Tamara S Ritsema, associate professor and honorary reader in physician associate education12,
Amy Donaldson-Perrott, reader in physician associate education2
PAs want robust research evaluating their practice, but adequate funding is needed, write Tamara S Ritsema and Amy Donaldson-Perrott
Over the past year, a firestorm of debate has been swirling around the role of physician associates (PAs) in the NHS. Many commentators have used the lack of regulation of PAs and oversight of their education as evidence that PAs are trying to hide their practice or escape the consequences of their actions. Nothing could be further from the truth.
PAs, like doctors, nurses, physiotherapists, pharmacists, and all NHS professionals, want to ensure that only highly qualified people are admitted to their profession and that there is a mechanism to manage those who are not performing to standard. Just as all doctors do not bear responsibility for the mistakes of other doctors, nor do all PAs bear responsibility for every mistake made by another PA. Yet the government has been slow to respond to the need for regulation.
The lack of statutory regulation has meant that the PA profession took the initiative to develop the managed voluntary register for PAs in 2010.1 The government agreed to regulate PAs in 2018 and it has taken another six years for the agreed upon regulation to begin.23 PAs also welcome oversight for PA courses by the General Medical Council (GMC), which has already performed evaluation visits.4 The list of approved courses will be published in spring 2025.5
Like all health professionals, PAs want good outcomes for every patient. This is why PAs have been advocating for professional regulation for more than 15 years.6 PAs in the UK have wanted a similar system of government oversight of their education and practice as is in place in the US, the Netherlands, and parts of Canada. Regulation of the profession would have addressed some of the issues raised in a new review by Greenhalgh and McKee,7 such as inappropriate ordering of radiological investigations or misrepresenting of credentials by PAs.
The lack of appropriate regulation and oversight on the part of the government does not mean that the profession itself is not fit for purpose. Indeed, as is evident in the literature on PA practice in the Netherlands and US, PAs can provide effective care when the appropriate infrastructure is in place.8910 Like all health professionals, PAs need to be clear on their role in patient care and the wider health system. The GMC has published helpful frameworks for PA training and practice.1112 These outline multiple competencies for PAs, including being able to explain the PA role to others, working within the limits of their knowledge, recognising clinical risk situations, and escalating concerns about patients through appropriate channels.
The early development of the PA profession was actively supported by the Royal College of Physicians and the Royal College of General Practitioners. They helped to develop the role, as well as the curriculum, which acknowledged that PAs would work under the supervision of doctors to care for patients.13 PAs are not a replacement for doctors. This ideal has been lost in a turf battle played out largely over social media (an environment that rewards inflammatory posts, not reasoned discussion between parties). PAs are not asking to take the role of the “airplane pilot” from doctors. They are asking to be members of the team to provide continuity of care for patients and to accomplish the daily jobs that need doing in clinical practice.
Like Greenhalgh and McKee, we agree that the research on PA practice is sparse. Yet this lack of evidence comes not from a lack of passion within the PA community to rigorously evaluate PA practice, but from a lack of resources to do so. Two large research groups, which do not include PAs, have been funded to evaluate the profession and feature heavily in Greenhalgh and McKee’s study. One specifically evaluated PA practice in the early 2010s, and the other performed some studies of PAs in the context of an overall primary care workforce assessment.1415 Since the PA profession is still relatively small, the profession has not been able to fund its own health workforce research.
If the NHS wants to join other countries like the Netherlands, Canada, and the US who are successfully using PAs to increase access to care and provide continuity of care, more research funding should be provided to evaluate the implementation of them. The absence of evidence is not evidence of absence.
References
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Timmermans MJC, Van Vught AJAH, Peters YAS, et al. The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study. Moine P, editor. PLoS ONE. 2017 Aug 9;12(8):e0178212.doi:10.1371/journal.pone.0178212
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UK Department of Heath and NHS National Practitioner Program. Competence and Curriculum Framework for the Physician Assistant. 2006.
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