Ahead of the Leng Review, a study of the use of physician associates within the NHS finds little to support claims that they improve efficiency or maintain patient safety.
There is little evidence to support the safety and efficacy of physician associates (PAs) and anaesthetists associates (AAs) in the UK, which adds to the questions being asked about their role within the NHS.
A study in the BMJ by researchers from the Nuffield Department of Primary Care Health Sciences, University of Oxford, and the London School of Hygiene and Tropical Medicine was written to inform the ongoing government-commissioned Leng Review which is examining the effectiveness and safety of these roles.
“At present, we simply do not have the data to support claims that these roles improve efficiency or maintain patient safety,” said Trisha Greenhalgh, lead author of the study and professor of primary care health sciences in the Nuffield Department of Primary Care Health Sciences, Oxford. “The absence of reported safety incidents in research studies does not mean they do not occur – it means we are not doing the right kind of research to detect and analyse them.”
Limited research
The study’s key finding is that research on PAs and AAs is limited.
Only one small study assessed the competence of PAs through direct observation and no studies directly assessed the safety of AAs. Few of the studies screened for this research it found were of sufficient quality and relevance to current NHS policy and many studies were small, outdated, or lacked rigorous methods, making it difficult to assess the safety, effectiveness, or impact of PA and AA roles.
Significantly, it found no research that examined safety incidents or prescribing safety and there is no robust evidence assessing PA and AA in managing high-risk or complex patients.
There was some preliminary evidence that PAs could support hospital ward teams and emergency departments when undertaking carefully circumscribed roles and closely supervised. Evidence, however, suggests PAs struggled in primary care, where the role is more autonomous and clinically complex.
There is no direct evidence supporting the value of AAs in anaesthetics.
Absence of evidence
The limited evidence for the use of PAs in a clinical setting was jumped on by the British Medical Association which has long opposed the use of PAs and is currently taking the General Medical Council to court over what it calls a dangerous blurring of lines for patients between highly skilled and experienced doctors, and assistant roles.
“This research suggests that NHS leaders’ reliance on the absence of evidence of safety incidents in a small number of research studies is an error of logic that is likely to cost lives,” growled Phil Banfield, chair of BMA council.
The reason that the debate has become so fractious is because deaths have already occurred.
As Healthcare Today reported in early March, Karen Henderson, assistant coroner for Surrey, has raised concerns after an elderly lady called Pamela Marking was seen by an unsupervised PA in A&E in February last year and sent home without a medical review. She subsequently died.
“The mismatch between policymakers’ enthusiasm for expanding these roles and the lack of rigorous research evidence should be a red flag,” said Martin McKee, co-author of the study and professor of European public health at the London School of Hygiene and Tropical Medicine.
“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,” he continued.
Responses to the Leng Review close at the end of the month.
