This report covers the increasing presence of MAPs (medical associate professions) in the NHS, their regulation, prescribing rights and the BMA’s view on the these developments.
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What are MAPs?
The following four professions are part of the MAPs (medical associate professions) grouping. These are the only professions that are considered to be MAPs:
- physician associates (PAs)
- anaesthesia associates (AAs) – known as physician’s assistants (anaesthesia) prior to 2019
- surgical care practitioners (SCPs)
- advanced critical care practitioners (ACCPs)
For more information about the training and work of these professionals, please see our guide to new clinical roles within the NHS.
Medical associate profession numbers in the UK
Physician associates are by far the most numerous of the MAPs. The NHS Interim People Plan estimates that there will be over 2,800 physician associate graduates by the end of 2020, rising to over 5,900 by the end of 2023.
As of 2019, there are around:
- 130 advanced critical care practitioners working in the NHS
- 180 AAs working in the NHS
- 200 surgical care practitioners working in the NHS.
The decision to group the four professions
The move to bring the professions under a single umbrella began with HEE (Health Education England) in 2014, with the intention to work ‘towards a common education and training programme to support a route to statutory regulation’. This originally applied to PAs, AAs and SCPs with ACCPs added later.
HEE created a MAPs oversight board and invited the BMA to send a representative to its Career Framework & Quality subgroup along with representatives from employers, royal colleges and the devolved nations. The group’s task was ‘to describe quality management, training and a career framework for MAPs, so that a clear professional identity is developed which supports arrangements for statutory regulation’. The work of the subgroup has now been subsumed into HEE’s MAPs oversight board, on which the BMA is represented.
MAPs differ in crucial ways; in terms of the tasks they perform, the ways that they train and their entry requirements. These differences mean that developing a single career framework is challenging. Development is ongoing and with preparations underway for regulation, the role of the GMC may be crucial in the future of a combined MAPs career framework.
Reasons for the introduction of MAPs
The appearance of MAPs in UK healthcare reflects a trend towards the development of multi-disciplinary teams as well as ensuring that there is sufficient workforce to meet demand in the NHS.
PAs are seen by the UK government as one of the ways in which workforce pressures in the NHS can be alleviated. In June 2015, the then secretary of state for health, Jeremy Hunt, announced that 1,000 PAs would be introduced into general practice in England to assist in tackling GP workload pressures.
The devolved governments have also identified PAs as a potential way to address pressures.
The NHS in England remains committed to developing multi-disciplinary working and continues to promote PAs as a major component of the future workforce, as demonstrated in the NHS Interim People Plan.
None of the MAPs are currently regulated specifically for their role as MAPs, however surgical care practitioners and advanced critical care practitioners are subject to statutory regulation through previous roles. Unlike PAs and AAs, SCP and ACCP roles can only be taken up by individuals who are already registered healthcare professionals.
Currently, physician associates and anaesthesia associates are not subject to any form of statutory regulation, however following a 2017 consultation, PAs and AAs are now scheduled for statutory regulation by the GMC.
BMA response to the consultation
The BMA response to the consultation argued that all 4 professions should be regulated and that HCPC (Health & Care Professions Council) should take responsibility for regulation, rather than the GMC.
Download the BMA response
The choice of GMC as regulator
GMC are to take on the role of regulator for PAs and AAs. It is not clear exactly when regulation will be introduced, but the GMC has estimated that it will take at least 2 years (by 2021).
The DHSC (Department of Health and Social Care) provided the following reasons for their choice.
- The need to be assured that the chosen regulator will be best able to ensure effective public protection. Based on the independent assessment made by the PSA (Professional Standards Authority) on an annual basis, the HCPC has failed 6 out of 10 of the fitness to practice standards set by the PSA for the last two years. In contrast, the GMC continues to meet all of the PSA standards.
- PAs and AAs are both trained to the medical model and work closely with medical practitioners. Regulation by the GMC will mean that the organisation will have responsibility and oversight of all three professions allowing them to take a holistic approach to the education, training and standards of the roles.
- The majority of respondents to the consultation were in favour of the GMC taking on regulation, including the professional bodies representing the two roles and medical royal colleges (59% for GMC, 20% for HCPC from 3063 total responses).
The decision to only regulate PAs and AAs
Future regulation of ACCPs and SCPs has not been ruled out. This decision was confirmed when the government response was published in February 2019.
PAs and AAs must hold an undergraduate degree, usually biomedical sciences or a health-related science. To become a PA or an AA there is no requirement to be a registered healthcare professional. These roles are described as ‘direct entry’ roles and currently they are not subject to any form of statutory regulation.
To become a ACCP or an SCP, it is necessary to already be a registered healthcare professional. These roles, therefore, do not have direct entry and practitioners will be subject to statutory regulation through their background role.
It was decided to prioritise the two professions that are currently not subject to any form of statutory regulation.
Decisions on regulation and the career framework will apply across the UK.
Can MAPs prescribe?
Currently, none of the MAPs have prescribing rights because they are a MAP. However, prescribing is a part of the role for both SCPs and ACCPs. Candidates for SCP and ACCP roles must already be registered healthcare professionals, meaning that they are be eligible to take a qualification in non-medical prescribing.
AAs and PAs are currently not permitted to prescribe or request ionising radiation. Unlike SCPs and ACCPs, AAs and PAs do not need to be registered healthcare professionals from a previous role. However, a small number of PAs have previously held prescribing roles and are registered health care professionals, and this means that they personally retain those prescribing rights.
We believe that this is potentially confusing for patients, clinicians and employers and in 2019 the BMA endorsed a statement from the Royal College of Physicians and the Faculty of Physician Associates which recommended that no PA should prescribe until all PAs are able to do so.
The consultation on regulation of MAPs included questions about the prescribing rights for MAPs, but in their response, the government stated that prescribing would be treated as a separate question and that a separate consultation would follow.
The BMA's view
Many doctors see the potential that MAPs and other new clinical roles have in helping reduce workload pressures and allowing doctors to focus on tasks where their expertise is essential. In a 2018 BMA member survey, nearly half of doctors (47%) supported the expansion of the non-medical clinical workforce to ease pressures (compared to just 25% who disapprove of this approach).
Despite this general optimism, doctors have expressed a range of concerns. While new clinical roles cannot and should not be seen as replacements for doctors, they can help to support doctors.
To ensure they are genuinely able to do this and not add extra pressure, our Caring, supportive, collaborative report called for the following safeguards.
New clinical roles must not jeopardise doctors' training
Being employed in permanent roles within teams, MAPs naturally over time earn the confidence of senior doctors and are often chosen over junior doctors to assist on work that would be essential experience for a doctor in training. All departments and care settings must take measures to balance the service provision benefits of MAPs, such as PAs (physician associates), with the training priorities of doctors in training.
Everyone should have a clear understanding of MAPs' scope of practice
This includes lines of accountability and supervision responsibilities. The public and other clinicians need a better understanding of the roles that MAPs perform.
Regulation and prescribing rights must be granted
All clinicians should be regulated appropriately for the tasks they perform, which is why we have called for statutory regulation for each of the MAPs.
These issues are explored further in our guidance on principles for effective working.
Professional indemnity coverage
As with other members of staff, any MAPs working for an NHS trust are covered by the DHSC clinical negligence scheme for trusts.
In primary care, physician associates working in England and Wales are now covered by the clinical negligence scheme for general practice (CNSGP). Practice in England in Wales no longer need to secure indemnity coverage for their clinical staff. In Scotland and Northern Ireland practices will need to ensure that their practice indemnity coverage includes physician associates along with their other clinical staff.
MAPs working in any part of the NHS may also choose to have their own personal professional negligence insurance from one of the medical defence organisations.
What is a physician associate?
The Department of Health in England defines the PA as:
"…a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision”.
According to the Health Careers website, PAs:
- support doctors in the diagnosis and management of patients
- might work in a GP surgery or be based in a hospital
- will have direct contact with patients
- will be a graduate who has undertaken post-graduate training
- will work under the direct supervision of a doctor
- will be trained to perform a number of day-to-day tasks including:
- taking medical histories
- performing examinations
- diagnosing illnesses
- analysing test results
- developing management plans
Physician associates should not be confused with...
Physician assistants (anaesthesia)
Confusion arises from the fact that what are now referred to as Physician Associates, were at one time referred to as physician assistants. This is demonstrated by the fact that the DH’s framework document (referenced above) uses the old definition.
Currently the term physician assistant is used only in reference to a very different role specific to the multi-disciplinary anaesthesia team and normally described as physician assistant (anaesthesia) or PA(A). This role is part of Health Education England’s ‘MAPs’ work stream (more on this below).
A definitive description of this role has yet to materialise, however the clear distinction from a PA is that this role is focussed on clinical administration in general practice and is not a patient facing role.
Surgical Care Practitioners (SCPs)
An SCP is a registered healthcare professional (nurse, operating department practitioner or other allied health professional) who has extended the scope of their practice to work as a member of a surgical team. Part of the HEE ‘MAPs’ workstream.
Advanced Critical Care Practitioners (ACCP)
The ACCP role in critical care is designed to contribute to the care and management of critically ill patients and their families. It offers structured clinical career progression for members of the critical care team. This role is part of HEE’s MAPs work stream.
Why have PAs been introduced?
The appearance of PAs in UK healthcare reflects a trend towards the development of multi-disciplinary teams as well as the need to ensure that there is sufficient workforce to meet demand in the NHS.
“The NHS is treating record numbers of people. That’s why we are growing the workforce further with a new class of medic so busy doctors have more time to care for patients.”
Secretary of State, Jeremy Hunt, 2014
PAs are seen by the UK government as one of the ways in which workforce pressures in the NHS can be alleviated. In June 2015, the Secretary of State for Health, Jeremy Hunt, announced that 1,000 PAs would be introduced into general practice in England to assist in tackling GP workload pressures.
This commitment was included in the GP workforce 10 point plan partnership, between NHS England, HEE, the BMA and the Royal College of GPs, and has carried over into NHS England and Health Education England’s GP Forward View.
“We know that many practices now face recruitment issues and are increasingly reliant on temporary staff…We aim to double the rate of growth in the primary care medical workforce over the next five years, to create an extra 5,000 doctors working in general practice. This needs to be supported by growth in the non-medical workforce – a minimum of 5,000 extra staff – nurses, pharmacists, physician associates, mental health workers and others”.
General Practice Forward View, 2016
The devolved governments have also identified PAs as a potential way to address workforce and workload pressures.
“Ensuring a sustainable workforce…means further investment in a mixed economy workforce, and crucially, it means transforming roles so they are of more direct benefit to Scotland’s NHS patients in different healthcare settings… and physician associates are a recent and welcome addition to multidisciplinary clinical teams”.
National Clinical Strategy for Scotland, 2016
“Our goal is to meet the rising demand for healthcare by making the most of the skills our dedicated primary care workforce already have and supporting them in their continued desire to innovate and improve the services they provide every day…measures include…working with health boards and universities to develop an education and training programme for physicians associates in Wales”.
Health and Social Services Minister for Wales, Mark Drakeford, 2015
Entry requirements, training and development
A science-related first class degree is usually required to get onto a PA training programme.
Alternatively, a registered healthcare professional, such as a nurse, allied health professional or midwife, can also apply to become a PA.
PA training (postgraduate diploma) lasts two years, with students studying for 46-48 weeks each year.
Although it involves aspects of an undergraduate or postgraduate medical degree, the training focuses principally on general adult medicine in hospital and general practice, rather than specialty care. Training includes significant theoretical learning in the key areas of medicine. There are also 1,600 hours of clinical training, taking place in a range of settings, including 350 hours in general hospital medicine.
PAs will also typically spend 80 hours in:
- mental health
- obstetrics and gynaecology
According to the Royal College of Physicians (RCP) website there are currently 29 PA courses in the UK with more set to open in 2017 and more in earlier stages of development. The RCP is the home of the Faculty of Physician Associates.
There is currently no statutory regulation for PAs, which means that they are unable to prescribe. However, they do have to meet nationally approved standards of training and practice. This is a requirement of the Competence and curriculum framework for physician associates as laid down by the Faculty of Physician Associates.
PAs are able to practice in the UK as a result of a clause within the GMC’s (General Medical Council) guidance on Good Medical Practice (the guidance discusses delegation in paragraph 45). Once PAs have successfully completed their diploma, they can join the PA voluntary register.
The Faculty of Physician Associates is currently working to gain statutory registration for PAs. HEE has established the Regulation and Quality Management working group as part of their ‘MAPs’ programme (outlined below) in order to:
- explore the requirements of both statutory and non-statutory regulation
- assess the readiness of the medical associate professions to achieve these
- make the case for statutory regulation.
Doctors’ views of PAs
The BMA has been seeking views from members regarding PAs and their introduction in the NHS. We have heard some positive feedback about the potential for PAs to play a role in tacking workload pressures and about the constructive influence they already have in some parts of the country in changing how care is provided.
However, some recurring concerns have emerged around PAs and how they have been introduced into the health service. The most common concerns include:
- lack of professional regulation
- lack of clinical governance and supervision
- lack of clarity about who is responsible for supervising PAs on wards
- concerns about the impact of PAs on doctors’ training
- lack of clarity among doctors, patients and the public about PAs and their roles
- suitability of PAs to different care settings
- confusion over apparently interchangeable role terminology
- PA pay scales in relation to doctor pay scales
- PAs as a quick and cheap substitute for fully qualified doctors.
The 2016 BMA Annual Representatives Meeting called for:
- An impact analysis on the training of doctors and medical students
- The BMA to negotiate agreement on their scope of practice [AS A REFERENCE]
- The introduction of their professional regulation
HEE Medical Associate Professions work stream
The BMA has taken up a place on HEE’s MAPs (Medical Associate Professions) work stream, which first met in September 2016. Although set up by HEE, the group has a UK-wide focus and includes representatives from the devolved nations, as well as:
- Royal Colleges
- the GMC
- the Health and Care Professions Council
- Local Education and Training Boards
- the Faculty of Physician Associates
- patients and representatives from other stakeholder organisations.
The scope of MAPs covers:
- Physician Associates
- Physicians’ Assistants (Anaesthesia)
- Surgical Care Practitioners
- Advanced Critical Care Practitioners
A working group has been established to:
- develop a single MAP career and training framework;
- define the role of Medical Associate Professionals and other non-medical roles being developed and consider how the further development of these roles could be streamlined and supported nationally
- create an overarching professional title to form a common professional identity.
The group is essential to achieving professional regulation for MAPs and provides a platform for the BMA to address doctors’ concerns about these emergent roles.
Through the MAPs group, we have now obtained an agreement that HEE will carry out a full impact analysis of PAs on the training of doctors and medical students, in line with the aforementioned ARM resolution from 2016.
A second MAPs working group has been focussing on Regulation and Quality Management and it is expected that a government consultation on professional regulation for MAPs will be carried out in the Autumn of 2017.
We have also been feeding in to the MAPs communications team to help ensure that doctors and patients start to receive more useful information about these new roles.
General Practice Forward View (GPFV)
As part of the General Practice Forward View work streams, we have also been attending a separate HEE Physician Associates Working Group, which is looking specifically at the introduction of PAs into general practice.
The Secretary of State has mandated that there should be 1,000 PAs working in primary care by 2020.
Read our guidance on what to consider when employing PAs in general practice