Jim’s Thoughts  – Episode 1

Welcome to the first edition of my bi-weekly column “Jim’s thoughts” in which I aim to break-down and discuss current PA news, and important clinical updates. This week I’ll be discussing my thoughts on the Nuffield Trust’s recent statement that Physician Associates should be regulated urgently.

The BMJ recently published an article in which the Nuffield Trust stated their position that without urgent regulation, Physician Associates cannot fulfil their full potential within an ever-evolving NHS workforce. PAs currently work alongside doctors in the medical team and are responsible for the medical management of primary and secondary care patients. They are, however, currently limited by  being unable to prescribe or request ionising radiation (x-ray, CT). In October 2018, the health secretary Matt Hancock announced that Physician Associate regulation would be taken forward by government.

The Nuffield Trust is an independent body of experts providing advice and ideas with the aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis. They have advocated the advancement of Physician Associate regulation for several years, in keeping with the Royal College of Physicians position that PA regulation was essential. In their May 2016 document “Reshaping the workforce,” the Nuffield Trust stated PAs represent viable solutions to a number of clinical workforce related challenges the NHS faces, but without regulation the role is limited in it’s potential and requires a prolonged period of supervision before clinical competency is assured. For many newly-qualified PAs, myself included, the prolonged supervisory period refers to the “graduate-year/internship year model”. I welcome this at this stage in my career since it offers a sense of security and support from a designated clinical supervisor. For more experienced PAs however, this model might be seen as restrictive, and recognition of clinical competence from statutory regulation and supporting portfolio evidence may be desirable.

From a general point of view, I firmly back regulation to ensure quality standards are maintained for PAs, and only qualified PAs, that is those who have passed both components of the national exam, are working under the PA title. Regulation is also important in the context of the ever-increasing numbers of PAs. In 2016, around 250 PAs worked in clinical practice. By 2020, the government aims to have 1000 working in primary care alone. With more and more Physician Associates working in clinical practice, statutory regulation would act as a much-needed form of quality assurance, ensuring that the role is only filled by suitably trained (and registered) persons. At present, it is at the discretion of the employing trust as to whether they elect to mandate that PA recruits have passed both elements. As a basic requirement, most trusts – but not all – require PAs to be registered with the Faculty of Physician Associates on the managed voluntary register, which can only be achieved if both the written and practical examination components are passed.

Many PAs and PA students, myself included, are passionately making their voices heard online, through twitter in particular, advocating statutory regulation as a matter of urgency. Some see regulation as a means of advancing their practice towards gaining prescribing rights, and being able to order ionising radiation (two key restrictions placed on the PA currently). Whilst regulation would open discussions surrounding prescribing rights, it by no means is a guarantee that PAs would automatically get prescribing powers, and in fact further consultation on the matter would inevitably be required before any decision is made in parliament. The “Physician Associates (Regulation) Bill 2017-19” states that within 6 months of the bill being passed, the Professional Standards Authority for Health and Social Care (“the PSA”) must report on PAs, including commenting on whether it is in the public’s interest for PAs to have prescribing rights, and be able to order ionising radiation.

Unfortunately, with the current political uncertainty regarding Brexit, it is difficult to comment on how much time is being devoted to expediting PA regulation. However, a quick online check shows that the “Physician Associates (Regulation) Bill 2017-19” has passed the second reading stage in the house of commons, and was due to be further discussed in late January. The bill still needs to go through the committee stage, report stage and a third reading before going onto the House of Lords for the same process of scrutiny. So whilst the bill may be anticipated to pass in 2019, it may be near the end of 2019 and almost certainly more progress will be made once our future relationship with Europe is determined.

Should statutory regulation for PAs pass, the next steps of gaining prescribing rights and the ability to request ionising radiation would be highly beneficial in my day-to-day practice as a Stroke Physician Associate. We deal with several acute and medical co-morbidities and complications surrounding stroke, many of which require pharmacological therapy. In addition, we utilise ionising radiation imaging greatly in diagnoses, management, and prognoses for our patients.

One option to make life a little easier for practicing PAs would be for government to alter legislation once PAs are regulated enabling them to give certain drugs under a patient group directive (PGD). I’m an advocate of this, as it would be at least a practical solution to some of the challenges I face, e.g. not being able to give paracetamol (or baclofen) to my patients who have pain related to spastic hypertonia. However, a PGD isn’t without its setbacks, notably that drugs being given to patients under a PGD cannot be delegated to someone else – the healthcare practitioner must physically give/administer the drug. Whilst this is advantageous for acute situations, it is impractical for the management of chronic illness.

In the meantime, we all eagerly await parliamentary progress on this key PA issue.