Recent years have seen an explosion of a new kind of medical role across the NHS: physician’s associates (PAs). Yet while their numbers are increasing in hospitals and GP practices – and all major political parties have committed to expanding the role further – today’s review into the job role have revealed some rather disturbing findings.
The report by the president of the Royal Society of Medicine, Professor Gillian Leng, found that despite approximately 4,000 physician and anaesthesia associates working across England and Wales, there remains limited data on whether the staff were safe or unsafe. Given the concerns of both the public and doctors – and the fact that there have been at least six high-profile deaths of patients misdiagnosed by PAs in recent years – it seems fairly obvious that the way the PA role has been interpreted thus far has led to a number of unnecessarily precarious situations.
The review finally states officially what doctors have been saying for some time: that these non-clinicians have ‘sometimes been used to fill roles designed for doctors’. Leng adds that ‘the rationale for doing this is unclear, and was probably one of pragmatism and practicality, relying on medical staff to provide the additional expertise when required’. This translates to: PAs were used to fill in for doctors when there was a shortage of clinicians around. Leng recommends that PAs should be banned from diagnosing patients who have not already been seen by a doctor.
That this was being allowed to happen is one of the more shocking parts of the report. People with no underlying medical training bar a two-year postgraduate degree were in the practice of dishing out diagnoses to patients – some of whom would never get seen by a doctor.
It’s an acknowledgement that, sadly, comes too little too late for some families who have lost loved ones at the hands of physician associates. In 2023, 30-year-old Emily Chesterton died of a blood clot after being misdiagnosed by a PA whom she assumed was a GP. Chesterton exhibited ‘red flag’ symptoms of shortness of breath and calf pain, but the physician associate examining her didn’t spot the seriousness of her presentation. More alarmingly, the PA did not make it clear that they were not, in fact, a medical practitioner. In February this year, a coroner issued a warning about PAs after a woman with severe abdominal problems was wrongly diagnosed as having a nosebleed. She died four days later. In another case, Ben Peters, 25, died after suffering an acute aortic dissection – a tear in the biggest artery in the body – the day after he saw a PA in November 2022. While the hospital trust concluded that the physician associate had ordered all the correct tests, Peters’ case illustrated yet another example of a patient being discharged without seeing a doctor.
It is in this vein that another of the main themes of the review was the confusion caused by the term ‘physician associates’. Families whose relatives had suffered at the hands of PA misdiagnosis were distraught to find out that the person they thought was a doctor was in fact a significantly less qualified individual. Lady Finlay, a palliative care doctor and fellow of the Royal College of GPs had previously suggested that the role should be renamed ‘physician assistants’ – and Leng agrees. Anaesthesia associates should, she added, be renamed ‘physician assistants in anaesthesia’, to avoid future confusion about exactly how qualified the person you’re being treated by is.
The Leng review will vindicate doctors who have raised the alarm on PAs before, but there remain serious concerns about the lack of regulation that exists for this group of quasi-medics.
Leng’s report hasn’t gone as far to say that the roles of PAs should be abolished, and certainly there is a need for a group of people able and willing to do administrative and basic clinical tasks in place of doctors. When I delved into the issue for The Spectator earlier this year, I made the point that there is no future for a health service that sees physician associates acting like doctors: the insidious creep towards PA-led care must be tackled and the scope of PA practice must be clearly defined and regulated. The question now is whether Leng’s recommendations go far enough.
A lot of what has been recommended today will vindicate those who have been raising the alarm about unsupervised PAs for years. The report urges PAs to, like resident doctors, complete a mandatory two years working in hospitals before being allowed to move into primary care units, like general practice surgeries or mental health trusts. Doctors should be provided with more leadership training if they are to be given the responsibility of overseeing the work of PAs, while physician associates should wear clearly distinctive uniforms to avoid confusion with medical professionals.
But there remain serious concerns about the lack of regulation that exists for this group of quasi-medics. As the BMA’s Professor Philip Banfield told me earlier this year: ‘There’s no national scope of practice that puts the ceiling on what they can and can’t do. There’s nothing stopping an employer training a physician associate to do a caesarean section, for example, and then two years later calling them a “consultant” – without any understanding of the underlying anatomy, physiology, pathology and things that can go wrong.’ The Leng review has called for standardised job descriptions – but the work to definitively lay out what PAs across the country can and cannot do must be accelerated. While this report makes the right noises, if the fears of patients and doctors alike are to be allayed there remains much more to be done.
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