A simple solution to the Physician Associate issue in the NHS

There are c. 4,000 Physician Associates (PAs) working in the UK health service and right now they are a political football.

Physician Associates are a great idea. They are clinicians trained in the same way as a doctor but over a shorter period of time and with a focus on the common, core presentations. They are typically permanently employed as part of a medical team, so while the junior/resident doctors rotate constantly every 4-6 months they represent permanent junior members of the medical team (in hospital and GP setting).

PAs are good for patients because they get to know the patients where they work, they also get to know the presentations, this “continuity of care” is a massive benefit. PAs are good for rotating doctors because they help them get up to speed faster and they are also a highly effective training resource for resident/junior doctors – they can teach them the skills they need in a consistent, standardised way. PAs are good for other members of staff like nurses because they represent a permanent, approachable member of the medical team that is easy for them to communicate with. PAs improve safety, hasten the flow of patients through the hospital and they improve patient satisfaction. PAs mean doctors learn more on rotation.

However, the British Medical Association or BMA (a union for doctors) has been taken over by a radical pressure group called Doctors’ Vote (DV) who have an agenda to get rid of PAs and drive up doctors’ pay. Doctors’ Vote see PAs as a threat. The DV/BMA have organised a sophisticated slur campaign and been very effective. They called for a review into PAs, the Leng Review.

Unfortunately the Leng Review’s recommendations satisfied no one. It recommended changing the job title of Physician Associates to Physician Assistants. They also recommended PAs stop seeing “undifferentiated” patients. This has huge implications because it threatens the jobs of PAs working in GP practices, Emergency Departments and potentially even AMUs.

The Leng Review implementation is now subject to a legal challenge seeking a judicial review and the implementation of its recommendations are on hold. The issue is that, if the government goes down the implementation route, because it is essentially a demotion of PAs, then they risk what is called “constructive dismissal” where they make the job so bad that people leave. The government could well end up facing an employment tribunal with 3,500 people – potentially very expensive.

So what solutions are there:

1. Government comes out in support of PAs and fully backs them and seeks to expand the role with minor changes to improve safety and oversight. This is the best solution but it is one the DV/BMA would fight hard against, certainly initially. Then they would give up. Remember, the BMA opposed the formation of the NHS.
2. Government gets rid of all PAs – not a great outcome. The DV/BMA would be delighted but getting rid of 3,500 experienced clinicians would not be sensible. It also opens the way to multiple, expensive employment tribunals.
3. Government does nothing and keeps being indecisive, the pain rumbles on – this is the poorest solution for everyone. No one is happy.
4. Government decides to convert all PAs into Advanced Clinical Practitioners (ACPs). ACPs are experienced health professionals who undertake further training and then are able to take on a clinical role as part of the medical team that is similar to a doctor. ACPs can work in the GP or hospital setting. This solution probably works best, they preserve the job roles of PAs so the threat of employment tribunals is minimal, they can also claim to have gotten rid of the PA role so the DV/BMA is happy (in theory).

However, right now PAs are prevented from joining the ACP training programme. The ACP programme is covered by a document called the “Multi-professional framework for advanced practice in England”. Anyone who is a registered health professional with master’s level training should be able to apply. That means PAs should be able to apply as the PA qualification is Master’s level. However currently they are “not accepting associate professions”. If they make this small change and include PAs into the ACP programme then suddenly the PA issue is resolved.

We are in a crazy situation where people in professions like Art therapists, Drama therapists, Music therapists and Podiatrists can enrol onto an ACP training programme to work in the emergency department of a hospital while a PA with 8 years of experience in the same emergency department cannot. Something needs to change.