Draft Anaesthesia Associates and Physician Associates Order 2024

Rachael Maskell Excerpts

Wednesday 17th January 2024 General Committees

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

It is a pleasure to serve on the Committee, Dame Caroline. Before I begin, I declare that I was a registered professional with the Health and Care Professions Council, and worked in the NHS for 20 years before coming to this place. I was also the head of health at Unite, so I have a strong background in understanding the regulatory frameworks in the NHS.

I understand the issues that the Government are trying to resolve, given the changing nature of the NHS, the emergence of new professions, and the need to protect patients. I agree that all NHS professionals must be registered, and regulatory reform is long overdue, including for anaesthesia associates and physician associates. When Agenda for Change was piloted in 2003 and fully instituted in 2004, a job evaluation scheme was designed for this very purpose, and was overseen by the formidable Sue Hastings. However, emergent professions cannot just be add-ons to existing regulation. They required their own registers, governance and accountability, not least to ensure professional competence. The order is the first expression of that, 20 years on.

Also, the knowledge and skills framework enabled people to grow in their professional competencies and provide a higher level of care. That could lead to hybrid roles forming. I remember Alan Milburn saying at the time that the NHS career framework should enable someone to move from the role of porter to neurosurgeon—I do not know if that has ever been achieved. It is important that at every stage there is protection for the professional and, most importantly, the patient.

The reality behind the order is that the professional silos of the last 150 years or more are rapidly evolving and morphing in new ways, and the regulatory framework has to capture that and catch up. I agree that we urgently need a system of statutory regulation for anaesthesia associates and physician associates. They are working at a significant level of decision making, and they have a duty to uphold professional standards, their training must be of the highest standard, and there must be a fitness-to-practise process through which they can be called to account. I agree with my hon. Friend the Member for Bristol South that we need to ensure that that is rigorous and upholds standards, but I also welcome the fact that they may be expedited within the new system.

I have been asked whether the GMC is the right regulatory body. I understand the arguments for and against. This is where a lot of the concern comes from, which is why regulation is important. The challenge to this order is the lack of clarity about titles, roles and the competencies associated with each role. It could be argued that, for greater distinction, the HCPC, for example, is a more relevant registrant. I believe that that should have been examined further, not least as AAs and PAs are professionals allied to health and sit within the “Agenda for Change” family.

The public are nearly universally unaware of different roles in the NHS, let alone what they can or cannot do. In a clinical setting, if someone with a stethoscope around their neck calls themselves part of the medical team and they assess, diagnose and treat a patient, it will generally be assumed that they must be a doctor. I remember that when I started practising, if you were a woman, you were a nurse, and if you were a man, you were a doctor, so I certainly know that the distinctions are not always there. However, some use the title “Dr” because they hold a doctorate in another field, and that needs to be looked at. Further, there is a new lexicon of technicians, assistants, associates, advanced practitioners, and no doubt many more. I urge the Minister to find a common language so that there is simplicity and accuracy, and so the public understand the distinctions between these roles and those of the established professions.

In talking to the British Medical Association, I heard how people are now working above their competencies as AAs and PAs—carrying the consultant’s bleep, for example. That is deeply disturbing and just reinforces the public confusion over the distinct identity and purpose of each clinical role. Boundaries must be clear and distinct and, for the sake of safety, defined nationally rather than determined locally.

While the Government are very much focused on vertical integration, which can exacerbate things such as skill mix, I urge the Minister to further consider the power of horizontal integration. We have seen some, for example with advanced practitioners reaching across professional silos, and in developing a focus on primary care it could bring strong benefits. We need to ensure that new regulatory frameworks address that. The blueprint for a future professional regulation framework must account for this opportunity.

As with all professions, medicine must not be exempt from looking at how it can be reshaped. However, when someone who has had two years’ training is paid more —ironically, 35% more; Members might recall that number—and assumes more authority than a doctor of seven years’ training with a higher level of competency, there is clearly a problem in the design of the role and cause for concern. We need to look at how we can move beyond traditional silos and create skills pathways that honour professions and the level of their skills, so that competencies can be gathered, tested and examined along the way. I believe that there needs to be a full job evaluation to understand the challenges between the professions—yes, across the two core NHS pay structures—and then a clear delineation of roles. For example, senior doctors in training in anaesthetics are now in a logjam, unable to progress to a consultant post due to the rise in the redeployment of anaesthetist competencies to AAs.

The same could be said of the Government’s prioritisation of PAs over, for instance, traditional senior house officers. There is serious concern about the diagnostic skills of PAs; there have been examples of failure, as we heard so powerfully about Emily Chesterton, the daughter of the constituent of my hon. Friend the Member for Worsley and Eccles South.

These functions need serious reconsideration and tight regulation. The GMC must ensure that their scope is clearly defined and that, before further role reforms occur, there are assurances that there will be no further scope creep. Clarity of role is really important in prescribing too. Some AAs and PAs may have transitioned from professions where they were already prescribers. We need to hear from the Minister how that situation will be managed, with clear delineation.

I want to touch on the issue of liability—where responsibility lies. With registration, AAs and PAs will be autonomous practitioners, liable for their own conduct and practice. How will the regulator ensure that liability is apportioned in the right way between them and those who provide supervision? Will they receive one-to-one supervision, and how far will liability carry on to, say, the consultant or senior registrar? That is a really important issue to consider in the immediate future, not only for AAs and PAs, but for doctors and doctors in training, who must receive supervision too. We need to ensure that a new generation of doctors in training are able to receive the support that they need, and that it is not all dedicated to AAs and PAs.

Furthermore, with the envisaged rapid expansion in the number of AAs and PAs, the GMC needs to determine that supervision is safe and appropriate, and at the level required to enable people to mature into highly skilled professionals. It must also ensure that there is not a spike in fitness-to-practise cases due to lack of investment. The call from the medical profession is for us to slow down and properly evaluate and understand the consequences, seen and unforeseen.

On part 3 of the order, which concerns the register, can the Minister clarify that the associates will be on a separate register to doctors at the GMC, and that they will have their own register, as identified in article 5(2)(a)? I note that AAs and PAs will be on one register, but in separate parts. Will he explain to the Committee exactly how that will operate? Holding information separately would enable greater access for the public to the information they seek with respect to the new associate roles. The register must be robust and easy to navigate and, like the register for doctors, provide the public with all the information that they require. I know that the GMC has agreed to put a simple prefix ahead of registration numbers, but the professions are calling for more distinction so that there can be no confusion.

I am mindful of the higher proportion of cases generated from AAs and PAs. Will the Minister ensure that the registration fees reflect that? It is vital that the Government and the GMC, in formally setting up the statutory register over the coming three years, work closely with the professionals to ensure that they are engaged in the process and that their concerns are picked up and addressed along the way. I am asking the Minister to commit to that today, as I know my hon. Friend the Member for Bristol South will when she has the opportunity later in the year.

Patients, the wider public and fellow clinicians need to understand these fine lines and distinctions for their safety and safe practice across the NHS. The culture of “get it right first time” must be central to this debate and all that flows from it. If regulation lands in the wrong place, the Minister and the GMC need to be candid and ensure that it is changed so that it is fit for purpose. I trust that Parliament will have further opportunity to scrutinise these developments.