From colonial roots to 20 years of low-quality evidence from the NHS, physician associates are not what Australians deserve.
The world is facing an international shortage of doctors. The root causes are complex – despite more doctors being trained than ever before, need is outstripping demand as the population ages and suffers from more chronic disease.
The medical workforce is also aging, with ~30% of Australian doctors set to retire within the next decade. Solutions to this crisis include not only for all healthcare workers to practice near the “top of scope”, but the development of newer types of professionals, including “physician assistants” (PAs). Indeed the Queensland government has already made public the fact that it is considering the introduction of such a category of healthcare worker.
Some health economists have supported what is a very new paradigm in healthcare for Australians.
“As demand for health services increases, it makes sense to explore the addition of physician assistants to Australia’s healthcare workforce,” they wrote.
The rationale for PAs is that they are able to take on routine clinical tasks, thereby freeing up doctors to perform more complex tasks and see more patients.
The lineage of PAs can be traced back to the colonial powers offering sub-professional qualifications in African countries when it became clear that European doctors could not be enticed to work there.
Training for the roles typically focused on infectious diseases, manual tasks and administrative duties. When the US faced similar workforce pressures in the 1960s it harnessed a workforce of returned military medics and corpsmen who had served in Vietnam and brought back with them useful healthcare skills. These physician assistants now number in the tens of thousands across the US and work under the supervision of medical practitioners commonly in primary care and emergency care.
PAs were first introduced into UK about 20 years ago, as part of the Tony Blair-Gordon Brown reforms of public services, with a cohort of American PAs recruited to work in Scotland and across the Midlands.
Subsequently, university courses were set up, a curriculum was developed jointly by the Royal Colleges of Physicians and General Practitioners and the UK Association of Physician Assistants – with the title later changed to “physician associate” – was created. Subsequently the UKAPA was absorbed by the Royal College of Physicians to yield its Faculty of Physician Associates.
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The role of PAs in the NHS became a bitter political flashpoint for the former Conservative government as it became embroiled in a dispute with doctors in specialty training who demanded pay restoration after inflation saw them take a 25% pay cut in real terms.
This contrasted sharply with the relatively high salaries of PAs, who outearn resident doctors in the first 3-4 years of their careers, despite having a fraction of the training (PA courses are two years).
As part of the then-government’s strategy for dealing with the dispute former Secretary of State for Health, Steve Barclay, attempted to “flood” the NHS with “fake doctors”.
Funding streams for GP have been shifted to favour the employment of non-doctors, with the upshot that, despite a national shortage of GPs, newly qualified GPs are struggling to find work with medical unemployment reaching record levels.
The debate has intensified following a number of patient deaths, including that of Emily Chesterton, who died of a pulmonary embolism after being diagnosed by a PA as suffering from anxiety. Such cases highlighted that PAs were no longer being used as “assistants”, but were seeing undifferentiated patients in high-risk settings, such as general practice and emergency departments, often with minimal or no oversight.
To help settle the debate around PA roles and responsibilities, current UK health and social care secretary, Wes Streeting, called for a review of how physician and anaesthesia associates are deployed in the NHS. The review is to be chaired by Professor Gillian Leng CBE, former CEO of the National Institute for Health and Care Excellence – NICE.
With PAs operating across general practices and in NHS hospitals for more than 15 years it would be reasonable to expect a robust body of evidence regarding outcomes of PA practice such as patient safety and the impact on other members of the health workforce team.
Expectations, unfortunately, do not match the reality.
University of Oxford physician and academic Professor Trish Greenhalgh has conducted a comprehensive literature search as part of her submission to the Leng review. Her overall conclusion was that:
“The UK-based research literature on PAs in [the] UK is sparse, of variable quality, has important gaps and parts of it are out of date. Most significantly, no UK-based research evidence currently exists which directly examines the safety of PAs’ clinical decisions and actions.”
Professor Greenhalgh could not find any cost-effectiveness analyses, and the small number of studies she did identify for hospital-based care “found that the costs or value of PAs could not be disaggregated from those of the wider team”.
The single study that she identified addressing PAs in primary care – involving only seven PAs – found that consultations “appeared to be slightly cheaper” but that “the input and cost of the supervising doctor was not included” and, indeed, not even measured.
Two outcomes of importance are measures of clinical performance and safety, and of public acceptance. Professor Greenhalgh’s literature review found “limited evidence” and the evidence available was more than a decade old, gathered “before a substantial increase in NHS pressures, general practice workload and skill mix”.
In none of the studies identified were safety incidents even logged.
The literature revealed that many patients thought they were being treated by doctors, although they didn’t mind this “provided the PA was working within their competence and adequately supervised”. They did, however, want to be informed that the person seeing them was a PA and not a doctor.
Greenhalgh’s review did not cover the contentious issue of medico-legal litigation.
While suits against doctors have typically dwarfed the numbers brought against PAs in the US, the number being lodged has been rising since covid with the move of PAs out of highly supervised practice into more risky settings. Some have estimated that the costs of medico-legal litigation will quickly outweigh the relative lower costs to train and employ PAs.
During the two decades in which such a potential transition has played out across the UK a number of key concerns have been left largely unaddressed. Recent surveys both of consultant staff and of specialty trainees have shown that a large majority of respondents did not consider that the PA workforce achieved their stated aims. This body of opinion was mishandled by the leadership of the College of Physicians, further eroding confidence.
By contrast, Australia piloted the use of PAs at about the same time as they were introduced into the UK, with university courses established in Queensland and South Australia.
However, concerns about patient safety and integration into the Australian healthcare system led to courses being halted. About 40 PAs continued to work, despite not being registered with AHPRA or recognised under the Medicare Benefits Schedule or the Pharmaceutical Benefits Scheme.
It is matter of some concern that PAs are again being discussed in Australian context, particularly in light of the controversies in the UK. Moreover, while PAs have been moving towards regulation in the UK, the Queensland government will be allowing PAs to prescribe and order ionising radiation, despite not being registered with AHPRA, which in any other circumstances would carry a jail sentence.
For PAs to be viable, there would need to be either heavy recruitment from overseas, or local universities must be prepared to introduce new courses at pace and scale, again risking problems with safety and integration into the system.
Shortages are most acute in rural parts of Australia. Longer-term studies of PAs have suggested that when initially introduced, PAs do tend to work in hospitals in rural areas, although this is not true in the longer term.
As with other health professionals, PAs migrate towards urban areas and private practice and there is emerging evidence that work substitution of doctors with other types of practitioners simply recreates the same problems with shortages, just with a different workforce group.
The proposals to deploy PAs predominantly in rural areas raises the spectre of a two-tier system in Australia, with non-urban populations deliberately being starved of high-quality care delivered by doctors.
At the heart of the matter is the shift in role from being an “assistant” to aid doctors to outright substituting for them, and whether a two-year course is sufficient to train people to diagnose and treat illness, when the training for doctors is 10-15 years, depending on specialty.
Australia has some of the best outcomes for healthcare in the world, achieved by an insistence on high standards for training and practice. Watering these down through the use of “second tier” clinicians can only have a negative impact on the health of the country. Australians deserve better.
Dr Louella Vaughan is a consultant physician at the Royal London Hospital, a senior research fellow with the Nuffield Trust, and researcher in health policy.
Steve Robson is an ob/gyn, former president of the federal AMA and is now chief medical officer for Avant Mutual. He is also a health economist with Bell Health Advisory.
