The 'noctor' will see you now: Unregulated physician associates putting lives at risk

In the early hours of Friday, 11 November 2022, Ben Peters attended Manchester Royal Infirmary’s Ambulatory Care Unit feeling unwell. He experienced chest pain, shortness of breath, a sore throat, and an aching arm. Despite his normal ECG, the 25-year-old felt sick while waiting for review, and his blood tests revealed an abnormal result.

Reviewed by a physician associate, he was diagnosed with a panic attack and/or gastric inflammation. He returned home to his parents and passed away there the following day.

Ben was a well-loved son, friend, and colleague. Since his passing, Ben's friends have organised races and marathons to raise funds in his honour, while his employer established a prize for law students at Manchester Metropolitan University in his memory.

“He was popular with his clients and colleagues alike and had a very bright legal future ahead of him,” Richard Carlin, director of Pluck Andrew, tells The Lead. “Ben is sorely missed by all.”

Ben was one of many people seen by a physician associate, one of the few new roles created by the Department of Health to help prop up a chronically understaffed and underfunded national health service and ‘cut NHS waiting lists’. Despite seeming to offer to increase the stretched NHS workforce, physician associates have become a divisive figure for doctors, particularly as their need for supervision is often seen as drawing clinicians away from patients rather than freeing them up.

In fact, doctors are now up in arms. Their main union, the British Medical Association (BMA), has called for a hiring freeze of PAs – and patients are also concerned. Some are so incensed by the lack of regulation around these roles that the derogatory term ‘noctor’ – non-doctor – is being used on social media to denigrate the job. 

First introduced in 2003, a physician associate is a generalist healthcare professional who works alongside doctors and other medical professionals. They can’t prescribe medication but can examine patients, make diagnoses, and take histories. Their training usually involves a bioscience degree at an undergraduate level and then two years of training as a postgraduate.

“Physician Associates (PAs) have worked in the NHS for over two decades,” a spokesperson from the Department of Health and Social Care tells The Lead. “They are an important part of clinical teams across the NHS, providing support to thousands of patients every day, under the supervision of doctors. We have been clear that the role of associates is to work with doctors, not to replace them, and we expect healthcare organisations to have robust clinical governance.”

Despite the role having been part of the NHS for nearly 20 years, the mainstreaming of PAs arrives as NHS doctors find themselves under unprecedented pressure. There are currently over 8,500 vacancies for doctors in the UK, and even at the height of the pandemic as clinicians maximised their workload, doctors’ vacancies only came down to 6,634. 

Sustained pressure on politicians to act prompted new investment through ring-fenced funding for PAs such as the Additional Roles Reimbursement Scheme, launched in 2019: for example, a group of practices covering 100,000 patients could claim nearly £1.5m for PAs last year alone.

Yet, according to BMA’s comprehensive survey, 55% of doctors have found that PAs increase their workloads, even though they were sold as a way to reduce them. 87% of doctors who took part said the way medical associate professionals currently work in the NHS always or sometimes risks patient safety.

An investigation by the Telegraph in January received responses from over 600 doctors in the campaign group Doctors’ Association UK. Respondents accused PAs of missing life-threatening diagnoses and of illegally attempting to prescribe drugs. 

Doctors’ concern is not unwarranted. The same year that Ben Peters died, Emily Chesterton, 30, died after two appointments with a physician associate whom she believed was a GP.

No regulation

Other medical professionals, including GPs, are also not immune to diagnostic errors, some of which have had severe or even fatal consequences. A 2021 study revealed that in England, over half (58%) of diagnostic mistakes in general practice happen during GP consultations. Yet, the primary issue with physician associates is their current lack of regulation.

While many GPs welcomed the news that they would be regulated from December 2024 onwards, others were unsettled by the idea that they would be covered by the General Medical Council – the same regulator as doctors – rather than the Health and Care Professions Council. 

Professor Philip Banfield, the BMA's council chair, warned that allowing the GMC to regulate PAs would confuse patients by equivocating the role with a doctor’s.

“The rubberstamp approval of this harmful legislation by the House of Commons is hugely disappointing,” he tells The Lead. “MPs have consented to the blurring of the roles of doctor and PA, and in so doing, potentially risked thousands of patients believing they will be getting care from a doctor when they will not. 

“It is dismaying for this fundamental change to patient care to have been carried out by a legislative process outside the public’s knowledge or control, notwithstanding the powerful contributions of those individual MPs who listened to both their constituents and the medical profession and raised their voice against it.”

More fuel was thrown on the fire when it emerged that the cost of regulation to PAs could be as much as half what it costs doctors – meaning that doctors are paying twice as much for the same service. It is not yet clear how much PAs will pay the GMC. 

What was intended to remedy an overburdened workforce now appears to have created a new set of problems.

Unknown by patients

Physician associates are still not widely recognised by patients, with a survey finding that 57% of people have never heard of them. While the public gets to grips with the concept of the ‘physician associate’, Ben Thompson has already been seen by two.

For him, the gap between the two experiences characterises what’s wrong with the role as it is.

The 45-year-old saw his first PA after securing an urgent GP appointment. Informed beforehand that he was seeing a PA, Ben was introduced to a friendly, down-to-earth medical professional who quickly put him at ease.

Ben could hardly walk; the PA couldn't help immediately but advised him and his wife to call the hospital daily, explaining his problem to get a last-minute appointment. This advice helped Ben get the treatment he needed and back on his feet.

“It was an all-round positive experience, and better than some GP experiences that I've had,” he tells The Lead.

The second time Ben saw a PA at his local GP surgery, he wasn’t told he would be seeing a PA at the time the appointment was booked, and this PA did not introduce himself as such either. There was nothing on the door or in the room to differentiate him from a GP. 

Like the first PA, the second PA left the room to seek advice from a colleague but didn’t warn he might at the start of the appointment, or explain what he was doing when he did so. 

“Imagine if you went to see a GP and halfway through the consultation, they got up to get advice from a colleague,” Ben says. “If it had been someone who wasn't aware of the PA role or how they work, it would have been quite alarming.”

Leaving the appointment, Ben reassured his wife, who’d attended with him, that seeing the PA had been better than nothing.

“Although the first PA couldn’t prescribe me anything, I felt more reassured. But after the second one, when the PA had prescribed me something [PAs cannot prescribe, so this script would have been supervised by a doctor], I wasn't reassured. Part of that came from the fact he hadn't explained who he was, or what he was doing.” Last year, a survey revealed that only 24% of the public are satisfied with the NHS, marking the lowest level of satisfaction since 1983. Ben's experience mirrors a broader public dissatisfaction with the health care they receive.

“I am not anti-physician associate, I’m pro-patient.”

– Dr Stephen Katona, an out-of-hours GP and carer.

A workforce crisis

Politicians have posed PAs as a solution to NHS workforce woes. Yet, for many medics, the problems seen during the rollout and regulation of this role typify the government’s historical failures to tackle wider shortages. 

The NHS workforce crisis was a well-defined problem even before COVID-19, but during the pandemic, the issue snowballed. Recruitment and retention are in freefall across NHS professions: the latest NHS stats show an 8% average vacancy rate across England. 

Efforts to mitigate the problem have fallen short: for example, the government quietly ditched its 6,000-GP target in 2021. Despite campaigns to bring back the nursing bursary and simplify immigration for newly qualified doctors, the government has largely ignored these well-advocated solutions. The NHS closed its visa support scheme for overseas GPs last month despite begging pleas from the Royal College of GPs not to do so; 46% of UK GP trainees come from outside the UK. The bursary – a grant for nursing students – is now capped at £1,000 in England before means-testing despite having been restored in full in Scotland and Wales. Applicants for student nursing were down 12% last year. 

As the workforce dwindles, remaining clinicians struggle to patch the gaps. Last year, Nuffield Trust authors found that monthly sickness rates in 2022 were consistently above the highest rate in 2019; on average, they were a third higher. Anxiety, stress, depression, and psychiatric illness account for around a quarter; burnout is a serious problem across health and social care. 

Doctors’ strikes in 2023 aimed to improve recruitment and retention through better pay and pensions, but the health minister’s failure to reach settlements means that the union has re-balloted junior doctors to extend their mandate for another six months this year. GPs are likely to take industrial action this winter. 

Dr Julius Parker, a GP and deputy chair of the General Practitioners’ Committee, is naturally concerned about physician associates’ relationships with the doctors he represents. 

“Despite government promises to increase GP numbers, we still have fewer full-time GPs than nearly ten years ago,” Dr Parker tells The Lead. “We are having to do more work with fewer resources and are being stretched to the limit, leaving patients frustrated that they cannot always access the care they need.

“As more people are living longer, often with multiple and complex conditions, we desperately need more GPs if we are to provide the level of care that people deserve and we want to deliver. 

“Unfortunately, the government has chosen to focus on recruiting thousands of non-GP staff as a cheaper alternative, who aren’t qualified doctors and cannot do the tasks patients rely on from general practitioners. The government must prioritise GP recruitment and retention otherwise the NHS will continue to haemorrhage doctors, putting patient care and safety at risk.”

The physician associate role was designed to create fast-acting pain relief for doctors. Routes into the role include existing NHS roles (nursing, midwifery or an allied health profession), undergraduate bioscience degrees, and apprenticeships. The training takes two years – compared to the five to graduate from medical school. 

The roles are well-paid – but the discrepancy between training and pay has irked doctors. Physicians associates start on band 7 (from £43,742) with an NHS pension. This has proven a bone of contention for doctors: qualified doctors now start on £32,398. Salaried GPs, who have completed ten or more years of training, start on a wage of around £68,975. Although PAs can’t replace GPs because they are not as qualified or skilled, they are increasingly being asked to fill in the gaps and see patients where there are not enough GPs to do so. 

Wes Streeting, the Shadow Health Secretary, has recently voiced significant concerns about the physician associate role. He has raised questions about the potential substitution of doctors with physician associates, the possibility of associates being asked to perform tasks "beyond their scope of practice", and the issue of pay in relation to junior doctors.  

GPs will walk

Amid the funding crisis in general practice, the introduction of PAs has further driven GPs to leave. GP numbers have fallen from a peak of 29,537 in 2016 to 27,153 last summer, with only a slight increase since. Factors include high inflation, funding cuts, poor pay, decreased work-life balance, and the imposed 2024/25 GP contract, prompting plans for industrial action as early as this summer.

Last month, analysis estimated that GP funding had been cut by £350 million in real terms since 2019. It also revealed that 1.5 million GP appointments in November occurred four or more weeks after booking. If PAs were meant to solve long wait times and the NHS backlog, the solution isn't working.

GP redundancies have followed, with one Surrey practice losing three GPs in March. A survey last year found half of GP locums had cut their shifts due to dwindling work availability due to lack of funding. The NHS is 1,900 GPs short, yet sessional GPs report a lack of vacancies. Locum leaders say experienced colleagues are now out of work, with some even turning to jobs like Uber driving. Some GPs are urging the government to allow 'Additional Roles' funding to be used for GPs and practice nurses, as well as the roles the government wants to subsidise.

GPs are furious, having balloted for industrial action by year-end. Over 99% voted to reject the current GP contract. Dr Katie Brammall-Stainer, chair of the union’s General Practitioner’s Committee, said, “The unanimity of the vote in our referendum demonstrates the depth of feeling among the profession. In 20 years, I’ve never known GPs to be so frustrated, angry, and upset.”

A recent conference of GPs voted to block PA colleagues from undertaking anything but admin. Junior doctors’ strikes will run until mid-September, and GPs’ industrial action, scheduled for late November, hangs over the NHS like a dark cloud.

Dr Stephen Katona, an out-of-hours GP and carer in Manchester set up a petition last December to support this proposal. Over 11,000 people signed it, but it closed early due to the general election.

“Just over a month ago I became aware many GPs were struggling to find work because practices didn't have sufficient funding to employ them,” Dr Katona tells The Lead. “I couldn't understand why ARRS funding did not list GPs and practice nurses amongst the list of roles it supported. Creating a petition seemed a simple solution.”

“I am not anti-physician associate, I’m pro-patient,” Dr Katona continues. “Any health professional that knows their stuff, who studies and works hard and cares about patients is worth their weight in gold. 

“The real enemy is time: there should be enough time for a proper liaison between the doctor and PA to occur, and that would be of benefit to the PA, doctor and patient.”