NHS physician associates (PAs) should be banned from diagnosing patients who have not already had contact with a doctor for their illness, a Government-ordered review has found.
The report suggests a major change to the role of PAs after acknowledging they have been used as substitutes for doctors, despite having significantly less training.
PAs were created to free up a doctor’s time by doing medical tasks that do not require full medical training. A handful of PAs specialised in anaesthesia.
They are postgraduates who have taken a two-year course to qualify. PAs are overseen by a dedicated medical supervisor, but they can work autonomously with appropriate support in GP surgeries and hospitals.
More than 3,500 PAs and 100 anaesthesia associates (AAs) are working in the NHS, and there have been previous calls for an expansion in their number.
However, a bitter row with medics over their responsibilities – plus high-profile deaths of patients who were misdiagnosed by PAs – led Health Secretary Wes Streeting to order a review.
Six patient deaths linked to contact with PAs have been recorded by coroners in England. One high-profile death involved Emily Chesterton, 30, who died from a pulmonary embolism. She was misdiagnosed by a PA on two occasions and told she had anxiety.
Presenting her findings, Professor Gillian Leng, president of the Royal Society of Medicine, said: “Crucially, I’m recommending that PAs should not see undifferentiated or untriaged patients.
“If [patients] are triaged, [PAs] should be able to see adult patients with minor ailments in line with relevant guidance from the Royal College of GPs.”
She said more detail was needed on which patients can be seen by PAs, and national clinical protocols should be developed in this area.
Professor Leng added: “Let’s be clear, (the role of PAs) is working well in some places, but there indeed has been some substitution and any substitution is clearly risky and confusing for patients.”
The report outlines 18 recommendations. Here, The i Paper takes a look at some of the most important.
Professor Leng recommended PAs should be renamed “physician assistants” to position them “as a supportive, complementary member of the medical team”, while AAs should be renamed “physician assistants in anaesthesia”.
The report said that while research suggests patients are satisfied after seeing a PA, concerns were raised in three key areas.
They were a lack of clarity about the role, including identification and confusion with a doctor; barriers to care, for example, if a prescription was required; and a lack of confidence in whether they were seeing an appropriate medical professional.
Anaesthesia associates should be renamed as “physician assistants in anaesthesia” or PAA.
Identifying the role
PAs should also have their own dress code to differentiate them from medics: standardised measures, including national clothing, lanyards, badges and staff information, should be employed to distinguish PAs from doctors in a bid to avoid confusion.
As part of her review, Prof Leng listened to the views of patients and the public.“Of particular importance was hearing from the families of those who died,” she said. “Relatives feel strongly that confusion between the PA role and that of the doctor was an important contributory factor in their relatives’ deaths.
“They were clear that, had they known a doctor had not been consulted, they would have responded differently and sought further help.”
Newly qualified PAs should also work in hospitals for two years before they are allowed to work in GP surgeries or mental health trusts.
The study said safety concerns in relation to PAs were “almost always about making a diagnosis and deciding the initial treatment, particularly in primary care or the emergency department, where patients first present with new symptoms.”
It added: “It is here that the risk of missing an unusual disease or condition is highest, and where the more extensive training of doctors across a breadth of specialities is important. Making the wrong initial diagnosis and putting patients on an inappropriate pathway can be catastrophic.”
Despite the shorter two years of training for PAs, where local NHS services have struggled with filling roles, “the easy option in some cases was simply to fill gaps in medical rotas with PAs”, the report went on.
“This seems to have been done without taking into account the more limited training of the PAs and how the roles would interact, other than with the caveat that they would be supervised by doctors.
“This lack of planning may have been responsible for driving the resentment felt by some resident (doctors) and potentially exposed patients to unnecessary risk.”
Named doctor should supervise every PA
Many doctors also told the review that they were concerned about the time required to supervise PAs and AAs and the lack of training for supervisors about the role of PAs.
A survey conducted for the report found “relatively few doctors felt it was appropriate for PAs to diagnose illness”, with only 29 per cent of those working with PAs in primary care backing this, and 14 per cent in secondary care.
The survey also found “marked differences in which tasks were considered appropriate in primary and secondary care, with PAs significantly more likely than doctors to believe that certain activities were appropriate for them to carry out”.
When it came to AAs, there were also questions over whether the role was actually needed, as fully qualified anaesthetists already face tough competition to find a job.
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Professor Leng concluded there were “no convincing reasons to abolish the roles of AA or PA” but there is also no case “for continuing with the roles unchanged”, adding: “The mistakes of the past must not be repeated.”
She recommended that both PAs and AAs should have the opportunity for ongoing training and development, with the potential to prescribe medicines in the future, and they should also have the opportunity to become an “advanced” PA or AA.
A named doctor should take overall responsibility for each PA, while clothing, lanyards, badges and staff information should be standardised to “distinguish physician assistants from doctors”.
Dr Hilary Williams, incoming RCP clinical vice president, welcomed the report and said: “Now is the time for clear timelines, funding and engagement with doctors and patients on the implementation of these important recommendations.”
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