Government-commissioned review says physician associates should not diagnose patients after deaths linked to errors when patients thought they had seen a doctor
The NHS has been ordered to make clear when patients are being treated by less qualified medics rather than doctors.
Physician associates (PAs) could now be banned from diagnosing patients in most circumstances after a number of deaths including the high profile case of Emily Chesterton. The 30-year-old was misdiagnosed twice by a PA who she assumed was a GP before eventually dying of a blood clot in 2022. The Government-commissioned the review into PAs and anaesthesia associates (AAs) has concluded they should be renamed “assistants”. Health Secretary Wes Streeting will announce whether the Government accepts its recommendations later on Wednesday.
The expansion of associate roles to fill NHS rota gaps has angered doctors who say they are taking their jobs and are much less qualified – despite in some cases earning more than them. The Leng review comes after at least six patient deaths linked to contact with PAs have been recorded by coroners in England.
Chair Professor Gillian Leng CBE said: “As part of the review I have listened to the views of patients and the public. Of particular importance was hearing from the families of those who died.
“Relatives feel strongly that confusion between the PA role and that of the doctor was an important contributory factor in their relatives’ deaths. They were clear that, had they known a doctor had not been consulted, they would have responded differently and sought further help. Sadly, no one can turn back the clock but I have listened to their experiences to help make improvements for the future.”
Associates were introduced to the NHS workforce in the early 2000s to allow doctors to focus on more complex cases. They were supposed to always be supervised by doctors but have faced increased scrutiny due to high profile mistakes.
Emily Chesterton
Emily Chesterton’s case became the tragedy that has united doctors demanding better guidelines over what physician associates can and cannot do. The 30-year-old was seen by a physician associate after she called her GP practice in Crouch End in north London complaining of pain in her calf, which had become hard. The PA recommended Ms Chesterton should take paracetamol.
Her mum, retired teacher Marion Chesterton, has said her condition became worse so that Emily had “difficulty walking” and “was breathless and lightheaded”. Speaking to the BBC previously, she said: “In the second appointment, the PA diagnosed her with a calf sprain, long Covid and anxiety. The PA did not examine Emily’s calves, and did not make it clear that she was not a doctor.”
Ms Chesterton had a blood clot in her left leg which led to her dying of a pulmonary embolism. The coroner’s conclusion was that she “should have been immediately referred to a hospital emergency unit” and, if she had been seen, it was likely that she would have survived.
Emily’s parents, Marion and Brendan, brought a Judicial Review, along with doctors’ group Anaesthetics United, to force an official scope of practice for physician associates by health setting. Over 5,000 physician and anaesthesia associates work in the NHS in England. Government plans are in place to increase the figure to 10,000 to help NHS short staffing.
Prof Leng said: “Despite the significantly shorter training, PAs and to a lesser extent AAs, have sometimes been used to fill roles designed for doctors. It seems to assume that much of the doctor’s role does not need the skills and qualifications of a doctor, which, if that is the case, requires a thorough reconfiguration of roles and restructuring, not a simplistic replacement of a doctor with an individual who is significantly less qualified.”
The Recommendations
The review recommended that they be renamed physician assistants (PAs) and “physician assistants in anaesthesia” (AAs). It found that they generally should not see “undifferentiated patients” – those as yet undiagnosed – except for already triaged adult patients with “minor ailments”.
The main doctors’ union the British Medical Association (BMA) has questioned this recommendation. Dr Tom Dolphin, chair of BMA council, said: “Minor complaints are only minor in retrospect and serious conditions can present in subtle or unusual ways.”
The review said safety concerns in relation to PAs were “almost always about making a diagnosis and deciding the initial treatment, particularly in primary care or the emergency department, where patients first present with new symptoms.” It added: “It is here that the risk of missing an unusual disease or condition is highest, and where the more extensive training of doctors across a breadth of specialties is important. Making the wrong initial diagnosis and putting patients on an inappropriate pathway can be catastrophic.”
Professor Leng recommends assistants wear clearly different uniforms from doctors as well as lanyards to avoid confusion. Other recommendations include that newly qualified PAs should gain at least two years’ experience in hospital teams before taking on roles in GP practices or mental health centres. A named doctor also should take overall responsibility for each PA.
Prof Leng added: “Many new roles have been introduced to the NHS since it was established, and many more will continue to be needed as healthcare becomes more complex. However the NHS now has more types of role than any other healthcare system in the world and care must be taken to ensure that these roles are understood by the public and by staff.”
READ MORE: ‘Why doctors are kicking off about their junior NHS colleagues being called medics’
Helga Pile, head of health at the union Unison, said: “By working closely with doctors and other healthcare professionals, these roles can make a real difference to the improvement of services and reduction of waiting lists. It’s vital those in associate roles are treated fairly, with good supervision, in order for them to thrive and contribute to the NHS.”
PAs and AAs qualify after completing a master’s degree and usually need a bioscience-related undergraduate degree. Their role includes taking medical histories, conducting physical examinations and developing treatment plans. They are not authorised to prescribe medicines. Becoming a doctor in the NHS typically requires ten years of training including medical school and postgraduate training.
READ MORE: Doctors fear two-tier GP plan following death of woman misdiagnosed by PA at practice
Dr Naru Narayanan, President of the hospital doctors’ union the HCSA, said: “It’s not enough to say that physician assistants should not do the work of doctors. We currently have little clarity on what they should be doing on the ground. That’s a key issue for hospital doctors because these roles have encroached into ever more complex aspects of patient care.
“While we’re waiting, supervising hospital doctors will continue to be held accountable for the actions of individuals working without clear parameters.
“Given how poorly these roles have been defined, and the fact physician assistants earn more after a couple of years of clinical training than resident doctors do after nearly a decade in medicine, it’s not surprising there’s been tension.”