The debate over physician associates is necessary—but needlessly toxic

  1. Kamran Abbasi, editor in chief

  1. The BMJ
  1. kabbasi{at}bmj.com
    Follow Kamran on Twitter @KamranAbbasi

Pepperer. Grocer. Apothecary. Surgeon apothecary. General practitioner (https://www.apothecaries.org/history/origins).1 The evolution of medical associate professionals in the UK may not enjoy quite the same narrative arc, steeped as it is in workforce practicalities, but it does echo many of the controversies accompanying the introduction of apothecaries into medical practice.

The Apothecaries Act of 1815 handed responsibility for medical training and education, previously unstandardised and based on apprenticeships, to the Society of Apothecaries (https://navigator.health.org.uk/theme/apothecaries-act-1815).2 In a lecture on the origins of general practitioners, the doctor and historian Irvine Loudon summarised the two contrarian views of the act as either “among the great reforming Acts of the 19th century” or “as a result of a degrading compromise” (https://bjgp.org/content/33/246/13.long).3

Disputes over professional training and regulation are invariably heated, sometimes damaging. The return of medical apprenticeships, seen as one route to widening access to a medical career and retaining skills in local areas while meeting workforce needs, is controversial (doi:10.1136/bmj.p2385).4 The dispute over regulation, training, and naming of medical associate professionals—who aren’t medical doctors—has reached such a point that the BMA has demanded that recruitment be paused (doi:10.1136/bmj.p2808).5

The UK has fewer doctors per head than other rich countries. This isn’t a new problem (doi:10.1136/bmj.j2940),6 but it is now an acute one. The government’s flawed workforce plan sets out ambitions to increase numbers of doctors, although it doesn’t explain how those doctors will be trained and how their career progression will be ensured (doi:10.1136/bmj.p1577 doi:10.1136/bmj.p1515).78 Having more doctors, however, will not meet escalating demand for healthcare. Reducing demand itself, by investing in primary care and public health, isn’t a political priority.

The rise of “physician assistants” and physician associates in various guises is an international phenomenon. The rationale is the same: meeting growing demand isn’t possible only by increasing numbers of doctors. Physician assistants were first introduced in the United States in the mid-1960s to relieve workforce pressures in primary care (doi:10.1136/bmj.325.7362.485).9 According to a recent study in The BMJ, around 25% of healthcare visits in the US, before the covid pandemic, were being delivered by either a nurse practitioner or a physician assistant (doi:10.1136/bmj-2022-073933).10 US primary care is likely to move further in this direction with the possible demise of family medicine, greater numbers of practitioners and assistants, and creation of a two tier system epitomised by “concierge care” for people who can afford it (politico.com/news/2023/11/26/future-of-primary-care-family-medicine-00128547).11

One way to solve the crisis in primary care, argue Aneez Esmail and Sam Everington, “is to establish a pathway” for physician associates to train as doctors and for newly qualified doctors to enter GP training immediately (doi:10.1136/bmj.p2797).12 Physician associates should be adequately trained and supervised, integrated into clinical teams, and regulated by the General Medical Council, they say. The BMA, however, believes that associates should not be regulated by the GMC (doi:10.1136/bmj.p2808).5

Partha Kar, in describing the current row over medical associate professionals as “an unqualified mess,” outlines a five point plan for us to pause, rethink with calm heads, and consider how we work together (doi:10.1136/bmj.p2689).13 With the ongoing dispute over doctors’ pay, where a government offer to consultants will be put to a vote (doi:10.1136/bmj.p2801),14 trainees are left wondering “why these roles exist and why they have no regulatory framework or definition of scope.”

Helen Salisbury helpfully boils the problem down to the question of what knowledge and skills are required, for doctors and associates in their complementary ways, to practise safely in the best interests of patients (doi:10.1136/bmj.p2793).15 It is a matter of adequate education, training, and supervision. Given the importance of these issues, says David Nicholl, the call for a pause in recruitment is the “most sensible way forward” (doi:10.1136/bmj.p2789).16

While new roles have always brought professional tensions, it is bewildering that the training, supervision, and regulatory needs of a patient facing workforce of hundreds of thousands have been a secondary consideration—a destructive case of service provision by spreadsheet. Avoiding the issue has made it toxic. It must be possible to agree that medical associate professionals can contribute to meeting the population’s health needs, to understand that roles, training, and regulation must be urgently clarified, and to respect the professionalism of medical trainees and associates in the process.



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