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.