What is the strategy behind the Doctors’ Vote/British Medical Association’s attacks on Physician Associates?

Ever since the junior doctor strikes of 2024 the British Medical Association (BMA) has changed its stance on Physician Associates (PAs) and kept up a barrage of attacks on PAs. What is going on, why is the BMA so concerned about this and what can be done about it?

The BMA is the major trade union for doctors in the UK. Historically it was supportive of the PA role, in 2023/24 that changed. A pressure group called Doctor’s Vote (DV) with a radical agenda pushed their candidates into the key roles within the BMA and essentially took over the organisation. DV is a populist movement akin to MAGA or Reform or any of the populist movements around the World. Their agenda is very much about putting doctors first, getting rid of any roles which they see as competing with doctors and driving up wages for UK doctors – they even oppose doctors coming here from abroad.

PAs are perfect for DV/BMA to pick on and bully

Like any decent populist movement they like to have a small, defenceless group to pick on and blame for their problems. They also take a very vocal approach to their hate on social media and are not against underhand tactics. They are also good at manipulating the medical establishment to get what they want. They are relentless to the point of obsession with their hate for the PA profession.

PAs support doctors, they are NOT a threat

Sadly the DV/BMA view PAs as a threat. This is unfortunate because PAs are the staff group within the NHS that is most aligned to and supportive of doctors. DV/BMA take a fanatical approach, they make constant and endless demands – look at the junior doctor strikes, not content with 22% one year ago they now want another 29%. They are like a demanding, spoilt child with an insatiable appetite.

DV/BMA claims to support “multi-disciplinary working” but their approach to PAs contradicts this. PAs are trained the same way as a doctor but over a shorter period of time. PA training is intense, it consists of two years of Masters level training on top of an appropriate healthcare-related degree. PAs learn all the same clinical history-taking and examination skills that doctors learn but when learning about disease the focus of PA training is on core common presentations, doctors spend more time learning about the complete spectrum of medical presentations. Doctors are obviously more highly trained but you do not necessarily need to see a doctor to diagnose the vast majority of presentations that patients bring to healthcare.

PAs are also permanently employed, which means they get to know the patients and the doctors and the systems. Doctors, until they are fully qualified as consultants, are constantly rotating every 4-6 months.

PAs know their limits; they and their work is overseen by doctors and when they reach the limits of their knowledge they refer to doctors.

The DV/BMA strategy is effective. They have used their credibility to create “guidelines” which downgrade the role. They have used their influence in the medical establishment to co-opt the medical Royal Colleges to do similar. They have a very effective PR campaign which highlights key examples of PA failure. The best of these is Emily Chesterton.

Emily Chesterton is NOT a reason to get rid of PAs

Emily was seen by a PA in a GP practice and the PA concerned missed a deep vein thrombosis (DVT) and pulmonary embolism (PE) and Emily sadly died. This example is being taken as a reason to get rid of PAs. The PA concerned lost their job and I imagine is absolutely mortified. But we have to be realistic. This is a case of misdiagnosis. All doctors, all PAs during their careers will misdiagnose and miss diagnoses. 310 pulmonary emboli (PE) are missed by GPs every year, almost one a day.

What about Lucy & Vince?

My friend Lucy was seen twice by her doctor GP last year with similar symptoms, given antibiotics and died a week later of a PE. My own brother died this year of a cardiac arrest, he had gone to his GP with chest pain and been prescribed anti-acid tablets. The GPs concerned have not lost their jobs, no one is saying doctors should be abolished or downgraded. The sad fact is all clinicians misdiagnose. And there are good PAs and bad PAs, as well as good doctors and bad doctors. Emily Chesterton’s death is a system failure, in GP practice PAs’ work is typically overseen by GPs so Emily’s death is a failure of the whole team looking after her. It is an opportunity to improve the system, not a reason to get rid of PAs.

The DV/BMA strategy

Currently the DV/BMA is focussing on downgrading and deskilling the PA role so that Physician Associates do not see “undifferentiated” patients – ie. those coming through the front door as a first contact. They want to turn Physician Associates into “Doctor’s Assistants”; staff members who can be subservient to doctors and “help out a bit”. They are trying to morph the role into one where PAs capabilities are lessened. This strategy forces employers to question whether PAs are worth employing and it forces PAs to question whether they want to continue to work with lessened capabilities and lower pay. Meanwhile the PA profession is constantly harassed in conventional and digital/social media to discredit the role. The objective for the DV/BMA is that PAs will then end up doing a lower paid, subservient role or (ideally) simply go away.

While this strategy sounds great for doctors, it does not fit with the PA role. PAs have been educated to Master’s level and are highly trained. They are also highly motivated to help patients and, like any professional, they want to progress and expand their capabilities.

Also, let’s say PAs go away completely, the DV/BMA then has a new problem – no whipping boy. They will have to find a new group to hate.

It is very difficult to combat this kind of ideologically motivated strategy from DV/BMA. As with any extremist ideology you beat them in one area and they pop up in another. And if you concede to their demands and they just push for more.

The research shows that the only way to really breakdown this kind of zeal is to spend time with people, listen to them and explain slowly and carefully. It is often fear-driven so you need to help that person to become comfortable.

What needs to happen? This is a kind of bullying and when you stand up to a bully, they become intimidated. Reasonable people are not always very good at this.

PAs need to come together to and start pushing a positive message about PAs and stand up for the profession. They need to counter the social media abuse online and expose it for what it is. DV/BMA is very good and pushing a divide and rule agenda. The PA stance needs to be about educating doctors and extending the love. PAs should avoid being drawn into a Drs vs PAs narrative. These poor DV/BMA guys need love not hostility.

Government needs to recognise what is going on and take a more assertive approach with the DV/BMA. They need to demonstrate to BMA members that their strategy is not going to yield results. Ultimately someone needs to stick up for the little guy.

Health service managers need to recognise the political game that is being played here and stand up to what is a kind of corporate bullying.

In conclusion

PAs are a valuable workforce within the NHS because it makes sense to have a permanent team of medically-trained personnel working alongside doctors; it is better for patients and it is better for doctors. PAs are a vulnerable staff group being bullied by a much larger, stronger group and, ultimately, if the PA profession is to survive in the UK, someone needs to stand up for them (Wes Streeting maybe?)