Government review of physician and anaesthesia associates

Approximate read time: 15 minutes

On 5 December 2024 the House of Lords is scheduled to debate the following motion:

Baroness Bennett of Manor Castle (Green Party) to ask His Majesty’s Government what the review, announced by the Secretary of State for Health and Social Care on 20 November, of the physician associate and anaesthetist associate roles will cover; and what actions they plan to take in advance of the outcome.

1.   What are physician and anaesthetist associates?

1.1 Scope of the roles

Physician associates (PAs) and anaesthesia associates (AAs) are healthcare professionals who work under the supervision of a medically qualified doctor or anaesthetist.^[1]

PAs carry out a number of tasks, including:

• taking medical histories from patients
• performing physical examinations
• diagnosing illnesses
• seeing patients with long-term chronic conditions
• performing diagnostic and therapeutic procedures
• analysing test results
• developing management plans
• providing health promotion and disease prevention advice for patients^[2]

Most PAs currently work in general practice, acute (internal) medicine and emergency medicine.

The types of tasks that AAs undertake include:

• reviewing patients before surgery and assessing them for anaesthesia
• taking a medical history and clinical assessment allowing for an anaesthesia plan to be created
• inducing, maintaining and waking up patients from anaesthesia under appropriate supervision
• using anaesthesia techniques/agents, medications and specialist equipment
• interpreting and monitoring clinical readings and patients’ parameters during anaesthesia and responding appropriately
• initiating and managing medications, fluid and blood therapy during surgery
• identifying potential issues during surgery and anaesthesia, taking action and seeking appropriate support when required
• ensuring there is a plan for patients following their operation and that it is carried out
• being involving in the teaching, supervising and assessing of other team members
• supporting innovation, audit and research within the anaesthetic department^[3]

1.2 Training and qualifications

To train to become a PA, applicants generally need to have completed an undergraduate degree in a bioscience-related subject or be a registered health professional such as a nurse or midwife.^[4] PAs must then complete postgraduate training that usually lasts two years and involves many aspects of an undergraduate or postgraduate medical degree, focused principally on general adult medicine in hospital and general practice rather than specialty care. A small number of higher education institutions have also introduced integrated Master of Physician Associate programmes which offer a more direct route to becoming a PA and take four years to complete.^[5]

To train to become an AA, applicants must have a biomedical or biosciences degree, or be a registered healthcare professional—such as a nurse or operating department practitioner^[6]—with at least three years’ full-time post-qualification work experience. They must complete full-time postgraduate training lasting around two years, with most of the time spent on clinical placement.^[7]

PA and AA qualifications do not entitle holders to prescribe medications. However, a small number of PAs and AAs can do so with the support of their employer, on the basis of a qualification gained in another regulated healthcare profession such as nursing.^[8] The government is currently working with representatives from the professions, NHS England, the devolved administrations and professional bodies to develop the case for extending prescribing responsibilities to these roles.^[9] The case would then need to be considered by the Commission on Human Medicines, an advisory non-departmental public body.

1.3 Number of PAs and AAs

The government has said that there are currently over 3,500 PAs and around 100 AAs working alongside over 180,000 full-time equivalent doctors and GPs in the NHS in England.^[10]

In the NHS long term workforce plan, published in June 2023, the previous government said that NHS England would incrementally expand the number of PA training places to over 1,500 per year by 2031/32, eventually establishing a workforce of 10,000 PAs by 2036/37.^[11] AA training places were also set to be increased to 280 per year by 2031/32, with an estimated workforce of around 2,000 by 2036/37.

1.4 Regulation of the roles

From December 2024, the General Medical Council (GMC) will begin to regulate PAs and AAs. The previous government legislated for this earlier in 2024.^[12] Further information about this change and the debate surrounding the decision is available in the House of Lords Library’s briefing, ‘Anaesthesia associates and physician associates’ (22 February 2024). More recently, legal action has begun against this decision which is discussed in the following section.

NHS England has issued guidance on the roles that PAs and AAs play.^[13] The British Medical Association (BMA) has also published national guidance setting out its ideas for the roles and responsibilities of Medical Associate Professionals (MAPs) which include both PAs and AAs.^[14]

2.   What concerns have been raised about the roles?

In recent years, concerns have been raised about the use of PAs and AAs in the NHS. Many of these concerns have centred on patients’ lack of knowledge and understanding of the roles. Medical professionals and patients have also raised safety concerns and argued that PAs sometimes carry out tasks they are not qualified for. Much of the debate has focused on the deaths of two patients, Emily Chesterton and Susan Pollitt who died after being seen by PAs.^[15]

A BMA survey found that many doctors had “overwhelming concern” about patient safety in the NHS due to the current ways PAs and AAs are employed.^[16] The BMA surveyed 18,000 doctors from across the UK and reported that 87% of those who took part said that the way PAs or AAs currently work was always or sometimes a risk to patient safety. It also found that 86% felt that patients were not aware of the difference between these roles and those of doctors. Responding to the results, BMA chair of the council, Professor Philip Banfield, argued that:

Patients deserve to know who is treating them and the standard of care they are going to receive. By blurring the lines and allowing a situation where PAs can act beyond their competence without the public understanding what they are qualified to do, both professions are demeaned and risk losing crucial public trust.^[17]

The BMA has launched a legal case against the GMC as it does not want the same body responsible for regulating doctors to regulate PAs and AAs. It argued that this would lead to a “dangerous blurring of lines for patients between highly-skilled and experienced doctors and assistant roles”.^[18]

Research by Healthwatch, a charity for people who use health and social care, also found issues with people’s understanding of the roles. In July 2024, Healthwatch published research it had conducted on public perceptions and experiences of PAs.^[19] It noted challenges in accurately gauging people’s experience and understanding as there are not many PAs practising in the NHS and “little national data” available about them. It commissioned a poll of 1,914 adults living in England and also spoke to local Healthwatch services (there is one in every area of England) about stories people had shared with them.

The polling found a “mixed picture on awareness of physician associates”, with over half (52%) of those surveyed having agreed or strongly agreed that they understood the difference between a PA and a doctor.^[20] However, it found that there were differences when it came to age. Respondents aged between 18–34 were more likely to have agreed than those in older age groups. Some local Healthwatch networks also reported that while patients might have heard of PAs and understood that they are not doctors, understanding of what they can and cannot do was more limited. In addition, many patients were found to be unaware of a local presence of PAs until they were given an appointment with one. When patients were aware they had an appointment with a PA, Healthwatch reported that experiences tended to be positive. However, it also noted several cases where patients were not made aware that they were seeing a PA rather than a doctor. Looking forward, Healthwatch recommended ‘five steps to improve clarity’, which it said would support the roll out of PAs. These steps included clarity on choice and communication. Linked to this, the BMA has called for PAs to be renamed as physician assistants to help ensure that they are not confused with doctors.^[21]

The Association of Anaesthetists has also raised concerns about plans to increase the number of AAs without an accompanying increase in the number of doctors in anaesthesia.^[22] It has argued that “to many, this looked like a replacement of doctors with AAs, rather than employing AAs to complement the anaesthesia team”. The association also highlighted social media and press reports of PAs and AAs working in ways that have caused concerns, particularly in regard to their scope of practice, levels of autonomy and misleading representations of their roles.

Within this debate, stakeholders have suggested that concerns about PAs and AAs have led to discussions about the roles becoming toxic. United Medical Associate Professionals (UMAP), a body which represents PAs and AAs, has said that there are “countless examples” of staff facing bullying and being sidelined due to their roles.^[23] The Academy of Medical Royal Colleges, which represents senior doctors, has also warned that the situation has become so “destructive” that it has damaged teamwork in areas where PAs and AAs work. It noted the existence of debates on social media which focused on the pay and professionalism of PAs and AAs as well as discussions about how they could be undermined at work. UMAP chief executive, Stephen Nash, has also argued that reporting on the deaths of those who have died after being seen by PAs has been used to “attack the whole [PA] profession” when there are “often multiple factors at play”.

In response to the debate around the use of PAs and AAs, various stakeholders have called for more clarity on the roles. For example, Nigel Edwards, a senior associate at the Nuffield Trust, has argued that the roles can work well but they need to be properly supervised and staff need to be clear with patients about their role.^[24] He therefore called for a “very clearly defined scope of practice”. In addition, in September 2024, the Academy of Medical Royal Colleges, which represents 24 medical royal colleges, called for an independent review into physician associates citing “mounting concern and adverse commentary by doctors at all levels” over plans to increase the use of PAs and AAs.^[25] It said that the review should focus on patient safety, cost-effectiveness and efficiency.

3.   What has the government announced?

On 20 November 2024 in a statement to the House of Commons, Secretary of State for Health and Social Care Wes Streeting announced an independent review of physician and anaesthesia associates.^[26] Acknowledging the concerns raised by medical professionals about the roles, Mr Streeting said that the review would “reset the discussion by stepping back and taking stock of the evidence”.

Mr Streeting explained that the government had commissioned Professor Gillian Leng, president of the Royal Society of Medicine, to lead the review.^[27] He said that the review would inform future reforms and be “vital to the delivery of the 10-year health plan”. The review is due to report in spring 2025.

An accompanying departmental press release set out that the review would look into PAs and AAs and consider:^[28]

• the scope of these roles
• the safety of these roles
• how they support wider health teams
• their place in providing patients with good quality and efficient care
• how effectively these roles are deployed in the NHS
• how new roles should work in the future

It also said that to increase transparency, the review would look into measures to ensure patients know when they are interacting with PAs or AAs so they are clear on the type of clinician they are seeing and for what reason.

Mr Streeting noted that evidence and data would be taken on both a UK and global level and would involve engagement with associates themselves, patients, the public, doctors and other professions, employers and researchers.^[29]

The government has also published terms of reference for the independent review.^[30] This document reiterated the purpose of the review and gave an overview of what it would cover. It stated that it would be an “end-to-end review” covering selection and recruitment; training; day-to-day work; scope of practice; oversight; supervision and professional regulation.

4.   What was the reaction to the government’s announcement?

Various stakeholders have welcomed the government’s announcement. For example, the GMC was one such body.^[31] In a statement, it said that the discussion about PA and AA roles and their deployment needed to be addressed and that “this review is an important step towards achieving that”. NHS Employers also welcomed the government’s intervention and the role of Professor Leng in leading the review.^[32] Danny Mortimer, chief executive of NHS Employers, said:

Leaders in the NHS, independent care and medical representative organisations have struggled to find constructive and coherent ways to respond to the public’s concerns about the clinical work of physician and anaesthesia associates who make up a small proportion of the sector’s overall workforce. At times, the responses have lacked courtesy and compassion, particularly for those in these professions.^[33]

The College of Medical Associate Professionals, the professional body for PAs and AAs, made similar comments regarding Professor Leng’s role and welcomed Mr Streeting’s acknowledgement of the “toxicity of the current landscape”.^[34] It argued that the review was a “significant and positive step towards understanding and enhancing the vital contributions MAPs make”.

In addition, the Academy of Medical Royal Colleges said that it “warmly” welcomed the independent review which it had previously called for.^[35] Dr Jeanette Dickson, chair of the academy, said that it offered a chance to “chart a way forwards” ensuring the roles support the delivery of safe patient care and enable training opportunities for resident doctors, “as envisioned”.

The BMA’s response to the announcement raised concerns about patient safety while the review is ongoing.^[36] Professor Philip Banfield, BMA council chair, said:

This government has acknowledged the concerns of doctors and accepted there is a safety issue with the employment of physician associates. Now the NHS must tell us how they are going to keep patients safe while this review is carried out.

You do not fly a plane under safety review, you ground it. So, we need to know what immediate safety measures NHS England will put in place, how quickly they will pause their PA expansion plans, and in the meantime if they will adopt the BMA’s own guidelines to start protecting patients now.^[37]

Professor Banfield also called for the review to “finally get to the bottom of the use by some hospitals of PAs and AAs in roles that should be filled by fully trained doctors”.^[38] In addition, he argued that the review must lead to a clear, nationally agreed scope of practice for the roles.

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