In the guidance, the RCP is clear that:

• PAs must support – not replace – doctors, have a nationally defined ceiling of practice, and have a clearly defined role in the multidisciplinary team (MDT).
• PAs must never function as a senior decision maker, nor should they decide whether a patient is admitted or discharged from hospital.
• Resident doctors are not, and must not be expected or asked to be, responsible for the clinical supervision of PAs. PAs should only be supervised by consultants, specialist or associate specialist doctors.
• PAs cannot prescribe medications regardless of any prior healthcare background while working as a PA.
• PAs must clearly explain their role to patients, their families and carers, as well as colleagues and supervisors, and provide details of their educational and clinical supervision when required.

• The remit of the review, and whether this should extend to consider the impact of the PA role on training opportunities for resident doctors and the “taskification” of medicine.
• With the Government having announced that the review will be published in spring 2025, wherever any interim measures will be put in place in the meantime to address patient safety concerns relating to PA and AA roles.
• A suggestion that it is time to pause the recruitment of PA and AA roles and to halt the expansion of their numbers, particularly until after the Government review reports.
• Concerns that individual cases have been cited to then equate the lack of patient safety with all PAs or AAs.
• The value of the NHS undertaking a refreshed national public campaign to raise awareness of PAs and what they do.

Responding to comments in the debate on behalf of the Government, Baroness Merron (Parliamentary Under-Secretary of State for Patient Safety, Women's Health and Mental Health) stated the following points:

• The Government review will cover training, recruitment, day-to-day work, oversight, supervision and professional regulation. It will assess the safety of the PA and AA roles relative to existing professions, the contribution that the roles can make to more productive use of professional time in multidisciplinary teams and whether the roles deliver good-quality and efficient patient care in a range of settings.
• All the above matters, among others that peers have raised in this debate today, will be considered as part of the review.
• On interim action, she noted that NHS guidance remains in place on PA and AA deployment while the review is ongoing. Furthermore, NHS England continues to engage with NHS organisations to ensure that this guidance is adhered to.

You can watch the debate in full here.

Related reading

• Government launches independent review of Physician and Anaesthesia Associate professions (20 November 2024)
• Physician associates: What are the patient safety issues? An interview with Asif Qasim (12 November 2024)

The shortage of anaesthetists prevents around 1.4 million operations and procedures from taking place each year. The RCoA warns this figure could increase to 8.25 million unless the government invests in training more anaesthetists because most operations cannot take place without one. 

On average across the UK, the number of anaesthetists is 15% lower than needed, although there is some national and regional variation. The shortage is slightly worse in Wales (17%) than the other UK nations and within England, the shortfall is greatest in the East of England and the North-West, at 18% lower than needed.   

The report highlights there are currently thousands of doctors who want to train as anaesthetists but there are not enough training posts for them to do so. This year there were 3,520 applications for an available 540 core anaesthetic training places.   

At the same time, NHS trusts and health boards are increasingly using expensive agency locum staff to plug gaps. In 2022, there were 399 locum consultants working in NHS trusts and health boards, a much costlier option than a permanent consultant anaesthetist.  

The shortage also puts anaesthetists under increasing pressure as they struggle with additional workload, fuelling burnout and compounding the NHS retention crisis. Of anaesthetists who retired or left the profession early, 25% did so because of issues to do with mental wellbeing, burnout, or stress. And one in five anaesthetists surveyed in 2021 said they intended to leave the NHS within five years.  

The report calls for urgent intervention to fund more anaesthetic training places, both in the immediate and long term and for urgent implementation of measures to improve retention of anaesthetists currently working in the NHS.  

Related reading

• Physician associates House of Commons debate in relation to the death of Emily Chesterton (6 July 2023)
• Prevention of future deaths report: Susan Pollitt (8 August 2024)
• Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates

A transcript of the interview is attached below.

Join the conversation

We'd love to hear your perspectives on the patient safety issues raised in this interview. Perhaps you are a healthcare professional with insights to share or a patient who has been seen by a physician associate? If you have an experience you would like to share with us, please do get in touch.

You can join the conversation by commenting below (you'll need to sign up first) or get in touch with us directly by emailing content@pslhub.org

• A significant association exists between higher standard infection ratio ranges and staffing status for certain health care-associated infection types.
• Almost 80% of hospitals participating in the study were identified as having lower than expected staffing levels.
• More than 85% of respondents who believed their staffing levels were inadequate came from hospitals found to have lower than expected IP staffing by the calculator.

This novel approach allows facilities to staff their IPC programme based on individual factors. Future versions of the calculator will be optimised based on the findings. Future research will clarify the impact of staffing on patient outcomes and staff retention.

Full results can be found here.

13 years ago, I came up with a formula. This formula works out how many clinical hours people needed to do when working annualised self-preferencing/self-rostering rotas, and it has become a passion of mine.

Last week I stood back from being involved in medical workforce issues at my Trust. Having spent these years helping colleagues to not burnout and get a better work-life balance, I am now trying to do the same for myself while allowing time to concentrate on my passion. Crucially though, because of the systems created, I am no longer needed to ensure what we have set up continues at my trust.

My last job in this role was inducting all the medical and A&E junior doctors into how their rotas would work.

To provide care today, we need the doctors working where the service needs it. To provide care next year, we need to provide jobs that are sustainable and don’t lead to burnout. To provide care in 2 years’ time, we need to do it in a way that is financially viable.

Working with the company HealthRota, we have managed to do all three and transform the management of the medical workforce at University Hospitals Sussex NHS Trust.

We now we have rotas where the doctors have a much better work-life balance as they choose when they are off and its much easier to work part time.

We have improved training for the doctors, for example, by guaranteed clinic weeks.

We have better continuity of care, even staffing during the week and 7 days a week ward-based care on medical wards, identical staffing 7 days a week in A&E, while guaranteeing the doctors get all their study leave, self-development time, bank holidays and annual leave they are entitled to without endless fights as is sadly so often the case.

We are locum free except for last minute sickness, had 100% fill rates in our jobs and at two of our hospitals have 70 FTE fellows doing 25% non-clinical time in research or education.

These ideas are simple. Work out how many hours you need to do after all the leave and non-clinical time is taken off and make rotas that work for the individual and the service using those hours to do so. This is what annualised self-preferencing/self-rostering rotas are. Simple ideas but ones initially not part of NHS policies and one impossible to implement with what was the dominant NHS rota technology.

I hope what we have developed gets spread out further across the NHS and not just with doctors. Please email me for further information drrobgalloway@gmail.com

*This blog is adapted with permission from Rob's LinkedIn post.  

Related reading on the hub:

• Case study: Using e-rostering to improve staff wellbeing and retention
• Patient Safety Spotlight interview with Rob Galloway, Emergency Medicine Consultant at University Hospitals Sussex

Attract and retain 

• Joined-up, consistent action on pay. Central government (lead) with local government, unions and employers.
• Consider the modelling in this Strategy in the Fair Cost of Care exercise. Central government with the Department of Health and Social Care (DHSC) and local government. We have modelled and costed three options for improving pay in the recommendations and commitments section. 
• A transition plan to increase domestic recruitment and reduce international recruitment.
• Continued funding to support ethical international recruitment. 
• Review the application of ethical recruitment.
• Regulator encouraging recruitment and retention plans.
• A 10-year attraction plan focusing on men, younger people and people with technical skills. 
• Support for individual employers. 
• A national programme to attract graduates and career changers. 
• Attract more social workers and occupational therapists with a clearer pathway and financial support for students. 
• Attract more registered nurses and nursing associates to social care and offer attractive career pathways to retain them.
• A People Promise for social care.
• Scope retention pilots in five ICS areas. 
• Regulator support for workforce wellbeing and equality, diversity and inclusion. 
• Create Workforce Strategy employer champions. 
• Retain more internationally educated registered nurses working in social care through pathways, support and regulation. 
• Implement the Social Care Workforce Race Equality Standard (SC-WRES).
• Improve wellbeing through guidance, training, NHS Health Checks, regulation and awareness-raising. 

Train 

• Regulator to signpost to what good looks like in learning development. 
• Expand skills through the Care Workforce Pathway. 
• Continue funding to support delegated health tasks.  
• Continue funding for new skills. DHSC.
• Develop leaders through a framework for Directors of Adult Social Services
• Streamline and communicate mandatory training requirements.
• Ensure level three competence for direct care staff. 
• Overhaul social care apprenticeships. 
• Ensure high-quality training in functional skills, digital, data and technology and AI. 
• Invest in training and developing social workers. 
• Invest in training and developing occupational therapists. 
• Invest in training and developing registered nurses working in social care.
• Develop managers through support, education and potential registration. 

Transform 

• Mandate workforce planning and strategy. 
• Create a responsibility for a central workforce body for the development and implementation of this and future workforce plans. 
• Investigate workforce registration. 
• Attract workers to social care in coastal and rural areas.
• Support ICS workforce planning. 
• Research on new roles for social care. 
• Expand digital skills training. 
• Pilot a new care technologist role. 
• Evaluation of current research priorities and funding in adult social care. 
• Adult Social Care to be prioritised by NICE. 

• Multiple indicators show that the past two years have seen constantly elevated medicines shortages, in a new normal of frequent disruption to crucial products, which if anything worsened in 2023. This has placed a significant burden on pharmacists, and has affected the medicines available to patients. The English NHS had to increase medicine prices to deal with supply problems on a scale which cost £220 million more in one year than the same products would have at their previous costs.
• These shortages reflect significant problems in the global medicine market, which are also having a serious impact in EU countries. However, Brexit has also contributed to difficulties by lowering the value of sterling and removing the UK from EU supply chains. In future it will pose the additional risk of being left out of EU measures to respond by shifting medicine between member states, buying products jointly, and trying to bring manufacturing back to Europe.
• The UK has intensified its reliance on migration following Brexit as a source for both health and social care workers. An expansion in social care workers in England is entirely due to migration from outside the EU; more EU and UK staff have left than joined the social care workforce. 
• Health care migration draws heavily on countries placed on the World Health Organization’s ‘red list’, which applies to countries judged to have too few trained clinicians for employers and recruiters from other countries to be allowed to recruit them. There are now 45,000 staff from red list countries in the English NHS, a 30% increase in just one year. One in five nurses trained outside the UK or EU who joined the UK register came from these countries in 2022/23. 
• Heavy reliance on migration without the underpinning of EU free movement of labour means a permanent risk of political choices suddenly affecting staffing availability. The recent decision to end the rights of social care workers to bring their dependants to the UK illustrates that the sector’s access to migration is subject to unpredictable change. 
• Life science and medicine regulation in Great Britain is now often lagging behind such regulation in the EU, caught between the strategies involved in trying to diverge and the demand from industry to align. The EU’s new law on artificial intelligence opens up a significant point of divergence from the UK and risks dividing off markets for medical devices. This could create a difficult situation in Northern Ireland, which has to align with EU rules on devices, but potentially with UK rules on artificial intelligence. In most other cases, the UK has moved towards realigning with the EU, but in a way that the life sciences industry has found unpredictable. 
• There is a similar pattern across both the movement of people and products, with the UK rapidly moving away from initial efforts to take a different course after Brexit and returning to strategies used during the period of EU membership, but with additional frictions. 
• Medicine authorisations for products that the EU approves centrally are typically slower in Great Britain than they would be if it were still a member state. From December 2022 to December 2023, four drugs authorised by the European Commission had been approved faster in Great Britain than in the EU; 56 had been approved later in Great Britain; and 8 had not been approved at all in Great Britain as of March 2024.
• Despite some recovery in relations between the EU and the UK, rebuilding the EU–UK health relationship at a formal level is not currently a priority for EU institutions and representative bodies, which have gone through an exhausting and at times bitter negotiation process with London, and are faced with many ambitious health reforms in train in Brussels.

Whenever a health system introduces a new group of healthcare professionals, there are three ‘planks’ it needs to have in place to do so safely:

1. The role needs a clear introduction—the public needs to know what it is that these people do, especially when they’re being seen in a healthcare setting.
2. They need to have a clear scope of practice in place which outlines the work that individuals in this role can and can’t do. Training for the role needs to be formal and directly linked to this scope.
3. There needs to be a regulatory body keeping an eye on people, just as there is for every other healthcare profession. 

The problem we have with the Physician Associate (PA) role, is that until about six months ago, none of these three planks had been put in place. When they were brought into the NHS around twenty years ago, PAs were introduced as staff members who would lessen the workload of doctors, freeing them up to focus on clinical work by taking some of the administrative burden. But that’s not how they are being used in the NHS at the moment.

Defining the patient safety issues

There are several separate—often toxic—debates around the role of PAs, but my main concern is patient safety. NHS England and the General Medical Council (GMC) are all saying that PAs are not doctors, but the reality is that many are doing doctors roles, which is why we’re seeing safety incidents reported.

Cases are coming to light where PAs have been working unsupervised and outside of the limits of their skills and training. There’s a lot of catching up to do to define and standardise the role; even though PAs have been around for a decade or so, an introduction document was only published by the Faculty of Physician Associates late last year. 

Looking at the three planks I described above, the patient safety issues relating to PAs are as follows:

1. It is often impossible for patients to distinguish a PA from a doctor. Many patients have not heard of the role and the word ‘physician’ in the title is somewhat confusing. The introduction document may help, yet it is impossible to ignore how conflated the term PA has become with doctors for the public.
2. There has been no defined scope for PAs in this country, which is unthinkable, but true. The British Medical Association (BMA) has recently released a scope of practice that they propose is adopted, something which should have been done years ago by the royal colleges. 
3. The GMC have finally been given a legal mandate by Parliament to regulate PAs, but they won’t be doing it in full to begin with.

The final part of the safety jigsaw is supervision. Trainee doctors are supervised, but this isn’t always in place for PAs, so we have individuals with less training than a doctor working without supervision, outside of any scope. In some of the cases of harm I have looked at, the incident would not have happened if the PA had had a supervisor to speak with. 

When people say, “But doctors make mistakes as well!” The answer to that is that yes, they do, even with all their years of training. For me, the solution isn’t to give people less training, but to put in additional security measures to reduce the risk to patients. I do a lot of patient safety work in my field of diabetes and would be alarmed if I found out a PA was managing insulin with patients. People have asked me what the difference would be between a PA helping a patient manage their diabetes and a diabetes specialist nurse (DSN). The two roles as they stand aren’t comparable; DSNs are highly trained in a specialist area and have many hours supervised experience with patients before they qualify in their position.

Another argument I hear is that we need PAs because we don’t have enough doctors, but that’s not true. The issue is that we don’t have enough training places. Take GPs for example, only 3,000 out of 10,000 who applied got a training post last year. So we have a shortage of GPs and many doctors wanting to become GPs, but can’t train enough of them.

The PA debate - why now?

The trigger for these debates was the publication of the NHS Long Term Workforce Plan last summer, which includes the intention to expand PA numbers from 3,000 to 10,000. This intended expansion has caught the attention of doctors—and the public—and made the issues much more pressing. Until recently, most people didn’t know PAs even existed in the UK; before I joined the Royal College of Physicians (RCP) council I had no idea about the issues.

The need for a pause to assess safety

If somebody flags a healthcare safety issue, you don’t just carry on. I don’t believe we should just get rid of the role, but we do need a pause to ensure that PAs are working safely. We need to look into it just as we would with any intervention in healthcare—the same principles we apply to medicines and technology safety should apply to the workforce. 

My view is that the Government and NHS should delay the process of expansion, look into the problems being raised and see whether there is actually a safety issue. If there isn’t, we can resume the process and carry on integrating PAs into healthcare teams (though no one has actually clarified what they would add to an MDT set up beyond existing members such as Nurses, Pharmacists, Dietitians etc), but if we find a problem, we need to put additional measures in place to ensure safety. We should temporarily pause putting new PAs into the system and for the PAs already working in the NHS, we need to review their work, see what they are doing in different organisations and reassure the public and the rest of the workforce.

National leaders need to be doing more to stop the toxicity of this debate. They aren’t there to take sides, but they should stand up, listen and reassure people that they are looking into it. There are many PAs who just want to go and do the job they’ve been asked to do, and they are caught in the crossfire of this situation; it’s impossible to work like that.

Calm collective heads are needed, as well as recognition of the wider problems of lack of supervisory and training time from seniors to existing doctors, and lack of training posts. A failure of medical education strategy should result in introspection and resetting our course, not forcing through another group of professionals to make present angst worse and cause the safety issues I have outlined.