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Physician associates in the UK

Women in Academic Medicine Conference

As their presence in the NHS increases, there is growing interest in physician associates (PAs), what they do, and how they fit with the established roles and systems.

PAs currently work and train across England and Scotland, mainly in hospitals and in a wide range of specialities. As of February 2016 it was estimated that there were 260 PAs and 550 PAs students (Government Response to the House of Commons Health Select Committee Report on Primary Care, Fourth Report of Session 2015-16).

Due to a lack of central coordination or formal national programme of introduction of PAs into the NHS, there is local variation in their roles and how they are managed. Consequently, a considerable amount of fear and concern has been generated among the medical profession as to what PAs mean for the future of the role of doctors, and also about the way their introduction is already impacting on day to day life in the NHS.

This briefing aims to provide doctors with useful information about the role of PAs and the concerns that have been raised about them, as well as looking at how the BMA will be influencing the roles of PAs and the ways they are introduced into the service.

You can read the guidance below, or download the PDF for a printable version.

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For more information please contact the workforce and innovation team on [email protected]

 

  • 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).

    Medical assistants

    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
    • surgery
    • obstetrics and gynaecology
    • paediatrics

    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.

  • Regulation

    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:

    1. An impact analysis on the training of doctors and medical students
    2. The BMA to negotiate agreement on their scope of practice [AS A REFERENCE]
    3. 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.