None of that exists in the training pathway for physician or anaesthesia associates; in fact, as we have discussed, there is not even an exam for anaesthesia associates at the end of the process. It is absolutely essential that those issues are addressed as a priority, and it is little wonder that patient deaths and adverse incidents are occurring on such a scale. Perhaps when the Minister is suffering from insomnia late at night, he may wish to watch old episodes of “24 Hours in A&E”. He will see the huge variability in the expertise of physician associates. Some are very good, but some are not, and we should not be dealing with variability in the British health system. That is what we are trying to address, so the hon. Member for York Central is absolutely right in everything she has said.
That highlights the last point I am going to draw to the House’s attention from the BMA survey of 18,000 doctors. Some 75% of respondents said that the quality of training among medical associate professions—physician and anaesthesia associates—was woefully inadequate; 84% said that the quality of their supervision when they are at work was inadequate; 91% outlined the fact that they work outside their competence; and 86% of respondents confirmed that the public would confuse them with doctors, as the hon. Lady outlined. This is not just a few hundred doctors; this is 18,000 doctors saying in a survey that they have serious patient safety concerns due to the variability in training of anaesthesia associates. There have been far too many adverse incidents where things have gone wrong, and it is time for the Government to give NHS England some clear direction that this area needs to be looked at, and some proper planning and consideration of the expansion of this workforce put in place.
These are the asks I have of my right hon. Friend the Minister. First, we should ensure there is a standardised and quality assured training programme for physician associates, anaesthesia associates, surgical care practitioners and all other medical associate professionals, and indeed that there is ongoing training and supervision to a nationally standardised level when that group is in the workplace post qualification. Secondly, we should ensure that the General Medical Council sets up a register for the regulation of medical associate professionals, separate from the register for doctors. Thirdly, as is the case with all other healthcare professionals, we should ensure that the scope of practice of physician associates is clearly set out to make sure that we can develop appropriate training pathways and supervisory pathways, but, more importantly, to ensure patient safety. Finally, the Government should support the introduction of a system with greater flexibility to hire GPs and general practice nurses using the ARRS funding. I thank the House, and I look forward to the Minister’s response.
]]>If the GMC cannot regulate extended scopes of practice, they should be devised according to a national framework. There needs to be an understanding of what that should be. It is unacceptable for employing organisations in the NHS to devise their own extended scopes of practice without reference to at least some national framework—one that has the confidence of regulators and standard setters—so that we know and understand what good practice looks like.
Doctors should be directly involved in devising any changes to the scope of physician associate and anaesthesia associate practice, whether on qualification or at extended level. There should be no extension of roles beyond the scope of practice on qualification until national guidance is issued. Where organisations are planning such an extension, it should be paused for reasons of patient safety. Where physician associates or anaesthesia associates are already working in an extended role, it should be recorded on the healthcare organisation’s risk register, and the organisation should ensure that it has full confidence in its standards of supervision, access to support, indemnity of the anaesthesia or physician associate and the supervising doctor, and patient information and consent. Anaesthesia associates have a role to play as part of the wider anaesthesia team, but it is important to ensure that it is a complementary role as an addition to the workforce, not as a replacement for doctors and nurses, as the hon. Lady rightly underlined. Expansion in the number of anaesthesia and physician associates should not be at the expense of expansion in the number of doctors in specialist posts.
Let me come briefly to assessment, which is another area that has not been well thought through. It is important that assessment for anaesthesia associate roles is standardised at national level. The Royal College of Physicians does a national exam for physician associates, but a national body needs to be established to undertake the assessment process for anaesthesia associates if we are to ensure confidence in their competencies. It may be possible for that to be delivered locally, if there are stringent controls in place to ensure consistency. However, before the anaesthesia associate workforce is expanded, there needs to be some process for assessing competency.
On indemnity, which was also addressed by the hon. Lady, further information is needed around indemnity cover for both physician associates and anaesthesia associates, as well as for any doctors supervising them. “Good medical practice” expects all doctors to ensure that they are fully indemnified. The same standard should apply to physician associates and anaesthesia associates. Many doctors in anaesthesia, in general practice and in emergency departments are already worried about medicolegal liability when working with physician associates, and clear guidance is urgently needed. Although reference is made to accountability, more information is required in this area, given the challenges that we know have arisen.
The hon. Lady mentioned prescribing rights. Some physician and anaesthesia associates—for example, those with a nursing background—may already have those rights from their parent profession. The Commission on Human Medicines is responsible for deciding which professions are able to prescribe, and it is important that it is clear in its guidance and reasoning in respect of physician and anaesthesia associates before there is a wider roll-out of those roles.
I draw the Minister’s attention to key findings from the British Medical Association’s recent survey, which sought the views of over 18,000 doctors about the role of the medical associate professions. Almost 80% of respondents—that is well in excess of 15,000 doctors—had worked with or trained medical associate professionals, which means that contact with those professionals is widespread throughout the NHS. Medical associate professionals are currently unregulated and have a poorly defined scope of practice. The BMA survey respondents were very concerned about that, as well as about the fact that MAPs have been employed in the NHS in a variety of roles, which go well beyond what was originally envisioned as an assistant role. A staggering 87% of doctors surveyed believed that the way that physician and anaesthesia associates work in the NHS is a risk to patient safety. For the Minister’s benefit, that is the best part of 18,000 doctors who work with this workforce raising concerns about working practice and patient safety.
]]>I will talk briefly about general practice and the additional roles reimbursement scheme. Through the ARRS, the Government have provided funding to GP practices that can be used to pay for physician associates and other clinical staff, but not for hiring additional doctors and nurses. That is quite extraordinary, and results in GP practices having physician associates rather than fully qualified GPs. Currently, most physician associates in general practice are funded through the additional roles reimbursement scheme: an NHS scheme that funds primary care networks to support recruitment across a very limited set of eligible roles. The current rules for ARRS funding are causing inefficiencies as they are not flexible enough to respond to locality needs for healthcare staff. In particular, the rules do not allow practices to hire primary care nurses, practice nurses, or indeed GPs, as I mentioned.
Over the past year, there have been many developments in how the Government and the profession view the roles of physician and anaesthesia associates, but it seems extraordinary that when we are talking about supporting general practice in developing the right skills and competences, and delivering the right service for patients, one of the key funding schemes does not allow for the hiring of the GPs and practice nurses that are needed, and is skewed towards physician associates. I wonder whether the Minister might take that away, look at the scheme, and help to provide additional flexibility, which general practice would like and which seems eminently sensible, to allow recruitment at a local level, in line with patient need.
There are significant concerns connected with the roll-out of the anaesthesia associates project. While the GMC addressed some of those issues in its recent letter to NHS England, a number of concerns remain. In particular, the NHS long-term workforce plan suddenly projected a huge expansion in the number of anaesthesia associates, but no expansion in the number of doctors in anaesthesia—or, as we are talking about position assessments, in the number of doctors in other specialities. To many, that looks like a replacement of doctors with anaesthesia associates, rather than anaesthesia associates being employed to complement the anaesthesia team, which was the idea previously portrayed.
There are many examples of medical associate professionals in the wider sense working in ways that have caused concern, as we have discussed in this debate, particularly with regard to their scope of practice. Anaesthesia provision in the UK must continue to be led and delivered by doctors, who are properly trained and properly regulated. Anaesthesia associates are valuable members of the anaesthesia team in addition to doctors, but they are not a solution to the challenges of low workforce numbers in anaesthesia and growing waiting lists.
The answer is to expand consultant numbers, an expansion in training scheme places for doctors in anaesthesia, and the development of the large number of speciality doctors and locally employed doctors already in post. Creation of speciality and specialist doctors and consultants via the General Medical Council’s new portfolio pathway could result in our having many more independent doctors in anaesthesia and other medical disciplines. It seems extraordinary that we are not looking at that first, given that we have a properly regulated and properly trained profession, rather than at expanding a workforce that is not subject to proper regulation to date, does not have a certified training pathway, and has been associated with a significant number of adverse patient outcomes and incidents.
Regulation ensures consistent standards for training, and for the practice of physician associates and anaesthesia associates. It maintains standards and, critically, contributes to patient safety. As per the recent Anaesthesia Associates and Physician Associates Order 2024 laid before the UK and Scottish Parliaments, those associates will be registered with the General Medical Council. However, there are increasing concerns that that could further blur the distinction between doctors and anaesthesia associates.
In response to those concerns, the GMC has said that physician associates and anaesthesia associates will be issued with a registration number format that distinguishes them from doctors. That is to be welcomed. However, it must go further and present doctors on a separate register from physician associates and anaesthesia associates, whether we are talking about a register online or in print—that aligns with the point that
There should be a clear distinction between the register of doctors and other registers. That is necessary to provide absolute clarity for patients and others who wish to access the registers, and it is essential to protect everyone from accidental or deliberate misrepresentation. With modern information technology systems, there is no legitimate reason why that cannot be done. It would be simple, and it is about transparency, openness and patients better understanding the difference between the responsibilities of doctors, and those of physician associates and anaesthesia associates. I hope the GMC is listening to this debate and will ensure properly separate registers. That does not cost much, but is very important.
Perhaps the crucial point in this debate is the scope of practice. There should be a national scope of practice for physician associates and anaesthesia associates, both on qualification and after any post-qualification extension of practice. Any future changes to scope of practice should be developed in conjunction with the regulator and should be agreed at national level. I understand that currently the GMC will not regulate extended scopes of practice, which is very regrettable. For example, we are aware of whether a doctor is on the GP register or a specialist register, or just has a licence to practise. Those levels of expertise are part of the regulatory framework. It seems extraordinary that although the GMC has been asked to look at regulating physician associates, there is no understanding of the scope of a physician associate’s practice. That needs to be properly mapped out and explored.
]]>An agreement could be put in place that will properly renumerate junior doctors, and also look at the other terms and conditions of employment that are important in respect of retaining the medical and healthcare workforce. These situations are not always about pay; it is also about wider terms and conditions. The Government could certainly look in more detail at student debt, for example, as the Times Health Commission outlined this week, which may incentivise people to stay in medicine for longer.
We have diverged slightly into the broader healthcare challenges, so I will return to physician associates, which was the point of this evening’s debate. There are concerns about the regulation and training of this particular group in the medical workforce. Physician associates and anaesthesia associates are not currently regulated. There have been a number of recent high-profile cases of patient harm as a result of being seen by medical associate professionals, including, sadly, some deaths. We know, for example, of the tragic case of Emily Chesterton from Salford who died of a pulmonary embolism having been seen twice and had her deep vein thrombosis misdiagnosed as a musculoskeletal problem by a physician associate at her local GP practice.
Anybody who watches the TV programme “24 Hours in A&E” may have seen some fairly enlightening scenes in respect of the clinical skills of some medical associate professionals, including physician associates. There are many examples of poor clinical diagnosis and judgment, including, for example, making initial decisions to send patients with compound fractures home without an X-ray when the patient actually required surgery.
In my own clinical practice, I have worked alongside some very competent physician associates, but there is a high degree of variability in their training and skills. Only last year, I was forced to directly intervene to prevent patient harm following a paracetamol overdose by a patient who attended A&E. The physician associate incorrectly informed me that they did not require N-acetylcysteine treatment because their liver function test was normal, in spite of the fact that they were over the treatment line as a result of their paracetamol overdose. Of course, at that time, the patient’s liver function tests were normal, but they would not have been for very long. The consequences of that diagnostic decision by the physician associate could have been fatal. The key issue for me is that many physician associates do not know or have the self-awareness to understand the limits of their knowledge and practice, but this is perhaps understandable in a health system that fails to adequately regulate and indeed define its scope of practice.
There are many other areas of concern that have been highlighted in a recent British Medical Association survey of 18,000 doctors, an overwhelming majority of whom work with physician associates. In November 2023, due to severe concerns around patient safety, the BMA called a halt to the recruitment of medical associate professionals to allow proper time for the extent of patient safety claims to be investigated and the scope of the role to be considered.
When the physician associate role was introduced, it was clearly seen as part of the solution to a shortage of doctors, which currently stands at in excess of 8,500. By freeing up doctors from administrative tasks and minor clinical roles, it allowed them to see more complex patients and get the training required to become excellent consultants or GPs.
Unfortunately, physician associates and anaesthesia assistants have been employed in the NHS in roles that stretch far beyond that original remit, and in many cases that were reported in the recent BMA survey that I mentioned, they appear to be working well beyond their competence. That has raised serious patient safety concerns—I gave some examples earlier—and led to calls to review the role, limit the scope of practice, and protect training for the doctors that the NHS desperately needs. When consultant time is taken by supervising physician associates, that is to the detriment of training and supervising junior doctors. That has not yet been addressed or even considered in the NHS England workforce plan.
]]>The UK has a severe shortage of healthcare professionals, amounting to more than 110,000 in England alone, coupled with a growing ageing population with an ever-increasing need for a strong and responsive health service. To address the shortage, the Government in England have introduced the NHS long-term workforce plan, with additional proposals also set out in the devolved nations.
NHS England’s plan sets out a wide range of mostly unfunded workforce measures, including doubling the current number of medical student places to potentially add 60,000 doctors to the workforce by 2036-37. Controversially, it also includes plans to increase the number of physician associates from approximately 3,250 to 10,000, an increase of over 300%, and anaesthesia associates from approximately 180 to 2,000. That is not to say that physician and anaesthesia associates should not have an important role in the future NHS workplace. However, at this time, serious regulatory and safety concerns relating to associates need to be addressed before the NHS seeks to expand their numbers and roles. Furthermore, standardised high-quality training pathways and a properly defined scope of practice are essential.
Physician associates, anaesthesia associates and surgical care practitioners are collectively known as the medical associate professions, and I may use the terms interchangeably. Physician associates and anaesthesia associates currently complete a two year postgraduate course and are employed in a variety of settings in the NHS, including GP surgeries, emergency departments, and medical and surgical settings, and they have also been introduced to mental health settings.
]]>May I apologise, Mr Pritchard? I should, at the beginning, have drawn the attention of the House to my entry in the Register of Members’ Financial Interests as a practising NHS psychiatrist.
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