Physician associates: a pause in rollout is needed

A seminal moment beckons in the history of the Royal College of Physicians (RCP). Tomorrow the RCP is due to hold an extraordinary general meeting (EGM)—notably only the third EGM in its 505 year history. The centre of debate? Physician associates or medical associate professions (MAPs): their role, their relevance, their scope, regulation, and everything else.12 It is a debate which perhaps should have happened many years ago, yet here we are on the eve of such an event.

Before going into the motions at hand, there is a huge lesson for many to learn from how this debate has escalated and how we got to this point. In my experience, any previous attempts to raise concerns about the role, scope, and regulation of PAs have been brushed aside as the gripes of a small cohort of disgruntled groups, or just as a bit of social media noise. But this attitude has now come back to hurt us all. Many of our PA colleagues were given false assurances that these issues would be resolved, but instead this has now snowballed and a lot of them are caught in unenviable positions, wondering how much they can rely on what they were told or indeed what career path they have been sold. The medical leadership involved has lost the room and can’t dictate the course. It feels like everything is lurching from one extreme to another.

There are five motions up for debate at tomorrow’s EGM: PA’s scope of practice, accountability, evaluation, training opportunities, and the pace and scale of rollout.2 Ironically, four of these motions have already been supported by both the RCP and the Faculty of Physician Associates (hosted by the RCP).3 There is a broader debate as to how the RCP came to this position. I think a more sensible position would have been to remain neutral and be seen to follow whatever the RCP’s membership decides. That would be taking a leaf out of the BMA Consultant committee’s book, who held a neutral position on contract negotiations and are likely to benefit from that in the long run.

The biggest question that arises from the motions being debated is if everyone agrees that PAs are not doctors and cannot prescribe medications or request ionising radiation, then what are the next steps after the EGM? Do the RCP and FPARCP work actively to challenge NHS trusts about their rotas, hold people to account, and work to enforce their own EGM motions? Will there just be another document reinforcing the RCP’s position? Or will it fall to NHS Employers to take up the task of enforcing what everyone, including NHS England and the General Medical Council, are saying, which is that PAs are not a substitute for doctors? The uncertainty around these areas needs clarifying, and quickly, if people are interested in settling the current fracas.

The other motions are interesting too, yet I suspect some of the answers are self-evident. Is this harming training opportunities, for example? Well, if you haven’t heard that particular cry of angst from doctors concerned that, yes, it is harming their training opportunities, then who are you listening to? It appears that both the RCP and FPARCP agree too, based on their consensus statement.3

When it comes to debating PAs’ scope of practice, this raises a wry chuckle as the BMA has tactically outmanoeuvred the colleges on this one, by bringing out their own guidance on this last week.4 This has now placed the colleges in an unenviable position of either endorsing the guidance as it stands, or widening the scope of PAs’ practice beyond what the BMA suggests, which is likely to meet resistance. It is a case of being stuck between Scylla and Cheribdes.

Which finally brings us to calls for a “pause” in the rollout of PA roles, which is the area of dispute between the RCP’s leadership and the fellows who have brought the motion. My personal view is that there are three major reasons why we need a pause:

1. In a healthcare system, if there is any intervention such as a technology, or a drug where safety concerns have been raised, then the fundamental advice is to pause and investigate. If no concerns are found then there is nothing to fear and the process can continue without a safety flag hanging over it. And if there is an issue? Then you apply the necessary safety checks, make the amendments, and progress with caution while evaluating further. What you don’t do is carry on regardless. If that principle applies to a drug or technology, then why not to an intervention with a new group of health professionals too?

2. A simple timeout is needed to reduce the heat and frictions caused by the current debate, both for doctors, but also for existing PAs. Continued attempts to bullishly push through the expansion of PAs will not help anyone, least of all PA colleagues, who find themselves in the spotlight, mostly due to failed leadership of their own and the wider system. These individuals need a break, and a pause gives everyone time to take a deep breath while issues of safety are looked at and clarified.

3. Finally, it gives a chance for all parties to get together and complete the work on scope and regulation in a coherent joined up way. At present this is all being done back to front, with a workforce introduced into the system before their scope, guidance, supervision, or regulation are in place.

I call on everyone on all sides of the debate to consider what a pause brings, and I say this as someone without any particular axe to grind. I am not in a specialty which is expected to have a surge in PAs. We are blessed to have huge multidisciplinary teams already, with nurses, pharmacists, podiatrists, dietitians, and others working together. As someone who works in MDTs and who has worked on patient safety on a national basis, I am asking for a pause to give all of us time to reassess, regroup, and take a deep breath.