Partha Kar: We need honest, sensible conversation about physician associates—not false promises

The plan to introduce and further expand physician associates through the NHS workforce plan has become a clinical, financial, and strategic mess. The royal colleges—including the Royal College of Physicians, the Royal College of Anaesthetists, and the Royal College of General Practitioners—are finally starting to develop national scope for the role.1

Problems will arise with having multiple scopes of practice from different royal colleges setting different baselines or ceilings. This would create further conflict and raises questions about what happens if trusts decide to ignore their guidance—and whether doing so would put them at risk of legal challenge. This has opened a can of worms because there was a lack of defined scope for many staff for years, allowing local scope to develop without quality control. My advice to the colleges is to recognise that trust between their members and leaders is frayed, and pushing through scope for physician associates without gaining support in a membership vote will pitch us further into crisis.

In some areas, supported by clinicians with a genuine interest in developing a different part of the workforce, physician associate roles have evolved. Yet in many places their roles remain without suitable governance for a group that by any definition has less training than foundation year doctors. We need to be honest that a doctor in their foundation year, who has spent five to six years in medical school, knows more than a physician associate who has done two years of medical overview training (or, as described by some, has “trained to a medical model”). Otherwise, we need to start questioning why we have medical schools or why we allow young people to incur massive debts in the pursuit of a medical degree.

This brings us back to scope. Anything deemed within scope for a physician associate that isn’t considered suitable for a foundation year doctor makes medical degrees redundant. That’s a problem in itself, as the salary scale as per the Agenda for Change contract then makes the physician associate’s post non-viable for a cash strapped NHS2: they’re paid more than foundation year doctors despite having less experience.

Next, consider productivity and supervision. If supervision of physician associates relies on doctors above foundation year level it renders the senior doctors less productive. This would make the goal of improving NHS efficiency a pipe dream. Senior doctors barely have time to supervise existing doctors in training in their job plans, let alone take on this additional supervisory role. A fundamental problem is that physician associates’ roles are dependent on doctors. The ongoing fracas with doctors is going to prevent the role from evolving as smoothly as some organisations may want.

These issues leave the General Medical Council and NHS England in a quandary, as they’re the biggest proponents of the physician associate role.3 The GMC seems reluctant to set national scope, as I suspect it’s fully aware that keeping scope as a local responsibility allows role substitution. Allowing physician associates to follow local scope with little to no supervision could be a patient safety disaster, with liability falling on supervisors and trusts. NHS England and its workforce plan are teetering on the edge, with the royal colleges now formally raising concerns about the safety of physician associates’ practice and trying to allay this with guidance on scope.