Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates

Summary

In this opinion piece, Partha Kar describes patient safety issues relating to a planned increase in the number of Physician Associates (PAs) working in the NHS in England. Highlighting safety concerns being raised by healthcare professionals and members of the public, he calls for a pause to the planned expansion to allow these issues to be investigated. He outlines the need for a clear scope of practice, standardised training, full regulation and clear communication with all stakeholders, including the public.

Content

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.

About the Author

Partha Kar is the National Specialty Advisor, Diabetes for NHS England and Councillor of the Royal College of Physicians. He is also a Consultant Endocrinologist at Portsmouth NHS Hospital Trust and a public speaker and writer.