No Evidence Use of Physician Associates Is Safe or Improves Care, Study Finds

Report authors said there was ‘no evidence' that physician associates add value in primary care or that anaesthetic associates add value in anaesthetics.

A doctor checking a patient's blood pressure at the Temple Fortune Health Centre GP Practice near Golders Green, London, England, on July 29, 2024. Anthony Devlin/PA Wire

There is little to no evidence that deploying physician associates (PAs) or anaesthesia associates (AAs) across the NHS is either safe or has improved care, a University of Oxford study has found.

The review published in the British Medical Journal (BMJ) on Friday said that despite 3,500 people undertaking these positions, the number of studies examining the PA role was “very small,” with there being no research at all on AAs.

Researchers examined 29 papers on PAs and found that just one looked into the clinical competency of PAs, but that involved only four associates. No studies looked into the safety of PAs.

“No evidence was found that physician associates add value in primary care or that anaesthetic associates add value in anaesthetics; some evidence suggested that they do not,” report authors said.

The University of Oxford said the research, undertaken by Professor Trisha Greenhalgh and Professor Martin McKee, was the largest ever review of its kind and its findings raise “critical questions” about the rapid expansion of PAs and AAs in the NHS.

PAs Struggling

PAs and AAs are graduates who have degrees in health or life sciences and who have two years of postgraduate training, but do not have medical degrees.

The government’s current plan is to increase the number of PAs in England to 10,000 by 2036/37 and to recruit 2,000 more AAs.

The BMJ paper said that some studies did suggest that PAs could work in low-risk settings under supervision, but others found that PAs “seemed to struggle” in others where they had to work more autonomously.

Researchers also found that medical staff had concerns over the competency of PAs and AAs in their ability to manage “undifferentiated, clinically complex, or high dependency patients” or prescribe medication.

Misinterpreting Absence of Evidence

Authors stressed that the lack of evidence on safety of these roles should not be confused for there being proof that there are no issues or concerns.

“The absence of evidence of safety incidents should not be misinterpreted as evidence that deployment of physician associates and anaesthetic associates is safe,” they wrote.

“Conflating absence of evidence of safety incidents in a small number of research studies with absence of safety concerns when physician associates directly substitute for doctors is an error of logic that is likely to cost lives,” they warned.

May Be More Expensive

These medical associates have been deployed across hospitals and GP surgeries to support doctors in treating patients in a bid to ease staffing shortages and improve patient care.

However, researchers said that there was no evidence that using PAs or AAs improves efficiency or safes money.

Further, they added that because senior doctors are needed to supervise these medical associates and check their work, “this model may be more expensive than employing doctors.”

A general view of staff on a NHS hospital ward at Ealing Hospital in London, on Jan. 18, 2023. Jeff Moore/PA Wire

Report co-author McKee said that the “mismatch between policymakers’ enthusiasm for expanding these roles and the lack of rigorous research evidence should be a red flag.”

He continued, “Workforce shortages are a real challenge, but they cannot be addressed by replacing doctors with people whose training maps poorly to the duties expected of them, and who may be inadequately supported, without a clear, evidence-based strategy.”

Leng Review

The research was undertaken to inform the Leng Review, being headed by the president of the Royal Society of Medicine Professor Gillian Leng, which is examining the effectiveness and safety of medical associate roles.

Responding to the findings, a Department for Health and Social Care spokesperson told reporters that the Leng Review will “establish the facts and make sure that we get the right people in the right places providing the right care.”

“Regulation of PAs and AAs by the General Medical Council began in December to ensure patient safety and professional accountability,” the spokesperson added.

The Leng Review findings are expected to be published in the spring.

Misdiagnoses by PAs

The use of PAs has come to public attention following a number of deaths linked to misdiagnoses by medical associates in recent years.

One case was that of Emily Chesterton, who died at the age of 30 in 2022 of a blood clot that was misdiagnosed by two PAs as anxiety. She had been under the impression she had seen a doctor.

Last week, a coroner branded the term “physician associate” misleading, after 77-year-old Pamela Marking died last year following hospital failings, including a PA misdiagnosing her hernia as a nosebleed.

Marking’s son had likewise believed his mother had been treated by a qualified doctor.