Rapid Response:
Re: RCP members vote to limit physician associate roles amid calls for president to resign
Dear Editor
Extraordinary meetings called by Physicians and Anaesthetists underscore huge concerns around Medical Associate Professionals (MAP). While the Faculty of Physician Associates (FPA) (1), NHS England (NHSE) (2), and the Academy of Medical Royal Colleges (3) all agree that Physician Associates (PA) are not doctors and should not take the place of doctors, the FPA says (1) scope of practice includes seeing undifferentiated patients, formulating differential diagnoses and management plans, performing diagnostic and therapeutic procedures and delivering appropriate treatment – all of which sound very doctor like!
The NHSE contract for GP Primary Care Network, para B6.2, specified that PA must be given responsibility for providing first point of contact care for patients with undifferentiated problems (4). Confusingly, the amended contract for 2024/5 states: ‘17. Supporting guidance will also be issued to clarify that non-GP doctors (sic) should not see undifferentiated patients’ (5). While ‘non-GP doctors’ might possibly be a reference to SAS doctors (6) does it actually mean lesser trained PAs?
The language indicates either confusion or perhaps obfuscation in relation to professional roles. A deliberate blurring of the boundaries between MAP and doctors can also be inferred both from government insistence that Physician ‘Assistant’ was changed to ‘Associate’ to sound more professional, and that the GMC and not the Health and Care Professions Council (HCPC) should be the regulator. The HCPC (7) currently regulates fifteen different groups including paramedics and operating department practitioners and would seem far more appropriate.
Worryingly, some appear to think that doctors are over trained. Lord Bethell declared that ‘GPs don’t face huge amounts of complexity’ (8). Richard Meddings, chair of NHSE and a former banker by trade, argues that the medical staffing crisis could be solved not by improving retention and training more staff but by slashing the time it takes to train a doctor (9). Might they be advocates not only of MAP but also of ‘algorithmic’ medicine in the not too distant future (10)?
Doctors are right to be concerned: back pedalling on the increase in numbers of new medical student places (11); progress of 700 anaesthetic trainees blocked despite 680 unfilled anaesthetic consultant posts (12); only 56% of those entering core training remaining in the NHS eight years later (13); Panorama showing one London general practice where PAs were effectively working as GPs and without supervision (14); a general practice in Surrey making three of its GPs redundant (15), claiming ‘new ways of working’ including the use of non-medical staff.
The National Audit Office identified a gap between demand for GPs and numbers being trained (16). NHSE’s suggestion was that work could be moved from fully qualified GPs to those in training and to SAS doctors! Implementation of this plan seems implausible, and given the large increase in numbers of PAs, it appears far more likely they will be closing the gap. PA in the USA are permitted to work without medical supervision and are growing in number at a much faster rate than doctors, driven by the push from ‘for profit providers’ to reduce labour costs. Evidence indicates that these PA both over investigate and over treat compared with physicians – a deterioration in quality of care (17). In the UK, NICE considers that the clinical and cost-effectiveness of providing PAs is unknown and therefore requires research (18).
The Institute of Fiscal Studies characterises the current financial settlement for the NHS as the biggest cut in funding since the 1970s (19), bringing huge pressure on providers to sack clinical staff. Why is it so hard for College leaders to see which way the wind is blowing?
References
1. The Faculty of Physician Associates at the Royal College of Physicians. https://www.fparcp.co.uk/
2. NHS England. NHS England’s position on physician associates, 7 February 2024 letter to Royal College of Physicians. https://www.england.nhs.uk/long-read/nhs-englands-position-on-physician-…
3. Academy of Royal Colleges. High level principles concerning physician associates (PAs). Academy consensus statement. 4 March 2024.
https://www.aomrc.org.uk/wp-content/uploads/2024/03/Consensus_statement_…
4. NHS England. Network Contract Directed Enhanced Service. Contract specification 2020/21 – PCN. Requirements and Entitlements
https://www.england.nhs.uk/wp-content/uploads/2020/03/Network-Contract-D…
5. NHS England. Arrangements for the GP contract in 2024/25. 29 February 2024. https://www.england.nhs.uk/long-read/arrangements-for-the-gp-contract-in…
6. Royal College of General Practitioners. SAS Doctors working in primary care. https://www.rcgp.org.uk/representing-you/policy-areas/sas-doctors
7. Health and Care Professions Council (HCPC). Which professions do HCPC regulate? https://www.hcpc-uk.org/public/which-professions-do-hcpc-regulate/
8. Parr E. GPs ‘do not face huge complexity’, claims former health minister ahead of PA debate. Pulse 2024 Feb 26. https://www.pulsetoday.co.uk/views/regulation/gps-do-not-face-huge-compl…
9. Wooller S. Length of doctors’ training should be slashed from seven years to fix staffing crisis, says NHS boss. Daily Mail 2023 March 23. https://www.pulsetoday.co.uk/views/regulation/gps-do-not-face-huge-compl…
10. Goyal D. Physician Associates: the hidden agenda. Bylines Scotland 2024 Mar 26 https://bylines.scot/health/physician-associates-the-hidden-agenda/
11. O’Dowd A. Pledge to boost medical training places rings hollow, say leaders. BMJ 2024;384:q502 https://www.bmj.com/content/384/bmj.q502
12. Munro C. Nearly 700 anaesthetists have training interrupted after cuts. BMJ 2021;373:n1213 https://www.bmj.com/content/373/bmj.n1213
13. William Palmer, Lucina Rolewicz, Emma Dodsworth. Nuffield Trust. Research report September 2023. Waste not, want not. Strategies to improve the supply of clinical staff to the NHS. https://www.nuffieldtrust.org.uk/sites/default/files/2023-12/Waste%20not…
14. BBC Panorama – Undercover: Britain’s Biggest GP Chain. YouTube 13 June 2022
15. Parr E. Practice makes GPs redundant in favour of ARRS staff. Pulse 2024 Jan 9. https://www.pulsetoday.co.uk/news/breaking-news/practice-makes-gps-redun…
16. Parr E. NHS workforce plan relies on ‘significant’ substitution of qualified GPs, NAO warns. Pulse 2024 Mar 22. https://www.pulsetoday.co.uk/news/workforce/nhs-workforce-plan-relies-on…
17. Bhavneet Walia, Harshdeep Banga, David A. Larsen. Increased Reliance on Physician Assistants: An Access-Quality Tradeoff? J. Mark. Access Health Policy 2022, 10(1), 2030559; https://doi.org/10.1080/20016689.2022.2030559 https://www.mdpi.com/2001-6689/10/1/2030559
18. NICE. Individual research recommendation details. https://www.nice.org.uk/researchrecommendation/what-is-the-clinical-and-…
19. Lister J. NHS faces biggest actual cut in spending since 1970s – IFS. The Lowdown 2024 April 1.
Competing interests: I am co-chair of Keep Our NHS Public
10 April 2024
John Puntis
retired consultant paediatrician
Leeds
Leeds Keep Our NHS Public 