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Medical associate professions: how physician associate and similar roles are developing, and what that means for doctors

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3897 (Published 18 September 2018) Cite this as: BMJ 2018;362:k3897
  1. Abi Rimmer, deputy editor, BMJ Careers, London, UK
  1. arimmer{at}bmj.com

Doctors’ concerns about these new members of the medical team are not borne out in practice, finds Abi Rimmer

Discussions about the role of medical associate professions (MAPs) at this year’s BMA annual representative meeting in June served to highlight a longstanding feeling of unease that some doctors have about these emerging roles.

Doctors at the meeting voted in favour of a motion warning that MAPs or “non-doctors” were being put in a position of “taking decisions they are not qualified to make.” The motion will therefore become part of BMA policy.

Speaking at the meeting, retired consultant surgeon Anna Athow said that MAPs were doing “doctors’ work” such as taking patient histories, examining patients, arranging tests, making diagnoses, and starting treatment plans. “MAPs do not have a doctor’s training; nor are they regulated. They are to be supervised by a doctor. MAPs have two years’ training. This is not safe,” Athow said.

Despite such concerns, MAPs are already starting to become an integral part of the medical team. Physician associates (PAs) have been working in the NHS for around 10 years, with at least 297 employed across primary and secondary care in England, according to NHS Digital. The Faculty of Physician Associates, which runs a voluntary register of the profession and oversees training and education, has been part of the Royal College of Physicians since 2015.12 In 2016, the Royal College of Anaesthetists, in collaboration with the Association of Physicians’ Assistants (Anaesthesia), agreed on a scope of practice for these professionals.3 And earlier this year the Royal College of Surgeons launched a new associate membership category for MAPs who work within the surgical care team, such as surgical care practitioners and PAs.

Ian Eardley, vice president of the Royal College of Surgeons and a consultant urologist, says the move reflects the college’s recognition that surgery is delivered by a team of people, not all of whom are surgeons. “The first aim was to be inclusive of those other people who are delivering surgical care,” Eardley says.

“We also thought that, because the development of these roles has been haphazard, there was value in bringing some consistency and reducing the variation in the scope of their practice and training, as well as in the degree of autonomy that they have.”

Eardley says the college is convinced that MAPs will improve surgical care and it would therefore be wrong to exclude them from membership. “This workforce brings different skills, which are complementary to those of doctors, and all the evidence that we have shows that they enhance the continuity and quality of care. We also have a lot of evidence that they enhance the training of young surgeons,” Eardley says. “Not only do we think that they should be encouraged; we think that they will be encouraged and will continue to be so.”

Benefits for junior doctors

Despite the college’s confidence in these developing roles, there is still some concern among the profession that they will replace doctors and reduce junior doctors’ training opportunities.456 However, this doesn’t seem to be borne out by the experience of doctors who work with MAPs. Abbas Khakoo is medical director at the Hillingdon Hospitals NHS Foundation Trust, which has employed four PAs for the past 18 months. They were trained in the United States and came to the UK as part of the National Physician Associate Expansion Programme, which launched in England in 2015 seeking to employ 200 PAs to work in the NHS.7

Khakoo says that doctors working at his trust do not see the PAs as a threat. “They see them as a group of people who they work alongside and really help them.” PAs work particularly well alongside junior doctors, Khakoo says, because they are permanent members of staff who are able to build up the kind of organisational knowledge that junior doctors don’t have the time to acquire. “If organisations nurture PAs properly they will develop skills and stay in that organisation. This benefits junior doctors, who move from one hospital to another, because it gives them someone to work alongside who has been there for a year or more and can say, ‘This is how we do things. Let’s work together to provide patient care,’” Khakoo says.

Khakoo says that his trust is keen to employ more UK trained PAs. He says that, when used the right way MAPs and, specifically, PAs can be used to fill skills gaps in the NHS workforce. “We know which specialties are short of staff. For example, there aren’t enough nurse endoscopists in the country. Although endoscopies can be carried out by doctors, why would you use your most skilled workforce when the procedures could be provided safely by someone else who has trained specifically in that area?” Khakoo says. “We need to look at some of these gaps and find the niche for the physician associates. It’s clear that the numbers of physician associates are expanding.”

Peter Kopelman co-chairs Health Education England’s (HEE) medical associate professions oversight board. The board was established in June 2016 to provide HEE with expertise on MAPs and contribute to its national work programme. Kopelman says that the expansion of MAPs in the NHS is essential because of the current and future shortfall in doctor numbers. “The number of doctors in training has increased by 33% since 1999-2001—with the advent of new medical schools at the turn of this century—and yet we remain short of doctors,” Kopelman says. “Even with the further addition of 1500 medical students [the rise in places due by 2019] we shall be short of doctors; it is important that doctors are appropriately supported, and these new roles should be welcomed.

“Integrating MAPs into teams across acute medical specialties can build capacity and enable doctors to design, lead, and deliver medical care, focusing on specialist caseloads. They add to the team, they complement the team, they don’t detract from the medical team. They are welcomed by patients because they do not rotate and thereby provide familiarity and continuity of care.”

MAPs can also help to increase productivity in the system, Kopelman says, and physicians’ assistants in anaesthetics (PA(A)s) are a good example of this. “Trusts that employ PA(A)s are now able to run more operating lists because two PA(A)s are generally supervised by one consultant, which means you can potentially double your operating list … If you double your list you double the opportunities for doctors in training to get more experience in surgical techniques,” he adds.

Developing roles and regulation

One of the responsibilities of the HEE oversight board, Kopelman says, is to look at how MAP roles can be developed for the future. “It’s all very well training MAPs for today, but what we need to do is develop and establish a career framework so that they can progress their careers in the future,” he says.

“It's also about how their developing roles can continue to support doctors and other members of health professional teams. For example, in general practice we have seen PAs evolve to become an integral part of the primary care team. I know of one PA who is a partner in a general practice. Some would say that that should be a doctor, but that does not address the serious shortage of GPs at the present time.”

At the moment, one obstacle to developing the roles of MAPs is the fact that they are unregulated. When the HEE oversight board was established, one of its key tasks was to put together evidence for the government’s consultation on regulation of MAPs in the UK, Kopelman says.

In its evidence the board suggested that all MAP roles should be regulated. “I consider that the evidence we submitted provides the evidence for all four roles [box 1] to be regulated, particularly as they develop and take on more responsibility for patient care, albeit with their line manager being doctors,” Kopelman says. The government’s response to the consultation is expected later this year.8

Box 1

Medical associate professions9

  • Physician associates—Qualification requires a two year generalist medical education covering a broad medical curriculum. PAs are trained for roles such as taking medical histories, examinations, analysing test results, and managing and diagnosing illnesses under the supervision of a doctor. They work in both hospitals and general practices

  • Advanced critical care practitioners—Clinical professionals who are able to diagnose and treat patients or refer to an appropriate specialist. They make high level clinical decisions as part of teams led by intensive care consultants and will often have their own caseload

  • Surgical care practitioners—Registered practitioners who have completed a Royal College of Surgeons accredited programme. They work as members of the surgical team, perform surgical interventions, and provide preoperative and postoperative care under the direct supervision of a consultant surgeon

  • Physicians’ assistants (anaesthesia)—They complete a postgraduate diploma recognised by the Royal College of Anaesthetists. PA(A)s work within the anaesthetic team under the direction and supervision of a consultant anaesthetist. Their roles include preoperative and postoperative assessment, administration and maintenance of general anaesthesia, and procedural sedation, and they are qualified in resuscitation.

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Another limitation faced by MAPs is that they cannot prescribe medications or request imaging. Kopelman says that even if MAPs do get statutory regulation, a further consultation would be needed before they are able to prescribe. “MAPs would need to go through further postgraduate training, just as all other professions, such as nurses and pharmacists, do,” he says. “The government will need to consult further on prescribing because it was not the primary purpose of the consultation on regulation.”

These issues aside, Kopelman says that future expansion of MAPs’ roles will be driven by employers: NHS trusts and general practices. “If these roles are shown to complement and support medical roles, as I believe they do, trusts will be keener to recruit more numbers because of the critical workforce problems they face,” he says. “There is good evidence that multidisciplinary teams equipped with a range of generalist and specialist skills, not individual professionals, will futureproof the NHS to provide responsive, high quality care to an increasing and ageing population.”

Personal perspectives: working with MAPs

“A major source of help; I haven’t got anything bad to say”—Chris Leighton, ST5 in intensive care medicine and anaesthetics, University Hospitals Plymouth NHS Trust

“I’ve had a really positive experience with all the advanced critical care practitioners (ACCPs) that I have worked with. As a trainee I have found them very supportive. They basically function at the same level as a fully functioning junior doctor and that’s been invaluable, particularly lately when sometimes there aren’t enough trainees to fill a rota.

ACCPs have slightly different educational needs from senior trainees, which means they can take on some of the day-to-day running of the department to allow the senior medical trainees to begin to take on more senior clinician roles and gain some management experience. They can take the pressure off some of the everyday tasks by being that extra pair of hands the team needs.

People have discussed with me the concern that ACCPs could remove training opportunities, but once they begin to actually work with ACCPs they have found that concern to be unfounded. Within the units that I have worked in there have been enough ACCPs to be helpful but never enough to detract from medical training roles. It’s part of the ethos that we are a team, so if someone has a greater training need than you do then people are pretty happy to step back.

What is sometimes lacking with ACCPs is the type of flexibility that junior doctors have—the ability to take on different roles, particularly when things are tight, for example, within other specialties. The ACCPs are more confined to a particular area than junior doctors.

Overall, I think they are a major source of help on the team. I haven’t had anything negative to say about any of the ACCPs that I have worked with; they have done a really good job to get their role seen in a good light. and I think it’s a really valuable part of critical care.”

“A physician associate revolutionised my thinking on medical team working”—Natalie King, consultant physician in acute medicine, Surrey and Sussex Healthcare NHS Trust

“I trained at St George's in London so I learnt about physician associates right from their infancy. When I was a senior registrar I met one particular PA student, Rachel, who was in her second year of training, and she totally revolutionised my thinking on how medical teams could work.

When I started as a consultant at the East Surrey Hospital I took on two PA students and everybody loved them. My consultant colleagues thought they were great. A couple of years later we were experiencing increased demand at the front door of the hospital. Most patients were arriving in the afternoon, at around 4 o’clock, just when many of our ward staff and junior doctors were leaving. So we had to make a decision on how we could match the demand, and we introduced a twilight shift for our junior doctors. Obviously taking a raft of junior doctors away from the wards between 4 pm and midnight meant changes to working patterns that could deplete the wards in the afternoon. So we put a business case together for additional trust level doctors and eight PAs, and we were lucky to get them.

We’ve now got 15 PAs at my trust. The key thing for me is that they offer continuity; in medicine they are there Monday to Friday. That was the first thing that struck me—when my medical trainee rotated or went onto zero days my PA didn’t. For a consultant doing a ward round, the PA may be the one person who would know the patient inside out. And the PAs picked up the really small things that made big differences to patients and their relatives. They are trained in the medical model across the breadth of medicine, including general practice, which makes them like doctors but different from the other medical associate professionals.

Another thing about PAs is that they are flexible. So, for example, if an organisation has eight PAs employed in the medical division but it suddenly has increased need in the emergency department, it could move the PAs to that department and they wouldn’t have to retrain them because PAs have those generalist skills. There are very few professions that offer that flexibility.”

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References