The introduction of physician associates (PAs) into the NHS workforce has been a subject of considerable debate. Advocates argue that PAs can help alleviate pressures on an overstretched system, whereas critics highlight concerns regarding their scope of practice, limitations, and the implications for patient safety. The following write-up give you a “critical analysis” of the PA role, weighing its advantages and shortcomings, particularly in comparison to advanced clinical practitioners (ACPs).

Despite my personal reservations about the role, I acknowledge that the individual PAs I have worked with have been competent. However, broader systemic issues remain concerning their integration and long-term sustainability.

It is also important to note that I am an Enhanced Clinical Practitioner (ECP), rather than an ACP. However, when analyzing my workload and responsibilities, I often find myself functioning at an ACP level. This makes me question whether I am fully qualified to draw a direct comparison between the ACP and PA roles, but my experience does allow me to observe key differences in autonomy, training, and effectiveness in clinical practice.

The Promise of the Physician Associate Role

Physician associates were introduced to the NHS as part of a strategy to address workforce shortages and improve healthcare delivery. The role was modeled after the American physician assistant profession, with the intention of providing continuity of care, supporting doctors, and alleviating workforce pressures. The main promises associated with the PA role include:

Workforce Support and Alleviation of Physician Shortages

The NHS faces a chronic shortage of doctors, particularly in general practice, emergency medicine, and certain hospital specialties. PAs have been positioned as a workforce solution to help mitigate these shortages by taking on routine clinical duties

Proponents argue that PAs enhance efficiency by enabling doctors to focus on complex cases while PAs handle more routine tasks

Cost-Effectiveness

PAs are trained in a shorter period (typically two years post-graduate) compared to doctors, making them a cost-effective solution.

Their salaries are lower than those of doctors or ACPs, which could provide financial relief to the NHS

However, it is worth noting that PA starting salaries are higher than those of Foundation Year 1 (FY1) doctors, despite PAs having a significantly more limited scope of practice. This raises concerns about whether the financial savings associated with PAs are as substantial as often claimed, especially when considering their need for continuous supervision.

Improved Patient Continuity and Team Integration

Unlike junior doctors, who rotate frequently, PAs tend to stay in a department long-term, ensuring continuity of care and stability within a medical team

This could enhance patient satisfaction and contribute to improved multidisciplinary team (MDT) cohesion.

These are the positives I could come up with for this blog entry.

Limitations and Shortcomings of Physician Associates

I am going to just list a few to wet your appetite:

PAs are not independent practitioners; they work under the supervision of a doctor. Unlike ACPs, they lack independent prescribing rights, which creates bottlenecks in patient management

Their limited ability to make autonomous decisions can lead to inefficiencies, particularly in high-pressure environments like emergency departments.

PAs are unable to act on their examination findings due to their lack of prescribing abilities and restrictions on requesting certain imaging studies. This results in a duplication of workload, as doctors must re-examine patients, authorize prescriptions, and request necessary investigations, thereby negating some of the intended efficiency benefits.

The two-year postgraduate training program for PAs is considerably shorter than the extensive medical training undertaken by doctors or the rigorous clinical experience required for ACPs.

This has raised concerns about whether PAs possess the depth of medical knowledge necessary for patient safety, particularly when compared to ACPs, who usually have extensive prior healthcare experience as nurses or allied health professionals.

As of now, PAs are not regulated by the General Medical Council (GMC), which raises questions about their governance and accountability.

Unlike ACPs, who are often subject to Nursing and Midwifery Council (NMC) or Health and Care Professions Council (HCPC) oversight, PAs operate within a relatively ambiguous regulatory framework, which may impact professional standards and patient safety.

There have been frequent reports of PAs being prioritized over resident doctors for training and job opportunities, creating frustration among medical trainees – my X account is full of those.

This is particularly concerning as doctors undergo significantly more rigorous and extended training yet may find themselves competing with less-experienced PAs for roles and clinical exposure.

Such preferences can undermine medical training by diverting valuable learning opportunities away from future doctors, potentially impacting the quality of future NHS medical care.

Unfortunately, as with many professions, a few PAs have operated outside their scope of practice, which has contributed to the negative perception of the role.

There have been reported cases where PAs have made critical clinical decisions without appropriate supervision, leading to patient safety concerns. For example, in some instances, PAs have been found managing acutely unwell patients independently in emergency departments, despite their requirement for medical oversight.

Another example includes cases where PAs have prescribed medications despite lacking legal prescribing rights, relying on verbal authorization from supervising doctors but without direct review, raising concerns about accountability and patient harm.

These cases highlight the risks of role ambiguity and insufficient regulatory oversight, which can erode trust in the profession and place undue pressure on supervising physicians.

Many PAs May Not Have Fully Understood Their Role Before Entering Training

The PA role in the NHS has not been fully developed, leading to confusion and unrealistic expectations among new trainees.

Many PAs likely did not fully understand what they were signing up for, as the career trajectory, regulatory framework, and clinical responsibilities remain in flux.

This lack of clarity has resulted in professional dissatisfaction among some PAs, who find themselves unable to practice with the autonomy they may have anticipated, especially in comparison to doctors and ACPs.

Comparison with Advanced Clinical Practitioners (ACPs)

ACPs and PAs are often considered interchangeable by policymakers, but their roles, training, and capabilities differ significantly:

ACPs are typically experienced healthcare professionals (e.g., nurses, paramedics, physiotherapists) who undergo a structured master’s-level training program to expand their scope of practice.

PAs, in contrast, enter their training programs without prior healthcare experience, which can create disparities in clinical decision-making capabilities.

ACPs often gain independent prescribing rights and can function with a high level of autonomy.

PAs, due to their lack of prescribing rights and requirement for continuous supervision, are less able to function independently.

ACPs align more naturally with existing NHS structures, particularly within nursing and allied health professions.

The PA role, being modeled on the American system, does not integrate as seamlessly, leading to professional tensions and role confusion within clinical teams.

Personal Perspective and Conclusion

From my perspective, I am not inherently supportive of the PA role. The concerns regarding training duration, lack of prescribing rights, and ongoing supervision requirements make me question whether the PA model is the best fit for the NHS. The ACP route appears more robust in ensuring safe, competent, and independent practitioners.

That said, I acknowledge that the individual PAs I have worked with have been competent and professional.

However, their limited scope of practice often necessitates additional input from doctors or ACPs, which can reduce the purported efficiency benefits.

Apologies for the long read, but I hope this clarifies the discussion for those new to the PA/ACP(ECP)/resident doctor debate