Little evidence that employing physician associates in NHS is safe – research

There is little evidence that employing physician associates (PAs) in the NHS is safe or that they improve patient care, a review from Oxford University has found.

Experts said studies relating the role of PAs and anaesthetic associates (AAs) were severely lacking, despite more than 3,500 people being employed in these roles in the health service.

Writing in the British Medical Journal (BMJ), they found no studies have examined safety incidents relating to PAs, while others have concluded PAs seem “to struggle” when working in GP surgeries.

Researchers warned that one of the main studies on PAs working in GP surgeries only included information for seven PAs.

They also warned that “conflating absence of evidence of safety incidents…with absence of safety concerns when physician associates directly substitute for doctors is an error of logic that is likely to cost lives”.

While some research has suggested PAs could support the work of hospital ward teams and A&E when appropriately deployed and supervised, “the number of individuals and settings studied was small, and those findings should be considered preliminary”, the team said.

Furthermore, the researchers found some NHS staff had concerns about the competence of PAs and AAs “to manage undifferentiated, clinically complex, or high dependency patients… or prescribe”.

The review continued: “No evidence was found that physician associates add value in primary care or that anaesthetic associates add value in anaesthetics; some evidence suggested that they do not.

“The UK literature on physician associates and anaesthetic associates is sparse and of variable quality, and some is outdated.

“In this context, the absence of evidence of safety incidents should not be misinterpreted as evidence that deployment of physician associates and anaesthetic associates is safe.”

PAs have hit the headlines in recent years over a spate of patient deaths linked to misdiagnosis.

Last week, a coroner said the PA who treated Pamela Marking before she died at East Surrey Hospital last year “had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination”.

Mrs Marking was seen by the PA and told she had a nose bleed before she was sent home, with her son believing she had been cared for by a doctor.

Witnesses from the East Surrey trust gave evidence to her inquest that a PA was “clinically equivalent to a Tier 2 resident doctor” but there was no evidence to back this up, the coroner said.

Another high-profile death involved Emily Chesterton, 30, in November 2022 from a pulmonary embolism. She was misdiagnosed by a PA on two occasions.

PAs are graduates – usually with a health or life sciences degree – who have undertaken two years of postgraduate training.

According to the NHS, they should work under the supervision of a doctor and can diagnose people, take medical histories, perform physical examinations, see patients with long-term conditions, analyse test results and develop management plans.

Most associates work in GP surgeries, acute medicine and emergency medicine and there are NHS plans to recruit more.

In November, the Government launched a review of the role of PAs and AAs led by Professor Gillian Leng, president of the Royal Society of Medicine.

Her report is expected to be published in spring.

For the latest work in the BMJ, 29 research papers on PAs and AAs were examined but were found to be scant on data.

The total number of physician associates studied was “very small”, especially in GP surgeries, researchers said, and no studies reported direct assessment of AAs.

Only one study, of four PAs, involved any assessment by a doctor of their clinical competence by direct observation, and “no studies examined safety incidents”.

The experts also found no evidence that deploying PAs or AAs improves efficiency or saves money.

In fact, as a senior doctor is needed to oversee and check the work of PAs and AAs, this model may be more expensive than employing doctors, they said.

Many patients were also unaware they were seeing a PA, raising concerns about transparency and informed consent.

Trisha Greenhalgh, lead author of the study and professor of primary care health sciences at the University of Oxford, has been asked to speak to Prof Leng for her review.

Prof Greenhalgh said: “The expansion of physician and anaesthetic associates should be informed by solid empirical research.

“At present, we simply do not have the data to support claims that these roles improve efficiency or maintain patient safety.

“The absence of reported safety incidents in research studies does not mean they do not occur – it means we are not doing the right kind of research to detect and analyse them.”

Professor Martin McKee, co-author of the study from the London School of Hygiene and Tropical Medicine, shared these concerns.

He said: “The mismatch between policymakers’ enthusiasm for expanding these roles and the lack of rigorous research evidence should be a red flag.

“Workforce shortages are a real challenge, but they cannot be addressed by replacing doctors with people whose training maps poorly to the duties expected of them, and who may be inadequately supported, without a clear, evidence-based strategy.”

In December, the Royal College of Physicians (RCP) published guidance saying PAs should “never function as a senior decision maker” and they should never be allowed to decide which patients can be admitted to hospital or sent home.

Resident doctors, formally known as junior doctors, should not supervise PAs, the RCP added, with this responsibility lying with senior doctors.

Meanwhile, PAs should not be able to prescribe medications, the RCP added.

The guidance said that PAs must support, not replace, doctors and have a “nationally defined ceiling of practice”.

The British Medical Association (BMA) has also raised concerns about the role of PAs.

Professor Phil Banfield, chairman of the BMA council, said NHS bodies and the Government had “collaborated in the headlong rush” to expand PAs and AAs without first amassing the evidence that their role was safe.

He added: “By maintaining a postcode lottery, bizarrely supported by the General Medical Council, in which different hospitals can decide what physician associates can and can’t do, the NHS has created a genuine public policy scandal.

“The lack of both evidence of safety and a national agreement on what these roles can do is a combination that in any other field would have set off a chorus of alarm bells – yet healthcare policymakers seem content to charge ahead, having ignored the genuine concerns of doctors as well as warnings from coroners.”

A Department of Health and Social Care spokesperson said: “The Secretary of State has launched an independent review into Physician and Anaesthesia Associate professions to establish the facts and make sure that we get the right people in the right places providing the right care.

“Regulation of PAs and AAs by the General Medical Council began in December to ensure patient safety and professional accountability.”