Welsh Government backs use of ‘unqualified doctors’ despite safety concerns

Martin Shipton

The Welsh Government has defended the employment by NHS Wales of partially trained medics known as “physician associates”, despite concerns that they can pose a danger to patients.

PAs, as they are referred to, receive some medical training, but it falls far short of the level required for qualification as a doctor.

Critics argue they are a cost-cutting measure and fear safety standards are being compromised.

An assessment carried out by Health Education England (HEE) , and considered by all four of the UK’s health departments, concluded that patients were at high risk of harm from PAs. The health departments have therefore recommended the introduction of statutory regulation for the profession.

The relevant consultation document said: “HEE’s assessment of risk reflects the wide ranging scope of the PA role, including the provision of direct and interventional care to patients, the environments they work in, particularly primary care and the level of direct supervision they are subject to. For example, PAs are often alone with vulnerable patients and service users, and can make autonomous diagnostic and treatment decisions without the immediate direct supervision of a doctor. In addition, the types of intervention they undertake can also be invasive, such as performing diagnostic investigations.”

High risk

The document listed potential harms associated with PAs, and found them to be high risk in every domain.

Four patient deaths, none of them in Wales, have been linked to the involvement of PAs in their treatment.

* Susan Pollitt, a 77-year-old grandmother, died in July 2023 at Royal Oldham Hospital after an unnecessary procedure and neglect by a PA. A coroner raised concerns about PAs following her death.

* Actress Emily Chesterton, 30, of Salford, died in November 2022 after being misdiagnosed twice by a PA in London for a blood clot. Her parents believe she would still be alive if she had seen a doctor instead, and they are trying to raise awareness that patients should know who is treating them.

* Ben Peters, 25, died from a heart haemorrhage also in November 2022, less than 24 hours after being diagnosed with a panic attack by a PA at Manchester Royal Infirmary.

* Christopher Tucker, 81, a retired make-up artist, died from sepsis caused by a bladder infection in December 2022. A PA at the Royal Berkshire Hospital had performed a cystoscopy, an invasive bladder procedure, on him less than 48 hours before his death, despite signs of infection. The PA afterwards failed to document the need for antibiotics or to request them from the ward doctor.

Late last year a British Medical Association survey of more than 900 doctors working in the NHS in Wales revealed the scale of the profession’s concerns over the use of PAs and Anaesthesia Associates (AAs) in the Welsh health service – with 80% of those who responded saying they believe the way PAs and AAs currently work in the NHS is always, or sometimes, a risk to patient safety.

In addition, 83% reported that they felt patients were not aware of the difference between these roles and those of doctors, showing the immense scope for patient confusion about the level of care they are receiving.

Some 73% of those surveyed disapproved of the Welsh Government’s plans to expand PA and AA roles in the Welsh NHS workforce.

Confusion

Dr Iona Collins, Chair of the BMA’s Welsh Council said: “Patients should know who is treating them and what level of care is reasonable to expect from each of those roles.

“Currently, there are reports of confusion, whereby patients do not appreciate that the person treating them is not, in fact, a medically-qualified doctor.

“In addition, doctors in training report that they are forced to compete with AAs and PAs for educational opportunities – after so many years of gruelling study and significant student debt, these doctors report feeling both demoralised and betrayed. There is insufficient time for doctors to deliver NHS care and also train two separate professions.

“We are clear that expanding the GMC’s remit to regulate PAs and AAs is inappropriate, because regulating these professionals together adds to the current confusion regarding practise scope and levels of responsibility. The BMA maintains that these new roles, which depend on doctors’ supervision to deliver safe supporting care, should be regulated by the Health and Care Professions Council (HCPC) instead, for the sake of role clarity.

“We are calling on patient safety grounds, for a change to the professional titles of PAs and AAs to physician assistant and physician assistant (anaesthesia) or anaesthetic assistant to stop ongoing confusion for the public.

“We remain very concerned regarding the planned expansion of these roles in the Welsh NHS– while doubts about scope, impact on doctor training and confusion with the public are far from resolved.
“We are asking the Welsh Government and NHS in Wales to halt the further expansion of these roles in light of the serious concerns raised by doctors in Wales and the absence of any robust evidence as to their effectiveness.”

A BMA Cymru spokeswoman added: “It is an ongoing concern for our members. I don’t believe anything has changed since then to allay members’ concerns.”

Supervision

A Welsh Government spokesperson said: “PAs and AAs are there to support the work of doctors not replace them. While these roles can work autonomously, they must always work under the supervision of a named, fully trained and experienced doctor.

“Fifty-seven PA training places are being commissioned as part of the 2023/24 Training and Education Plan in 2023/24.”

The funding of Physician Associates is part of the broader annual Education and Training Plan, meaning that the numbers are commissioned annually, though there is no separate budget for this, as the costs are included within the total budget for the Education and Training Plan

The Welsh Government says Health Education and Improvement Wales (HEIW) works closely with its stakeholders and health board colleagues to ensure that PA roles are created where the appropriate supervision and training opportunities can be met, and where PAs can add value to the delivery of patient care as an integral part of the multi-disciplinary team

Earlier this year legislation introducing the regulation of PAs and AAs was passed by the UK and Scottish Parliaments, setting out a legal duty for the General Medical Council to regulate PAs and AAs from the end of 2024.