The notorious Labour Party conference bureaucracy may have successfully shunted a Socialist Health Association motion on Physician Associates off the prioritised agenda last month, but the controversy shows no sign of dying down since the change of government in July.
Indeed, so great has been the professional concern at the proposed expansion in numbers of Medical Associate Professionals (Physician Associates, Anaesthesia Associates and Surgical Care Practitioners) from around 3,000 to 10,000 as part of the NHS workforce plan that even the Academy of Medical Royal Colleges – conservative by reputation, has now written to Health Secretary Wes Streeting and NHS England chief Amanda Pritchard urging a “rapid review of the role of MAPs in a range of healthcare settings.”
The AMRC does not suggest who should conduct the review but insists that it should be “carried out by an individual or organisation with impeccable credentials for impartiality and neutrality and that it is carried out at pace with great thoroughness and academic rigour.”
The Academy is only rarely stirred into any challenge to the status quo, but it is responding belatedly to a growing storm of professional frustration at the way leading bodies connived at what they fear is a growing extension of the role of these much less qualified “professionals,” potentially putting patient safety at risk.
As The Lowdown explained back in June, doctors who have had to undertake upwards of seven years of intensive training, pay for and pass a series of challenging exams, and take out student loans of up to £100,000 to qualify to practice are increasingly angered at the way the bodies that are supposed to safeguard their status as doctors have effectively been derailed and drawn instead into justifying and expanding the roles of MAPs.
The General Medical Council, for example, set up in 1858 to regulate the UK medical profession and keep a record of qualified doctors, agreed in 2019 to a government request to take on the responsibility for regulating this very different and much less qualified group of “professionals”.
The legal responsibility to regulate PAs and AAs begins in December 2024 – but so far, the GMC has stubbornly refused to release the findings of the public consultation it launched in March this year on the rules, standards and guidance it will uphold and even now, two months before it takes on the legal role of regulator, it has refused to issue any proposed ‘scope of practice’ statement spelling out the distinction between what PAs and doctors can do.
In the absence of any other professional body willing to do it, that task has been taken on by the BMA – only to be bitterly attacked by PA organisations for doing so.
UMAPS Ltd, for example, the company founded in November 2023 that “aims to host the first MAP-specific trade unions” argued:
“UMAPs deems that it is inappropriate for a union that does not represent MAPs to unilaterally redefine and attempt to impose a scope of practice on another profession, and as such, the BMA are acting outside of their remit. This document was produced without stakeholder engagement or peer review. This is unprofessional and represents a wider problem within the BMA, and we urge them to reflect on this.
“[…] These professionals have been embedded in teams across the NHS for over 20 years with starting scopes of practice developed by their associated colleges, societies, and professional associations.”
UMAPS Ltd adds a curious phrase: “Largely, these professionals have undertaken Master’ s-level education in addition to their health science Bachelor’s degrees or preexisting healthcare profession.”
“Largely” suggests that some haven’t even received a Master’s degree, raising questions about what qualifications some MAPs may have.
The BMA’s frustration is understandable. They represent doctors and respond to what they fear is an undermining of their professional standards (and encroachment on the training available to resident doctors) by staff who have much less relevant training.
To make matters worse, newly qualified PAs in hospitals begin on higher pay than many junior doctors who have more years of appropriate training but who have the added responsibility of supervising the PAs’ work.
There have been well-documented accounts on social media of PAs being included in doctors’ rotas, allowed to run clinics, performing complex and demanding medical procedures, and, in some cases, requesting X-rays and prescribing, which are both strictly out of any agreed-upon scope of practice.
BMA polling suggests that almost nine in 10 doctors believe that the way physician associates are currently used in the NHS puts patients at risk. When things go wrong, it will be the doctors nominally ‘supervising’ the MAP, not the MAPs, who are held responsible.
All doctors are required to pay annual fees to the GMC to remain on the register, but even senior doctors appear to have no influence on its decisions.
Wes Streeting is now under pressure to say whether or not the government will help fund (and thus take sides with) the GMC to resist a legal challenge to the extension of its remit to include non-doctors – and the potential blurring of the distinction between doctors – waged jointly by the BMA and the ad hoc group ‘Anaesthetists United’.
UMAPs Ltd was much less overtly hostile to the potentially more far-reaching recent decision of the Royal College of General Practitioners (RCGP) to oppose the involvement of PAs in general practice. The RCGP then also recognised that around 2000 PAs already work in general practice and approved three new sets of guidance to support GP practices already employing PAs.
This was the second position shift by the RCGP, which resulted from pressure from members concerned at the failure to resist inappropriate use of PAs, concerns over the additional workload on GPs if they are to be properly supervised, and warnings of the potential risk to patient safety.
Another venerable body under fire for its complicity in the expansion of MAP roles is the Royal College of Physicians (RCP). The RCP faced a revolt that eventually forced an Emergency General Meeting, at which an overwhelming majority of Fellows rejected the College’s previous approach to PAs.
So seismic was the upheaval in the RCP that the King’s Fund was commissioned to carry out an “independent learning review”, published in September. It made ten key recommendations, which have been accepted in full, and revealed a “collective failure in leadership” in the College’s approach to MAPs.
It noted that if the EGM been held earlier, before the Parliamentary debate on the Anaesthesia Associates and Physicians Associates Order, “the concerns raised would have been fed into the parliamentary process and may have affected the passage of the legislation” establishing the GMC as the regulator of MAPs.
Acting RCP President Dr Mumtaz Patel said: “The report highlights an organisation that was neither listening, not responding quickly enough to the questions and concerns being raised by its fellows and members.”
The RCP launched the Faculty of Physician Associates in 2015, enhancing PAs’ “professional” status. The FPA will now close in December, leaving PAs the option of affiliate membership of the RCP, “in line with other non-doctor professional groups.”
At long last, the RCP promises to focus on its own core members: “A refreshed membership strategy will put physicians at the heart of college business, re-establishing the RCP as the voice of medicine and the voice of our membership.”
There are now 41 MAP courses in Britain, and there will soon be 3,500 PAs working in the NHS. St George’s University staff boast of how far some have been able to go: “We’ve seen some move into primary care, others running their own clinics or assisting in theatres. We’re now seeing senior PAs taking on managerial roles or become partners in practice.”
The problem thousands of doctors can see is that MAPs can qualify after just two years of a postgraduate Masters course, in which they are not even required to complete the full Masters qualification but can immediately step in to posts at Agenda for Change Band 7 and move up to 8 – with just a postgraduate diploma.
There are also serious concerns about the lack of any obvious rigour in the assessments since pass rates for these courses are commonly 100% (Hertford and Brunel Universities, for example, have recorded no failures in the past 3 years). On some courses, upwards of 90 per cent of students pass with merit or distinction. There are similarly extraordinarily high pass rates for the national PA exam, which all those seeking work in the NHS are required to pass.
Excessively high pass rates suggest worryingly low standards (and undermine confidence in the standards of all students passing their PA courses).
Perhaps even worse is the growing evidence that some of the Universities that are handing out these questionable qualifications are also leading students to believe they are studying “the same as medical students,” but condensed into two years, with no proper explanation of what depth of knowledge and experience they are missing as a result. Similar points have even been made on X by the GMC.
Some university staff encourage PA students to think they really will be “one of the medics”—especially at St George’s University Hospital, where the graduation ceremonies for PAs and doctors have been merged. The title “Doctor” has been eliminated for the medical graduates to ‘save time’.
Some employers also seem willing to reinforce these illusions by employing MAPs to run clinics, perform surgery, and perform other tasks that better qualified resident doctors would not be allowed to do alone.
In general practice, NHS England’s Additional Roles Reimbursement Scheme (ARRS) has been used to fully fund the appointment of PAs for several years, but it has only been partially opened up and expanded since the election to allow some of it to be used to employ qualified GPs.
The NHSE funding for Additional Roles staff comes with strings, requiring the PAs to deal with an undifferentiated caseload – which should properly be handled by a fully qualified GP, deciding which cases can safely be triaged to the care of a supervised PA.
The desperately inadequate funding of GP practices means that more and more are struggling financially and driven to employ PAs as a cheaper alternative. Meanwhile, 84 per cent of GPs seeking locum posts can’t find work and the public cries out for more GP appointments.
However, while doctors at all levels continue to sound the alarm over the inappropriate use of MAPs, there are also concerns that the skills and dedication of thousands of people who have sacrificed to gain their postgraduate qualification could be ignored. Some are stressing the useful work PAs do, some of whom have worked in the NHS for over 20 years.
Helen Fernandes, consultant neurosurgeon and chair of the Doctors Association, told MailOnline the concern was when the public “think they’re being seen by a doctor when they’re not,” but also expressed sympathy with PAs who work correctly within their proper level of training:
“I feel that they [PAs] have been mis-sold a degree, which is not really a master’s qualification. They’ve been mis-sold a career.
“It is a crying shame for both the NHS, patients and for the PAs themselves that the initial design of their role has morphed into something that’s become this unimaginable monster of inappropriate use of people who are well motivated and want to help in the care of patients but that are not qualified or trained to do so and never will be.”
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