Wider use of physician associates will increase inequality, say UK doctors

Doctors are warning the UK medical regulator that wider use of physician associates in the NHS may risk patient safety and lead to greater inequalities in care in deprived areas that struggle to recruit GPs.

The government’s plan to recruit 10,000 physician associates – healthcare professionals supervised by doctors – has angered many clinicians who consider the roles ill-defined and a potential threat to patient safety.

The General Medical Council (GMC) is to regulate physician and anaesthesia associates, who also work under doctors’ supervision, from December.

The doctors’ union, the British Medical Association, last week announced it was seeking a judicial review of the GMC over the “dangerous blurring of lines” between doctors and medical associate professions. It argues physician and anaesthesia associates need regulating, but not by the GMC.

Other professional membership organisations want clarification of associates’ roles. The Royal College of General Practitioners (RCGP) told the GMC that regulation is a “significant step forward”, but the scope of practice needs to be urgently developed.

In a submission to a GMC consultation on regulation, the RCGP stated: “There is concern that the deployment of [physician associates] in deprived areas, which often struggle to hire or retain GPs, could lead to inequalities in patient care and outcomes.” A RCGP survey found eight out of 10 respondents considered negative effects on patient safety to be one challenge of using physician associates in general practice.

Prof Kamila Hawthorne, chair of the RCGP, said physician associates should not be GP substitutes. She said: “We need to see more being done to boost numbers of GPs across the country, but especially in areas of higher deprivation.”

The Hospital Consultants and Specialists Association told the GMC lack of clarity over associates’ roles “will risk patient safety”. It said: “The current title of the roles, lack of clarity on scope and ambiguity on supervision make it very easy for [associate professions] to be mistaken for doctors and misunderstandings to arise around the level of skill and experience.”

Trisha Greenhalgh, professor of primary care health sciences at Oxford University, said physician associates lacked the training to be deployed on the frontline for patients with undiagnosed conditions. It was “the worst governance problem I have ever seen in healthcare in the UK”.

Physician associates, who can work in general practice and hospitals, have been working in the NHS since 2002 and anaesthesia associates since 2004. They cannot prescribe medicine, but can carry out physical examinations and perform diagnostic procedures. They are trained on a two-year postgraduate programme.

There are more than 3,300 physician or anaesthesia associates in the NHS in England. The NHS long-term workforce plan published last year set a goal of 10,000 physician and 2,000 anaesthesia associates by 2036-37.

Research from the UK and elsewhere has suggested that physician associates can deliver safe, cost-effective care, but the roles have created an acrimonious debate in the medical world.

Sarah Clarke resigned as president of the Royal College of Physicians this month after members said the leadership was failing to act on evidence that physician associates were “systematically replacing doctors” and had not properly responded to patient safety concerns.

The potential confusion over physician associate roles was recently highlighted by a poster on the website of Bradford District and Craven Health and Care Partnership, which pictured a physician associate and said “the physician will see you now”.

It is an offence under the Medical Act 1983 to use the title physician for a person who is not a registered medical doctor. The partnership said “genuine errors” were made for its promotional material and it was undertaking an internal review to understand how they happened.

Stephen Nash, a physician associate and chief executive of United Medical Associate Professionals (UMAPs), said: “These roles provide greater access to patients who would otherwise not be able to see a doctor. When we see patients with red flag symptoms, we can work with colleagues to stabilise the patient and refer to people they need to see. We absolutely do have the training to be the frontline.”

Nash denied physician associates were a risk to safety. In areas struggling to recruit GPs, they could provide improved access to care.

UMAPs said many physician and anaesthesia associates were experienced former nurses, radiographers and other health professionals. A mandatory register was a “welcome step”.

Lord Bethell, a former health minister, said: “Modern medicine depends on teamwork with a combination of people with different skills. There is clearly a role for physician associates to meet the booming demand for healthcare services.”

NHS England said: “The NHS has always been clear that physician associates are not a substitute for doctors. The NHS has also recently issued guidance on the appropriate deployment of these roles, which makes it clear that physician associates should provide support and perform tasks under the supervision of doctors to help them do their jobs.”

The Royal College of Physicians said it had adopted recommendations from a working group to call on NHS England to “limit the pace and scale” of the rollout of physician associates.

The college recognised significant patient safety concerns. It said it would work with other national bodies to contribute to an evidence database on the work of physician associates.