No ‘convincing evidence’ to abolish physician associates, Leng review determines

The independent review into the safety and efficiency of physician associates has determined the role does not need to be scrapped – however PAs should be renamed, more thoroughly trained and they should not see undifferentiated patients.

Amid key recommendations from the review, PAs should be renamed as physicians assistants; they should have at least two years’ training in secondary care before being allowed to practise in primary care; and they should not see undifferentiated patients outside of clearly determined national clinical protocols – in line with guidance set out by the RCGP.

A proposed ‘job description’ for newly-qualified PAs joining general practice suggests they should ‘play a central role in all aspects of preventative care, including undertaking NHS health checks and provide lifestyle support, and support the administration of basic therapeutic procedure’.

Quoting the RCGP guidance, which severely limits PA scope of practice, the report says they should only act as a ‘first point of contact’ for patients with ‘common conditions’ and only ‘within clear clinical pathways and escalation processes’.

Wider recommendations particularly relevant to GPs include clearer marking of who is a doctor and who is a physician assistant; the requirement of a named supervisor; and more support to doctors in the supervisory role, including management training and additional time for supervision.

The chair of the Government-commissioned review, former NICE chief executive Professor Gillian Leng, said the report’s recommendations ‘represent a pragmatic solution’ following an ‘impassioned’ debate which it was now time to ‘close’ and ‘move forward’.

Regarding the name change, the report said: ‘The role of physician associate should be renamed as “physician assistant”, positioning the role as a supportive, complementary member of the medical team.’

Professor Leng’s evidence review found that ‘even after PAs had introduced themselves, patients could remain confused about who they had seen, and the name of the role was seen as a contributing factor’. Renaming the role could help clear this confusion, the report said.

The aim of the review was to determine whether the roles of PA and anaesthesia associate (AA) were ‘safe and effective as members of a multidisciplinary team’, but it also looked what changes might be need to ‘improve confidence’ and ‘whether the rollout in England has supported safe and effective deployment’.

Since its launch in November last year, the team led by Professor Leng looked through formal research, national datasets and local audits; carried out an independent literature review; held an open call for evidence; reviewed data provided from NHS organisations and regulators; carried out a frontline staff survey, patient focus groups, and visits to hospitals and GP practices.

Notably, the report echoes the RCGP and BMA recommendations for PAs not to see undifferentiated patients. It said that ‘safety concerns raised 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 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 specialties is important. Making the wrong initial diagnosis and putting patients on an inappropriate pathway can be catastrophic. This was frequently flagged as the principal risk of PAs seeing undifferentiated patients.

‘PAs should therefore not see undifferentiated patients, unless triaged into adult patients with minor ailments and within clearly defined clinical protocols as agreed by the Royal College of Emergency Medicine and the Royal College of General Practitioners.’

On training, the report said that ‘newly-qualified physician assistants should gain at least two years’ experience in secondary care prior to taking a role in primary care or a mental health trust’.

‘In the same way that doctors do not immediately work in primary care after qualification, neither should newly qualified PAs,’ the document rationed. ‘Initial employment in secondary care provides an environment with much greater supervision, where any safety issues can be identified promptly and further training and development provided.’

It added that a two-year ‘grounding’ in the hospital environment would qualify PAs for ‘an initial role in primary care that focuses on aspects of work that reflect the strengths of the PA role’.

‘In particular, PAs are recognised as being excellent communicators and are skilled at providing advice on prevention in areas such as smoking cessation and diet. Wider public health messages are often missed in consultations with doctors because of time pressures, and the PA should have a lead role in following up at-risk individuals to ensure that they are supported and can act on preventative advice.’

The report also said PAs should wear ‘national’ clothing, badges and lanyards’. ‘Although clothing and badges are not the answer in themselves, the system needs to make greater efforts at communicating the function and identity of this assistant role.’

On regulation, the report also instructs the GMC to separate Good Medical Practice guidance for doctors and physician assistants, amid concerns the body’s regulation of PAs has further confused patients about their role and training.

The report said: ‘Lack of distinction between the role of the associate and the doctor has been central to the debates about the positioning and function of the PA and AA roles, and regulation must not blur the line further. Regulation of PAs and PAAs must therefore reflect their roles in the system and underpin their different and distinct roles.’

Professor Leng also made a number of recommendations on AAs, including that they should be renamed as ‘physician assistants in anaesthesia’ (PAA) and ‘should continue working within the boundaries set in the interim scope practice published by the Royal College of Anaesthetists’. The report also questioned whether there was a need to train any further members of the PAA profession at this time.

In a foreword to the report, Professor Leng said: ‘Despite the significantly shorter training, PAs and to a lesser extent AAs, have sometimes been used to fill roles designed for doctors. 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.

‘It seems to assume that much of the doctor’s role does not need the skills and qualifications of a doctor, which, if that is the case, requires a thorough reconfiguration of roles and restructuring, not a simplistic replacement of a doctor with an individual who is significantly less qualified.’

Regarding her recommendations, she concluded: ‘Inevitably, this data provided only a patchy overview and significant gaps in our knowledge remain but, with the urgency of current workforce challenges, now is not the time to defer to the wisdom of future research. Instead, I have viewed the evidence in the context of wider considerations, including the perspectives of patients, clinicians and health systems internationally.

‘The recommendations therefore represent a pragmatic solution that aims to bring cohesion and clarity. They won’t be universally popular, but we must now close the debate and move forward constructively, focusing on excellent teamwork and delivering world-leading patient care.’

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