The risk of using ‘physician associates’ to take the strain for doctors
The pivotal evidence at the inquest into the death of Emily Chesterton came from the 30-year-old herself. Chesterton — described by her parents, Brendan and Marion, as a generous and empathetic young woman, who was building a successful career in musical theatre — had developed a sore leg in October 2022. Soon after, she began to have breathing difficulties.
These were textbook symptoms of a pulmonary embolism. But after attending her local doctor’s surgery in north London, she was diagnosed with a sprain, anxiety and long Covid. Less than a month after falling ill, she collapsed, then died on the way to hospital.
Emily’s WhatsApp messages to her family and partner showed that she believed she was being treated by a family doctor. In fact, her care had been in the hands of a “physician associate” (PA) who should have been working under the supervision of a fully qualified medic. Had Emily been referred to an emergency department, the coroner found, she would probably have lived.
“We’re working-class people,” says Marion who, like her husband, is a retired teacher. “We brought our children up to be respectful of police, doctors, nurses, teachers . . . and to be grateful: ‘Sir, Madam, thank you very much.’ Looking back now, I think, ‘Was I right in doing that?’ Perhaps I should have made her a little bit more bolshie.”
Now, as they strive to find meaning in their loss, the Chestertons are campaigning to alert people to the need for tighter oversight of PAs — a role first introduced into the taxpayer-funded NHS around two decades ago but whose numbers have grown sharply in recent years.
In September 2023, 3,300 physician associates were employed across primary and secondary care in England; in 2015, the number was just 122. In nursing in England, meanwhile, FT analysis has found that the number of support roles is up by 38 per cent since 2010, a more rapid increase than that of qualified nurses. The trend has also occurred across mental health, community, adult and children’s services.
“Task-shifting” — assigning some work to lower qualified people in order to preserve higher-skilled staff for jobs only they can do — has become an increasingly prominent feature of health systems in many parts of the world, as they battle to deal with structural rises in the demand for care caused by growing and ageing populations, exacerbated by the shock of Covid-19.
FT analysis of WHO data also found a surge in the number of healthcare assistants — an ancillary role that in a hospital involves helping patients wash or monitoring their vital signs, or assisting with equipment and health checks in a surgery — in Ireland and Germany between 2009 and 2021. Countries such as Norway and Denmark already have a larger per capita number of healthcare assistants than the UK, according to the latest data.
Yet there are serious questions about the long-term impacts, which are still relatively poorly understood. Alison Leary, a healthcare professor at London South Bank University who has made a particular study of nursing associates, says that, while adjunct roles can be valuable, “the issue is when those roles are substituted for the registered professional”, noting a wider “deprofessionalisation” of the public sector which she argues has occurred in multiple fields over the past 15 years.
In England, an added pressure is a decade-long funding squeeze which has led to under-investment in the healthcare workforce and left the country far shorter of doctors and nurses than comparable nations. Official data published last week showed around 1 in 13 posts for registered nurses, midwives and health visitors is currently unfilled.
Wes Streeting, health and social care secretary in Keir Starmer’s Labour government, made clear in remarks before July’s general election that he believes that PAs have a role in the NHS. However, he acknowledged that, owing to staffing constraints, they are “sometimes being asked to work beyond their scope of practice”.
“Loading your front line with a huge amount of inexperienced, less qualified people has real safety implications,” Leary argues. “That’s why safety-critical industries don’t do it. It’s why we don’t have associate pilots.”
Qualifying as a PA is a considerably shorter — and less expensive — process than becoming a doctor. Whereas medical training typically lasts at least seven years, PAs are required to complete a two-year masters degree or diploma, before undertaking a third internship year with a doctor to “solidify and deepen their skills”.
The Faculty of Physician Associates, a UK membership body, describes the course as “intensive theoretical learning in medical sciences, pharmacology and clinical reasoning as well as over 1,400 hours of clinical placement experience in community and acute care settings”. A first degree in bioscience is generally required, but not always — a fact that shocked the Chestertons when they discovered it.
Starting salaries for PAs in England are around £44,000 a year, about £11,000 more than early-career junior doctors — adding to a sense of resentment at the erosion of medical pay over the past 15 years, which has led to protracted industrial action.
Thea Stein, chief executive of the Nuffield Trust, a UK health think-tank, said the idea behind the introduction of associate roles was that it would allow doctors and nurses to work “at the top of their licence” by relieving them of more routine tasks. But so far evidence to back up the notion is lacking. “We don’t know what impact it’s had in terms of both productivity and satisfaction with care . . . There needs to be more research,” she says.
For many critics, the biggest concern is the lack of clarity about the PA role — starting with the name, which, Marion and Brendan Chesterton argue, suggests someone who actually has superior skills to a regular doctor. They would prefer “physician assistant”, the term often employed in the US.
While PAs and nursing associates must work within a set “scope of practice” — PAs are not permitted to prescribe medication, for example — the precise contours of the role are determined individually by the hospitals and practices that employ them.
Strikingly, PAs and anaesthesia associates (who work with surgical teams to provide anaesthesia and other services under supervision), are currently unregulated — although from December both will come under the jurisdiction of the General Medical Council, the UK doctors’ regulator. Both will also be required to register with the GMC, replacing systems that are currently voluntary.
Even regulation will only do so much. The GMC told the FT that, “like many other professional healthcare regulators, we don’t set a defined post-qualification scope of practice that determines what tasks registrants can safely carry out, as this depends on their individual skills and competence which develop over time”.
But that means doctors cannot rely on a base level of expertise. Jennifer Barclay, a resident doctor in north-west England, recalls being asked by one PA to sign a prescription for fluids for a patient with pneumonia. After insisting on seeing the patient herself, she quickly diagnosed “pulmonary oedema”, or fluid overload on the lungs — a common complaint in elderly patients — rather than an infection. “So the last thing they needed was more fluid. More fluid could have literally killed this patient,” she says.
Although she has since had more positive experiences with PAs, Barclay remains wary. The gulf in knowledge became clear to her when she lectured at the University of Manchester medical school, teaching PAs in addition to trainee doctors and other clinicians. “The depth of knowledge they have from an anatomy perspective, compared to a medical student — honestly, it’s a drop in the ocean,” she says.
Nursing associates are regulated in England by the Nursing and Midwifery Council (NMC). But even so Su Hickman, who worked as one in south-east England for three years before going into clinical research and education, says that “nobody really understood what the role was. So we were either used as glorified healthcare assistants, or we were given a really big caseload of complex patients that we weren’t trained or qualified to take care of.”
Sam Donohue, an assistant director at the NMC, says: “Our code makes clear that all professionals registered with us must recognise and work within the limits of their competence, and have a duty to raise concerns if they think something isn’t safe.”
For all the concerns about healthcare workers acting out of scope, there is evidence to suggest that, when used appropriately, PAs can provide much-needed ballast.
Vari Drennan, professor of healthcare policy and research at Kingston University, who completed five research studies into the deployment of physician associates in both general practice and hospital settings between 2010 and 2019, argues that, provided they are properly supervised, they are “safe and complementary” to more qualified practitioners.
Even so, a number of organisations representing doctors, including the British Medical Association, have expressed serious reservations — not simply on safety grounds, but because of concerns that associate roles may take precedence for training opportunities.
The Royal College of Physicians says: “The NHS workforce is under immense pressure. PAs may have a limited role in supporting doctors, but retaining our fully qualified doctors and reducing the rotation of trainee doctors is paramount to provide safe and effective care.”
Drennan also discovered that many patients, even if they were satisfied with their care, “didn’t really understand who and what physician associates were”. Even when a PA had introduced themselves as such, the patient would often say “thank you, doctor,” as they left the room, she notes.
Approached by the FT for comment, the NHS says it is “working with patient groups on producing further materials for patients and the public to explain the roles”.
The changes in England’s NHS are unusually fast, but they are far from unique. Healthcare systems in many countries now rely on less highly trained healthcare staff. “With the ageing of the population [and] the increase in chronic diseases, demand is growing at a faster pace than the health professions are able to fill,” says Tomas Zapata, a World Health Organization expert on the global health workforce. According to WHO estimates, the world will be short of around 10mn healthcare workers by 2030.
The trend was exacerbated by the coronavirus pandemic when many practitioners left healthcare because they were themselves sick or burnt out. But Jeremy Lim, associate professor at Saw Swee Hock School of Public Health, part of the National University of Singapore, says an increased focus on roles such as advanced practice nurses and pharmacists had been evident in the city state even before Covid-19.
This was “partly to ameliorate the shortage of doctors and the higher cost of the doctor relative to other healthcare professionals”, he explains.
Discussions about boundaries between professional roles are under way in many countries, including the US. “The debates over scope of practice are fierce . . . and in part, it’s prompted by shortages,” says Michael Sparer, professor in the department of health policy and management at Columbia University in New York.
He highlights a dearth of primary-care physicians in particular: “Should you substitute . . . nurse practitioners or physician’s assistants or others to provide some basic primary care work?”
One consequence of putting a greater emphasis on less highly trained personnel may be to exacerbate socio-economic inequalities. FT research shows that areas such as Birmingham and Solihull in the English Midlands — some of the most deprived parts of the country — had more PAs per capita than almost all other areas. Rates are over 1.7 times the national average.
Similarly in the US, Sparer says there is “maldistribution”, with fewer qualified physicians working in poorer inner city or rural districts. “In the areas that have the greatest shortages and the greatest need, you’ll find mid-level providers trying to fill in some of those gaps,” he adds.
Again, some commentators argue that these changes aren’t undesirable per se. In the US’s corporatised health system, the presence of physician assistants and other associate roles may allow less expensive care, Sparer points out.
Joseph Betancourt, head of the Commonwealth Fund in New York, a foundation dedicated to affordable healthcare that funded some of the earliest research into this area, says that there has also been a clear shift in attitudes. Doctors, once worried about being displaced, are now grateful to be relieved of some relatively routine tasks.
And patients are no longer as averse to speaking to someone less qualified — particularly if it’s difficult to get access to a medic. “Whereas 10 or 15 years ago, patients might say, ‘I don’t know if I want to be seen by a nurse practitioner’,” he says, “[they] are becoming increasingly comfortable and actually sometimes feel like nurse practitioners spend more time with them than their doctor.”
The relentless demands from expanding and ageing populations mean that the trend for task-shifting within healthcare is set to continue. A long-term workforce plan for the NHS in England, published last year, charted a clear upward trajectory in associate roles, setting a goal of 10,000 PAs by 2036-37.
The plan also envisaged a rise in anaesthesia associates. Around 160-180 AAs currently practise in the country, compared with about 14,000 fully trained anaesthetists. The plan envisages a rise to 2,000 by 2036-37.
Many people agree that both regulation and better communication with patients are an urgent priority. As an exemplar of good practice, the WHO’s Zapata mentions France, where a “medical assistant” role was introduced in 2019.
“It’s very well defined what they can do,” he says: administrative jobs, including medical record-keeping, appointment co-ordination, maintaining equipment “and other basic tasks like taking temperature and blood pressure”.
Zapata argues it is crucial that jobs now embedded in many European healthcare systems are clearly delineated, so that both the public and staff themselves understand what to expect. “I think what we have to be careful of is when the role, and the scope of practice, of new professions are not well-defined. Here comes the risk, because then the boundary is not clear.”
The Chesterton family, meanwhile, are relieved that PAs will finally be regulated, but disappointed that so much latitude will still be in the hands of employers. “We need absolute limits on what a PA can and cannot do,” Marion says.
In a statement, Charlie Massey, GMC chief executive, lamented Emily’s “terribly sad and avoidable death” and promised to reflect on her parents’ views as it prepares to start regulating PAs.
The Chestertons are determined that their daughter — and her sparkling, all-too-short life — remain central in those deliberations. After a meeting with Massey earlier in the year, says Marion, “I sent him a follow-up letter with a photograph of Emily and said, ‘Please remember Emily’”.