would not mean anything to patients.

In the past, if you walked around a hospital, it was easy to know who was a doctor, as they mostly wore white coats; who were the nurses, because they wore different uniforms, including the matron’s uniform, which was a different colour; and who was a trainee nurse, because they wore a pink uniform, which is why junior doctors referred to them as “pinkies”. Physiotherapists wore yet another colour of uniform. However, nowadays everyone wears suits or jackets or jerseys, so you cannot distinguish from that which profession is looking after you.

I take the point that the noble Lord, Lord Winston, made, that for all of us who have done surgery, a qualified, competent anaesthetist is our friend. But sometimes—as he and I have no doubt done—we operate on pretty vulnerable patients for whom the surgery is necessary but they are not a safe bet for anaesthesia, unless by an extremely competent anaesthetist. But I interpret the anaesthesia associate as someone who does not induce anaesthesia but only maintains anaesthetic under strict supervision by a qualified anaesthetist. And that is quite distinct from what a physician associate might do, because they might be involved in different ways in assisting the physician. The point made by the noble Lord, Lord Winston, is important because it is an example that shows up the importance of the scope of the practice of physician associates and anaesthesia associates.

It does not help—and this debate is an example of why so much concern has been expressed—when the NHS health careers website says, in relation to physician associates, that they will be trained in

“taking medical histories … performing physical examinations … diagnosing illnesses … seeing patients with long-term chronic conditions … performing diagnostic and therapeutic procedures … analysing test results … developing management plans”—

which I presume means patient management plans. If you see that, you can see why there are concerns and confusion over what their responsibilities will be and the limitation of the scope of their practice.

I absolutely appreciate the need for physician associates —I keep calling them assistants—and anaesthesia associates and the need for regulation, but I think this crosses the Rubicon since it is the General Medical Council that will regulate this. It is important that what it defines as the scope of the practice is understandable to patients and professionals clearly.

The noble Lord, Lord Hunt of Kings Heath, commented that he took the legislation through this House in 1999, and that Act will subsequently be the vehicle for SIs to be used for future regulation. I am sorry that some of us were not here at the time because some of us might have opposed it. An Act from nearly 25 years ago cannot be the one that continues to be used. If we are going to have further reforms of the regulation of doctors and nurses—where we are talking about 1.5 million health professionals, not 3,000 physician associates or anaesthesia associates—I hope we are not going to have an SI to do that, because there are lots of issues of regulation.

[Lord Hunt of Kings Heath (Lab)]

My Lords, to be fair, I said that that Act had been subsequently amended by the Health and Care Act 2022. If you do not have flexibility through regulation, you will never get anything done in relation to modernising health regulation. Governments simply do not find time in primary legislation to update regulation.

[Lord Patel (CB)]

I hope they do find time, because that allows for better scrutiny and better ability to amend, which we always claim to be our key role—to scrutinise and amend. It is a major piece of legislation to go through using SIs, and it is inappropriate to do so. Maybe we must consider how else we could do it in a way that maintains flexibility.

Moving on from that, as the noble Lord, Lord Harris, already mentioned, if this legislation is going to be the template for future legislation to regulate all health professionals, some issues will need to be discussed. This order does not require that health is considered as a category in the regulation of physician and anaesthesia associates. The statistics show that, when the GMC or, I presume, any other regulator investigates, it is a very stressful situation for the person involved. Some statistics suggest that one in three considers suicide; they are depressed by it. If the category of health is removed as a consideration when a person is investigated, as this order does, it is a backwards step. I need to ask the Minister why health has been removed as a consideration. If this is the template, I presume that this will also apply to other regulations in the future.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, the noble Lord, Lord Patel, just said many very important things, with which I agree, far better than I would. I thank the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, because this debate has revealed the importance of this order: it is not a minor regulatory matter that can be put through by an SI, in a back room. That it has created so much debate outside the Chamber indicates why it is important that we discuss this and that it is not nodded through behind the public’s back. I am glad of that.

I have been embroiled in discussions about this for some time. The noble Lord, Lord Hunt of Kings Heath, made a good point when he said that the discussion has become quite toxic. I thought it was perfectly reasonable to be worried about PAs and AAs; I did not anticipate this kind of savage attack on them. There has been a real scapegoating of these individuals, which is not how we should resolve this issue. We should also remember that doctors can be guilty of clinical negligence. We do not want to wander around pointing the finger at who is more negligent.

However, if there are preventable never events as a consequence of people not being fully equipped for the roles that they are asked to do—by the way, they are being asked, very often told, what to do when they are not really up to it, through no fault of their own—it is a matter for public concern. That is the way that accountability works and why we need to be very clear and have no muddle over what somebody is supposed to be doing, what they are not supposed to be doing, and what they can and cannot do.

There were a couple of things that confused me in the arguments made in the briefings we received. I lost the will to live in the rows going on about the differences between physician associates and physician assistants, as though “associate” or “assistant” was the key difference. I think the difficulty is when people think that any of them are physicians, because that means that they think they are doctors. That is the confusing bit and it shows that people can get lost in the midst of this.

It is also worth bearing in mind some context when it comes to the public. Most patients would prefer to see anyone at a doctor’s practice than wait for two weeks in pain. That makes the public vulnerable to having a lesser service. I understand that. I also thought that the noble Lord, Lord Patel, was absolutely right about a big team: when you are in hospital, you are surrounded by people wearing a million badges, different colours and lanyards. They all introduce themselves to you in great detail, but you do not care because you are ill. You want to lie back and trust them, and assume that a division of labour is going on.

Sometimes, when I was reading the briefings, it felt as though there might be a bit of vested interest about who was regulating who and what numbers were on the badges. This seemed to miss the point of the real concerns, which are whether there is sufficient clarity about the scope of PAs or AAs, or whatever we call them; that there is not too much mission creep; and that we have a clearly defined set of protocols and specific tasks allocated. I think it important that PAs in GP surgeries have a different set of protocols and scope than in hospitals—they are not the same, even though in both instances they are called PAs.

--- Later in debate ---

[Lord Markham (Con)]

It is a protected title. The point I was trying to make about the general overhaul and understanding of the titles, however, is that there will be the scope to do this, as doctors and consultants are not protected titles today. I think we need to develop clarity on that, which is why the further reforms and SI changes will set out to protect other titles as well.

[Lord Patel (CB)]

Sorry about prolonging the debate, but is that the only protected title of all healthcare professionals?

[Lord Markham (Con)]

My understanding is that currently none of the titles is protected. These are the first set of titles that will be protected as a part of the secondary legislation that we are passing. The idea is to understand the hierarchy of titles and start to introduce the protections. I am happy to follow up in writing in more depth on all of this. I thank the noble Lord for his intervention.

Hopefully, this order will provide a standardised framework of governance and assurance for clinical practice and professional conduct for AAs and PAs. It will enhance patient safety and enable AAs and PAs to make a greater contribution to patient care. I beg to move.