Yet a series of revelations over the past three years, including four coroners’ reports into patient deaths, have raised serious concerns about the way the health service has deployed this type of NHS worker. Some in the medical profession are asking: should the job even exist at all?

Maryam Habib was on her way to the waiting room to collect her first patient of the morning when she spotted something odd on her consulting room door: someone had changed her job title. When she’d left for her summer holiday two weeks earlier the sign had identified her as a “physician associate”, as it had done for the three years she’d been working at her GP surgery in Manchester. Now her own door told her she was something else: a “physician assistant”.

The change wasn’t just cosmetic for Habib. She noticed that the appointment slots earmarked for her to assist the duty doctor with the day’s urgent workload had been blocked. She was also told by the practice manager that she was now banned from seeing anyone under the age of 16. Young patients she’d been working with for months, building rapport and trust, were abruptly transferred to an unfamiliar GP.

“For the first time I didn’t feel welcome in my workplace,” Habib, 27, tells me. “I felt like a lesser colleague.” She started to overthink every decision, feeling acutely vulnerable in case she put a foot wrong. “It went from 0 to 100 really quickly.” 

Recommendation 1: positioning of the role

The role of physician associate should be renamed as ‘physician assistant’, reflecting the role as a supportive, complementary member of the medical team.

Recommendation 2: credentialling

Physician assistants should have the opportunity for ongoing training and development in the context of a formal certification and credentialling programme. This should include the ability to take on added responsibilities that are commensurate with that training, including the potential to prescribe and order non-ionising radiation.

Recommendation 3: career development

Physician assistants should have the opportunity to become an ‘advanced’ physician assistant, which should be one Agenda for Change band higher and developed in line with national job profiles.

Recommendation 4: undifferentiated patients

Physician assistants should not see undifferentiated patients except within clearly defined national clinical protocols.

Recommendation 5: initial deployment in primary care

Newly qualified physician assistants should gain at least 2 years’ experience in secondary care prior to taking a role in primary care or a mental health trust.

Recommendation 6: teamworking and oversight

The physician assistant role should form part of a clear team structure, led by a senior clinician, where all are aware of their roles, responsibilities and accountability. A named doctor should take overall responsibility for each physician assistant as their formal line manager (‘named supervisor’).

Recommendation 7: identifying the role

Standardised measures, including national clothing, lanyards, badges and staff information, should be employed to distinguish physician assistants from doctors.

Recommendation 8: professional standards

A permanent faculty should be established to provide professional leadership for physician assistants, with standards for training and credentialling set by relevant medical royal colleges or the Academy of Medical Royal Colleges.

Anaesthesia associates

Recommendation 9: positioning of the role

Anaesthesia associates should be renamed as ‘physician assistants in anaesthesia’ or PAA and should continue working within the boundaries set in the interim scope of practice published by the Royal College of Anaesthetists.

Recommendation 10: credentialling

Physician assistants in anaesthesia should have the opportunity for ongoing training and development in the context of a formal certification and credentialling programme, with the ability to take on added responsibilities that are commensurate with that training, including the potential to prescribe and order non-ionising radiation.

Recommendation 11: career development

Physician assistants in anaesthesia should have the opportunity to become an ‘advanced’ physician assistant in anaesthesia, which should be one Agenda for Change band higher and developed in line with national job profiles.

Recommendation 12: workforce planning

Any further expansion in the deployment of physician assistants in anaesthesia should be taken forward in conjunction with the Royal College of Anaesthetists to build safe and effective models of anaesthesia delivery that are supported by the consultant community.

Recommendation 13: ongoing monitoring of safety

There should be an ongoing national audit of safety outcomes in anaesthesia practice in conjunction with the Healthcare Quality Improvement Partnership to provide assurance of the safety of the physician assistants in anaesthesia role, in teams with and without physician assistants in anaesthesia.

Recommendation 14: professional standards

A permanent faculty should be established to provide professional leadership and set postgraduate standards for physician assistants in anaesthesia, under the auspices of the Royal College of Anaesthetists.

Wider system

Recommendation 15: regulation and accountability

The General Medical Council requirements for regulation and reaccreditation of physician assistants and physician assistants in anaesthesia in Good medical practice should be presented separately to reinforce and clarify the differences in roles from those of doctors.

Recommendation 16: supporting doctors as leaders and line managers

Doctors should receive training in line management and leadership and should be allocated additional time to ensure that they can fulfil their supervisory roles, and to ensure effective running of the health service.

Recommendation 17: redesigning medical and multidisciplinary teams

DHSC should establish a time-limited working group to set out multidisciplinary models of working in different settings. The group should include input from a small group of experienced leaders covering medicine, other relevant healthcare professionals, management, and human resources.

Recommendation 18: safety reporting

Safety systems should routinely collect information on staff group to facilitate monitoring and interrogation at a national level, against agreed patient safety standards, to determine any system-level issues in multidisciplinary team working.

• the control objectives that the regulator expects to be in place 
• a practical guide to the controls that need to be in place to cover the setting of establishment, recruitment, temporary staff usage and reporting
• case studies of good and bad practice
• the impact that next generation electronic patient record (EPR) systems might have on rostering.

This study presents a method for extracting new insights from routinely collected operational data, identifying common drivers and specific predictors for retention among the ambulance NHS workforce. It emphasises the importance of workforce-centred retention strategies, highlighting the need for non-JCT time, which in turn would allow paramedics to have time to reflect and recuperate to avoid burnout and attrition. The study also suggests that a lack of sick leave might indicate a lack of trust and self-care culture, potentially leading to paramedic staff attrition. Our approach to retention analytics provides a new mechanism for trusts to monitor and respond to their attrition risks in a timely, proactive fashion.

The review found that misunderstanding of AHP roles, from senior leadership to frontline staff, led to AHPs being disempowered and excluded from conversations/decisions, and patients not getting sufficient access to AHPs, contributing to safety incidents. A central thread ‘organisational culture’ ran through five subthemes: (1) (lack of) effective multidisciplinary team (MDT) working, evidenced by poor communication, siloed working, marginalisation of AHPs and a lack of psychological safety; (2) (lack of) AHP involvement in patient care including care and discharge planning, and risk assessment/management. Some MDTs had no AHPs, some recommendations by AHPs were not actioned and referrals to AHPs were not always made when indicated; (3) training needs were identified for AHPs and other professions; (4) staffing issues included understaffing of AHPs and (5) senior management and leadership were found to not value/understand AHP roles, and instil a blame culture. A need for cohesive, well-led and nurturing MDTs was emphasised.

UNI warns that these conditions are driving workers away from the sector, exacerbating a crisis that governments and employers have failed to address. The survey shows that union membership and collective bargaining significantly improve worker retention and satisfaction.

Safe staffing levels are essential for high-quality care and safer work environments, but chronic shortages in hospitals and care homes undermine patient health – even causing preventable deaths. For care workers, understaffing leads to poor morale, increased workplace violence and injury rates, and high turnover.

“Five years after the pandemic, care workers are still being overworked, underpaid and exposed to dangerous conditions,” said Christy Hoffman, General Secretary of UNI Global Union. “This report is a wake-up call. Without immediate action to raise wages, improve staffing levels, and combat workplace violence, care systems will collapse.”

• 89% of doctors felt sleep deprived at work some of the time, 22% said this happened daily and 19% weekly.
• 35% said tiredness had impaired their ability to treat patients and 34% said tiredness may have played a part.
• There were 69 near misses and 17 cases in which a patient sustained harm.
• 38% were rarely or never able to take breaks during the working day, including lunch breaks with 27% not having a staff room to take a break in.
• 62% said winter pressures had increased this year and added to tiredness levels.
• 90% want government to continue funding specialist practitioner support programmes.
• The most common reasons for tiredness were high patient demand (67%), being unable to take a break because of work pressures (65%), being unable to switch off outside work (50%) and no opportunity to eat/drink during a shift/session (29%).
• The most reported impacts of tiredness included poor concentration (72%) not looking after yourself (70%), difficulty switching off from work (62%), decision making difficulties (53%) and poor mental health (42%).

The MDU has called on the government and NHS employers to do more to ensure there are adequate resources in place to allow exhausted doctors to take regular breaks. This is part of a package of measures needed to support the health and wellbeing of the NHS workforce including the need to continue funding support services like Practitioner Health for those experiencing burnout.

Further reading on the hub:

• Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan
• Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett
• Fatigue | Association of Anaesthetists