Royal College hailed for stance in Physician Associate row

It was issued with little fanfare – but it attracted plenty of interest among medics on social media.

On April 19, the Royal College of Physicians Edinburgh (RCPE) drew a clear line in the sand with an updated position statement declaring that "no further expansion of the [Physician Associate] workforce should occur in the UK".

This contradicts Scottish Government plans to "gradually" increase their numbers; a projected expansion from around 3,000 to 10,000 in NHS England by 2036; and – most notably – the position taken by its counterpart, the London-based Royal College of Physicians, which has faced a backlash from doctors over its seemingly pro-PA stance.

What are PAs?

Physician associates (PAs) are not doctors – although one of the criticisms has been that the job title could be misleading to patients (formerly they were known as Physician Assistants).

In most cases they are bioscience graduates or nurses who have gone on to complete a two-year master's degree, although some are arts graduates.

They can take medical histories, carry out physical examinations, order ultrasound or MRI scans, and develop treatment plans for patients.

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Inside the NHS | Physician associates: A workforce solution – or a risk to patients?

However, they cannot prescribe drugs or order scans ionising radiation (X-ray, CT) and should be supervised by a consultant or GP who will triage low-risk, "straightforward" patients to PAs.

However, critics argue that shortages of senior clinicians mean that some PAs are going beyond their remit and working without proper oversight, putting patients at risk.

There have been some highly publicised cases of misdiagnosis, and also anger from junior doctors who say they are already struggling to get the training time they need with consultants – something that will worsen if consultants have to spend more time supervising a growing number of PAs.

Change of heart?

Back in January, the RCPE was lukewarm rather than hostile to PA expansion. It cautioned that the "unique role of the doctor as the clinician... must be preserved and strengthened" and that PAs "must not be regarded as substitutes for doctors".

It recommended reverting to 'physician assistant' terminology "to avoid confusion for the public" and stressed that the "scope and limits" for PA clinical practice must be clearly demarcated in the interests of patient safety and standards of care.

Three months on, the College's line has hardened: recruitment of new PAs should be frozen until there is more clarity on how they are, and can be, deployed in the NHS.

For example, the College is "concerned that supervision of PAs, in contemporary, real life, day-to-day NHS practice, will not match the theoretical levels described in published protocols".

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It argues that supervising medical students and doctors-in-training should be the priority for senior medical staff, adding: "We are concerned that it is not possible, within the terms of current consultant job plans, to supervise additional PAs without compromising the training of doctors and medical students."

It is "increasingly illogical" to expand PA numbers at a time when a growing number of early career doctors in the UK NHS "cannot access training posts", and there is a "concerning lack of evidence to suggest that... PA expansion will reduce costs of care, without compromising outcomes".

Reaction

Doctors online have welcomed the statement as "clear and logical", "exemplary", "true leadership", and Scotland "leading the way" (though its membership is UK-wide and international).

It remains to be seen how the Scottish Government will respond.

The College itself also stresses that PAs are "very well integrated" in some NHS units, providing "excellent support" to doctors and contributing to "high quality patient care".

It condemns "insulting and often bullying behaviour" – some of which has been directed via social media to PAs, in a sign of quite how bitter and polarised the issue has become.

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In Scotland, their numbers remain comparatively tiny – 154 by headcount at the end of December, compared to 7,101 doctors-in-training – but the College notes that in some regions the NHS has employed PAs "because it has been difficult to attract doctors to training and [health] service posts".

That will be harder to remedy.