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Opinion Acute Perspective

David Oliver: Senior medical leaders have mishandled doctors’ concerns over physician and anaesthesia associates

BMJ 2024; 384 doi: (Published 15 March 2024) Cite this as: BMJ 2024;384:q665

Rapid Response:

Re: David Oliver: Senior medical leaders have mishandled doctors’ concerns over physician and anaesthesia associates

Dear Editor

Concern over Physician Associates – missing the wood for the trees

Mafi, Oliver and Salisbury identify a myriad of issues which surround an ever- expanding Physician Associates (PAs) workforce; and they urge all those involved in the management and delivery of clinical care to consider these carefully and without delay (Opinion, Acute Perspective and Primary Colour, 23 March). But the problem with this is the very considerable diversity as well as the number of ways the issues can be ordered and arranged. What then might be the core elements?

`Form follows function` has long been the mantra of architects. And it would be of considerable help if the NHS would adopt it when planning for the future role of PAs. Ever since its inception in 2003 (as a transformation of Physician`s Assistants), there has been no clear and consistent policy on the clinical needs PAs would respond to, or where they would be located within the complex organisation that is the NHS. It is essential to put these matters to bed before proceeding further.

Next, PAs are the new kids on the block; and their arrival in ever-increasing numbers is not without challenge for anyone with even a passing interest in clinical accountability and governance, and in professional status. One view is that PAs are merely joining the ranks of an increasingly large number of clinical practitioners, including Foundation doctors. But none of the others are `Associates` to physicians by title even though many would consider themselves to be so in practice, and most a have professional code of practice encompassing self-autonomy. Beyond `role` there is `position` - in the team, the hierarchy, in personal relations with others. This must be addressed for multi-disciplinary teams to function properly.

Last, there is `risk`. In the case of most new entrants with just two years training their bandwidth of clinical knowledge and experience will be limited. Others, such as transitioning experienced nurses or paramedics, are likely to have a well-developed clinical acumen across a broad bandwidth. The former might, for example, undertake some discrete activity on a neurology ward, while the latter could safely be the first contact for on-the-day GP appointments. For consultants managing a clinical service to have an inexperienced PA engaged in a highly defined task may constitute low risk. But the same person seeing patients with undifferentiated presenting complaints may cause a supervising GP great concern. Only proper matching of clinical skills and experience can result in risk minimisation.

Who will take the walk through this nettle patch?

Competing interests: No competing interests

02 April 2024
Morton M Warner
Emeritus Professor of Health Strategy and Policy
Welsh Institute for Health and Social Care
Vale of Glamorgan