‘If a doctor can do it, why not a PA?’

A lack of scrutiny has let the physician associate role run away with itself, writes BMA Wales council chair Iona Collins

Location: Wales
Published: Wednesday 29 November 2023
Iona collins

Healthcare has become increasingly complex over time, with new techniques creating new roles and increasing specialisation, along with sub-specialisation. In oncology, when histopathology, radiology, radiotherapy, surgery and chemotherapy required careful coordination between different specialists, the MDT (multidisciplinary team) method of working developed therein. 

With MDT working proving to be an effective method of pooling diverse expertise in oncology, the MDT working method has been extrapolated beyond this area of clinical practice and across the professions, to involve the NHS as a whole. The multidisciplinary team is now a multiprofessional team, or MPT, as recommended by Derek Wanless, who identified the need to increase the number of professionally qualified staff (2002).    

Across the Atlantic, PAs (physician assistants) have been assisting physicians since the mid-1960s, when military paramedics returned from Vietnam and received additional training to work for doctors in a civilian setting.  The American PA role has matured into a recognisably separate profession with their own PA regulatory bodies throughout the USA. 

Back in the UK, a workforce expansion initiative explored the possibility that PAs could be adopted in the NHS. This was literally done by recruiting senior PAs from the USA to work in Birmingham, with the result that American PAs could indeed be a very useful addition to the healthcare workforce. While the UK has subsequently trained thousands of PAs, who now work throughout the NHS, it is pertinent to highlight that a USA-trained PA can work in the UK, but a UK-trained PA cannot work outside the UK. 

In England, the relatively high number of PAs working without defined scope of practice, as well as without clear lines of accountability and responsibility in the NHS, has caused alarm throughout the medical profession. The level of supervision required to ensure patient safety has placed pressure on an already overstretched medical workforce.

Whereas other mid-level practitioners are experienced healthcare professionals with extended roles, by contrast, for PA students ‘some prior health or social care experience’ alone is required, along with a bachelor’s degree. Newly qualified PAs, therefore, are typically lacking in the clinical experience of nurse practitioners, extended scope practitioners, clinical nurse specialists, etc.   

When the 2017 president of the FPARCP, Professor Jeannie Watkins, reported at interview that PAs were not ‘handmaidens’ or ‘subservient’,  with an internal consultation with PAs resulting in the change of title from physician assistant to physician associate, the job suddenly sounded synonymous with that of a medically qualified doctor. Prof Watkins is currently the programme director and professorial lead for physician associate studies at Swansea University.

Doctors have associate specialists and associate GPs as senior members of the medical profession, with other professional bodies using the term ‘associate’ to reflect the stage of training within the defined profession, eg solicitors and architects. 

The lack of checks and balances appears to have let the PA role run away with itself. The same two-year clinical training is now pitched against traditional medical school training, as exemplified by a quote from the Health Education and Improvement Wales site: ‘that this role also provides an opportunity for people who want to provide direct medical care to patients a different route other than traditional medical training’.

The GMC, which has been the regulator of doctors alone, is due to include physician associates, along with anaesthesia associates, under their regulatory umbrella – instead of the HCPC, which regulates most other healthcare professionals.

Earlier this month, the South East School of Physician Associates proudly stated: ‘If a doctor can do it, why not a PA?’

I suggest that this question should be asked of the public with absolute transparency regarding the level of clinical competency that a two-year clinical course achieves. 

Iona Collins is chair of BMA Welsh council