College publishes new statement on Medical Associate Professions

College publishes new statement on Medical Associate Professions

This statement updates the Royal College of Physicians of Edinburgh’s (“The College”) position on the Medical Associate Professions (MAPs), with specific regard to Physician Associates (PAs), following our original statement in January 2024.

The College believes that no further expansion of the PA workforce should occur in the UK, and specifically that there should be a suspension of the recruitment to new PA posts in Internal Medicine and its specialties across the NHS, until the implications of such expansion for the following can be more clearly defined:

• patient safety, in turn related to PA scope of practice;
• medical training in internal medicine and its associated specialties; 
• medical recruitment, at all levels, across training and service posts;
• health service costs.

The reasons that we adopt this position include:

A). Patient safety and PA scope of practice

We are concerned that multiple and potentially conflicting scope of practice documents are currently being created; some based on specialty of practice, some based on geographical location of the employer. We believe that this will lead to confusion, for patients and for other healthcare professsionals alike, and that more serious consideration must be given to nationally defined scope of practice, to specifically include “ceiling of practice” for PAs.

We are also concerned that supervision of PAs, in contemporary, real life, day-to-day NHS practice, will not match the theoretical levels described in published protocols and frameworks regarding such supervision.

B). Medical Training 

The priority for senior NHS medical staff should be the supervision, education and training of medical students and doctors in training or service posts. We are concerned that it is not possible, within the terms of current consultant job plans, to supervise additional PAs without compromising the training of doctors and medical students.

C). Medical Recruitment

There is growing evidence that increasing numbers of early career doctors cannot access training posts. 
 
We welcome the increase of UK medical graduates and international medical graduates available to enter UK employment. However, those increases must be matched by urgent expansion of training posts for all who require them across all specialties and in all parts of the UK. Failure to expand training opportunities can only lead to extreme frustration in the medical workforce and will undermine attempts to retain doctors in the NHS.

Given this context, the notion that we should expand another professional group (PAs in this instance) who substitute for doctors, as “associates”, rather than support them, as “assistants”, is increasingly illogical.

D). Health Service Costs

There is a concerning lack of evidence to suggest that the preferred strategy of PA expansion will reduce costs of care, without compromising outcomes. Change of this magnitude should not be introduced without a better evidence base.

In making this statement we note the following:

A). Our primary responsibility and charitable purpose, as a Medical Royal College, is to sustain and develop the highest standards of patient care, now, and in the future, wherever our Fellows and Members work. 

We do not believe that standards of patient care in medicine and its specialties will, in the short term, be enhanced by the roll-out of PAs in the numbers envisaged within the currently planned time-scale. 

In the longer term, we fear that the in-service training, supervision and mentoring of doctors will be compromised, and that the access of doctors to postgraduate training posts will also be compromised. This, we believe, will not lead to an increase in the standards of patient care across the NHS in the intermediate future – rather, the opposite.

B). We recognise that some localities in the UK have employed PAs because it has been difficult to attract doctors to training and service posts. We believe that alternate means must be found to support medical recruitment in such localities, averting the need to employ PAs as substitutes for doctors.

C). We fully understand that, in some units, PAs have been very well integrated into NHS roles, sometimes for considerable periods of time. We further note that some have provided excellent support for doctors at different career stages and contributed to high quality patient care. Their contributions and their roles should continue to be respected.

However, PAs themselves are now often being put into difficult professional positions, particularly when recruited into roles in which scope or ceiling of practice has not been clearly defined or supervision is suboptimal. We therefore feel that a halt in recruitment will also protect early career PAs from exposure to professional clinical risk.

D). PAs are also employed in roles in other specialties, including Psychiatry and General Practice. It is not for our College to suggest how PAs should be deployed in other disciplines; our request for a recruitment halt applies to Internal Medicine and its specialties only.

E). In line with our previous statement, we continue to believe that the term Physician Assistant is preferable to Physician Associate and ask that the Faculty of Physician Associates consider this change. 

F). We abhor and condemn the personalised, sometimes insulting and often bullying behaviour still occurring on social media in relation to the MAP issue, some directed at PAs, some at other members of the medical community. We note here that were such behaviour to prove to have been demonstrated by a Member or Fellow of this College, we would regard it as a potential disciplinary matter under the terms of our Code of Conduct.

The occurrence of such behaviour by a minority on social media, whilst unjustifiable, does not however negate the validity of the concerns described by many other doctors, at all stages of their careers, across all parts of the UK, in a wide variety of media.

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- Professor Andrew Elder, President
- Dr Sue Pound, Vice President (Scotland and Northern Ireland)
- Dr Conor Maguire, Vice President (International)
- Professor Sunil Bhandari, Vice President (England and Wales)

On behalf of the Council and the Lay Advisory Committee of the Royal College of Physicians of Edinburgh.