The role of physician associates has come under scrutiny after the Coroner’s findings in the inquest touching the death of Emily Chesterton on 20 March 2023. More recently, some doctors have raised concerns about the proposed use of anaesthetic associates and physician associates to undertake clinical tasks previously done by doctors, such as giving anaesthetics and prescribing medications.

Ms Chesterton died in November 2022 at 30 years of age from a pulmonary embolism. She had attended her GP and been seen by the same physician associate on two occasions who diagnosed sprain and long COVID. At the inquest, the Coroner made a narrative conclusion that included the following:

‘She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.’

The inquest finding led to a debate in Parliament as to the role and regulation of physician associates and whether the title itself was potentially misleading to patients who might assume the person was a doctor. Read more here.

It has been reported that the GP practice who cared for Ms Chesterton has since ceased employing physician associates.

History and Training

Physician associate roles have been in place in the United States for many years, dating back to the first graduates from Duke University in 1969 (referred to as physician assistants). In the UK, the role has been recognised since around 2005, being included in the Department of Health’s ‘New Ways of Working’ program and 2006 by the development of a Competence and Curriculum Framework.

Physician Associates are normally required to undertake 2 years of formal post-graduate training after completing a first degree in a bioscience-related field. However, integrated undergraduate courses are now available, requiring 4 years of training and only A-levels or equivalent for entry.

The usual two-year training program focuses on general practice and general adult medicine in hospital. It includes a significant proportion of time spent in direct clinical training, including specified time spent in general hospital medicine and some exposure to specialty settings such as mental health and paediatrics.

Qualified physician associates can join the Physician Associate Managed Voluntary Register (PAMVR), which commenced in 2010 and is maintained by the Faculty of Physician Associates at the Royal College of Physicians. Joining the register requires passing the Physician Associate National Examination (PANE). Physician associates are encouraged to join the register, which requires them to undertake continuing professional development and meet certain professional conduct standards. Whilst it is voluntary, the register currently provides a de facto system for employers to confirm the qualifications and fitness to practice status of prospective physician associates.

Once qualified, physician associates may undertake a number of clinical duties, including taking medical histories and carrying out physical examinations; formulating differential diagnoses and management plans; performing certain diagnostic and therapeutic procedures; requesting and interpreting some diagnostic studies; and developing treatment and management plans. As a non-regulated health profession, physician associates cannot prescribe medications or order ionising radiation.

Regulation

Moves to introduce formal regulation of both physician associates and anaesthetic associates began around 2014. In 2019, the Government determined that the GMC was best placed to take on the role of regulating physician associates and anaesthetic associates. This was followed by a broader consultation in 2021 into the regulation of all healthcare professional groups across the UK, which included the introduction of statutory regulation for physician associates and anaesthesia associates.

In early 2023, the Government released a draft of the Anaesthesia Associates and Physician Associates Order for comment. Once finalised, this order will give the GMC powers to commence regulation of anaesthetic associates and physician associates. The order gives powers to the GMC to draft rules providing for the regulation of anaesthetic associates and physician associates, including their registration, setting standards of practice and education/training, approval of training programs, and operation of fitness to practice procedures.

As presently planned, the statutory registration and regulation of physician associates and anaesthetic associates will not commence until the second half of 2024 or later (assuming Parliament approves the draft order). At the time of introduction, persons on the current voluntary PAMVR will be able to apply via a streamlined process to join the statutory register, which will operate under the governance of the GMC. Other persons working as physician associates will be able to apply, but there may be greater requirements to demonstrate appropriate qualifications and fitness to practice.

There is a proposed 2-year transition period, after which practicing as a physician associate and use of the title will be limited to those on the statutory register. Current practicing physician associates who are not on the PAMVR are encouraged to apply to join the register in advance of statutory regulation.

Establishing physician associates as a regulated profession may allow an extension of their roles to prescribing or ordering of ionising radiation.

Risk Management for Doctors Working with Physician Associates

With respect to the current role of physician associates in the provision of clinical care, it is important for doctors to be aware of their own responsibilities for supervision and delegation to other members of the healthcare team. Clause 45 of Good Medical Practice states as follows:

  1. When you do not provide your patients’ care yourself, for example when you are off duty, or you delegate the care of a patient to a colleague, you must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient.

It is becoming increasingly common for doctors, including those in general practice, to rely upon physician associates to provide clinical services, such as history taking, patient examination, making a provisional or differential diagnosis, and making management plans or recommending treatment. Doctors must be alive to their own professional responsibilities when relying upon physician associates to provide such services.

Doctors must be comfortable that the physician associate is properly trained and qualified and has the skills and competence to undertake the clinical role they are being assigned. Alternatively, they must ensure the physician associate will be adequately supervised when performing the delegated tasks. The GMC provides a short guidance with more details on responsibilities for delegation. The guidance includes the following:

If you are delegating to a person who is not registered with a statutory regulatory body, voluntary registration can provide some assurance that practitioners have met defined standards of competence and adhere to agreed standards for their professional skills and behaviour.

Ensuring that all engaged physician associates are listed on the PAMVR is, therefore, an important risk management strategy and may assist in compliance with professional obligations.

Ultimately, a doctor and/or GP practice partners may be held to have failed in their professional obligations if they allow physician associates to work with inadequate supervision or support and if they delegate work to them that is beyond the scope of their qualifications or training.

In general practice, it is also important to consider the indemnity arrangements in place for physician associates. All physician associates must have some form of professional indemnity cover. If employed in Trusts they should normally be covered by the Clinical Negligence Scheme for Trusts (CNST). In general practice, they are covered for clinical negligence claims under the Clinical Negligence Scheme for General Practice (CNSGP) for liabilities incurred on or after 1 April 2019. However, this cover does not extend to non-NHS or private work, inquests, regulatory and disciplinary proceedings, and non-clinical liabilities. For this reason, physician associates are recommended to obtain appropriate private indemnity cover from one of the major medical indemnity organisations. Where a general practice engages physician associates to provide clinical services, the GP partners are recommended to check with their own professional indemnity provider to ensure that the physician associates are covered under their policy.

Healthcare Solicitors Guildford and London

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About the Author

Roy Donnelly

Roy Donnelly

Consultant