Clearing up the PA mess

The wheels are quickly coming off the physician associate (PA) project. This is exemplified by the Royal College of General Practitioners, which has stepped up its anti-PA rhetoric: in June it called for an immediate freeze in recruiting PAs to general practice (BMJ 2024;385:q1376),1 and it now opposes the role altogether (doi:10.1136/bmj.q2078).2

The RCGP’s decision comes shortly after the findings of an independent inquiry into the behaviour of the Royal College of Physicians around PAs. The inquiry reported earlier this month that the RCP’s leadership had demonstrated “organisational bias” and been dysfunctional in its handling of members’ concerns over PAs (BMJ 2024;386:q1987).3

The fundamental shortcomings of the role are highlighted this week by former PAs who have decided to leave the role to train as doctors (doi:10.1136/bmj.q1989).4 “The reason I didn’t want to work as a PA is that I didn’t feel safe to do so,” says one. “I wanted to have the knowledge to be a safe clinician, but I don’t feel as though I necessarily got taught enough at university,” says another.

The push to introduce and expand the PA role is yet another example of a failed policy drive, where shortcomings need to be acknowledged and tackled rather than ignored and denied. Similarly, a missed opportunity to improve patient safety has been the lack of response to coroners’ official warnings made after a death, although there are signs that systemic problems are gaining recognition (doi:10.1136/bmj.q1943).5 And, as policies to attach financial incentives directly to the quality of care delivered have been largely ineffective in bringing service improvements, alternative models should now be explored in more detail (doi:10.1136/bmj-2023-077941).6

Partha Kar writes that plans to introduce and expand the PA role have become “a clinical, financial, and strategic mess.” He argues that the current shambles could be sorted out but that solutions may not come easily (doi:10.1136/bmj.q2060).7 “We could still have a more sensible discussion about how to help existing PAs integrate, with more training, and how to start new PAs with defined national scope,” he says. “It’s likely these conversations won’t happen, as the hubris of some leaders won’t allow it.”

Helen Salisbury argues that it would be worth taking the time to look at how we reached this position in the first place (doi:10.1136/bmj.q2083).8 “The PA project, while resoundingly rejected by practising doctors in the Royal College of Physicians and the RCGP, had its supporters within the leadership of both colleges, as well as NHS England and the GMC,” she writes. “When the dust settles, it will be interesting to work out where exactly the support came from and what the motivations were.”

Understanding those motivations—and how they have influenced the decisions about PAs made by the medical establishment—will be key to ensuring that the profession can learn from this experience and that medical leaders don’t make the same mistakes again.