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The BMA has submitted its response to Professor Gillian Leng’s independent review of the physician associate (PA) and anaesthesia associate (AA) professions in England. In it's submission, the BMA has urged the Government-commissioned review of physician associates to rename the role and set a national scope of practice.

The General Medical Council (GMC) has submitted its response to Professor Gillian Leng’s independent review of the physician associate (PA) and anaesthesia associate (AA) professions in England. In its submission the regulator emphasised the importance of statutory regulation for PA and AAs because - as with any regulated healthcare profession - PAs and AAs undertake complex work that will pose some level of risk to the public, and regulation mitigates this risk. The submission also highlighted that, as the multi-professional regulator for doctors, PAs and AAs, the GMC is well placed to work with others across the health system to identify and address issues that concern all three professions. For example, the availability of supervisors and student training placements. The GMC also said that regulation is already beginning to raise standards of practice through ensuring that only those individuals with the right clinical knowledge and skills are entered onto the GMC’s registers.

In my third year of medical school, my mother announced she wanted to become a physician associate (PA). I always encouraged her to follow her dreams — until she told me her motivation. “It’s basically the same as being a doctor, but with less time at university,” she said. Her words gave me pause. Despite years of medical training, even I wasn’t entirely sure where the line was drawn between doctors and PAs. And if I was confused, how could patients be expected to understand the difference? For some doctors, the PA role can feel less like a collaborative partnership and more like a threat to their professional identity. The British Medical Association has accused the government of using PAs as substitutes for doctors, compromising patient safety in the process. These concerns are not hypothetical.

In November 2023 the British Medical Association (BMA) established a reporting portal for doctors and medical students to share concerns regarding the deployment of physician and anaesthesia associates in both primary and secondary care. This report includes all submissions received by February 2025 that concern patient safety. This report presents evidence of doctor substitution, doctors being coerced or pressured into signing prescriptions or ionising radiation requests for patients of whom they have no knowledge, examples of doctors losing out on basic skills training and situations where neither the public nor other healthcare staff know the role or competencies of physician and anaesthesia associates. It also highlights examples of where harm has come to patients, or been narrowly avoided only by subsequent intervention from a doctor.

The aim of this study was to research on the efficacy and safety of UK physician associates and anaesthetic associates in the context of an ongoing policy review. The study found that UK literature on physician associates and anaesthetic associates is sparse and of variable quality, and some is outdated. In this context, the absence of evidence of safety incidents should not be misinterpreted as evidence that deployment of physician associates and anaesthetic associates is safe. Findings of apparent non-inferiority in non-randomised studies may obscure important unmeasured differences in quality of care. New research is urgently needed to explore staff concerns, examine safety incidents, and inform a national scope of practice for these relatively new and contested staff roles. The findings from this UK based study should be interpreted in the context of the wider international evidence base.

On 16 February 2024, Pamela Anne Marking – who was unable to give a complete history due to cognitive issues – was admitted to the Emergency Department at East Surrey Hospital from her home address after unknowingly vomiting blood-stained fluid, with right sided and suprapubic abdominal tenderness. She was diagnosed as having had an epistaxis (nosebleed) by a Physician Associate  and discharged home later that afternoon without a medical review or direct medical supervision of the Physician Associate who had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination which would have been likely to have found a right femoral hernia. Mrs Marking re-presented to the Emergency Department two days later with grossly dilated small bowel obstruction due to an incarcerated right femoral hernia containing ischaemic bowel requiring emergency surgery later that evening. Despite maximal support Mrs Marking died at East Surrey hospital on 20th February 2024. The clinical management Mrs Marking had on her first admission and thereafter during the Rapid Sequence Induction materially contributed to her death. The medical cause of death given was: 1a Respiratory failure and Sepsis   1b Aspiration of feculent gastric contents at induction of anaesthesia 1c. Strangulated femoral hernia. Coroner's concerns 1. The term ‘Physician Associate’ is misleading to the public. Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners. 2. Lack of public understanding of the role of Physician Associate. Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety. 3. The right of patients and family to seek a second opinion. The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor. 4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate. A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed, this gives rise to a concern they are working outside of their capabilities. 5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates. Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner. This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety. 6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery. Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice. 7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI. Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4). 8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic. Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.

The Secretary of State for Health and Social Care, Wes Streeting MP, has established an independent review of the physician associate (PA) and anaesthesia associate (AA) professions to consider the safety of the roles, their contribution to multidisciplinary healthcare teams and make recommendations to inform future government policy. This call for evidence seeking analysis and research to support this review. The deadline for responding is 11:59pm on 21 March 2025.

This document sets out details of the independent review of the physician associate and anaesthesia associate professions commissioned by the Secretary of State for Health and Social Care on the 20 November 2024. Led by Professor Gillian Leng CBE, this review will help to inform the refreshed workforce plan that the UK Government has committed to publish in summer 2025.

The Royal College of Physicians (RCP) has published new interim guidance on the scope, supervision and employment of physician associates (PAs) working in the medical specialties (also known as the physician specialties).  The interim guidance covers scope of practice for general internal medicine, supervision and employment of PAs, and how PAs should describe their role to patients, employers, other healthcare professionals and the public. It will be reviewed in collaboration with stakeholders, including RCP fellows and members, following the publication of the report of the Leng review. 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.

This was a debate in the House of Lords on the 5 December 2024 considering what the review, announced by the Secretary of State for Health and Social Care on 20 November, of the physician associate (PA) and anaesthetist associate (AA) roles will cover and what actions they plan to take in advance of the outcome. Key points raised by peers in this debate included: 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)

Recent guidance from both the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) has sparked significant discussion about Physician Associates (PAs) in general practice. While headlines might seem concerning,  this blog aims to break things down for primary care managers.

Upcoming regulation will hold physician associates and anaesthesia associates to higher standards, ensuring safer patient care and stronger accountability while addressing doctors’ concerns on team integration; however, there is still more to be which requires our collective energy to find solutions that deliver for all those who work in our health services, and ultimately for all those who rely on them for their care.