Physician Associates

Barbara Keeley Excerpts

Thursday 6th July 2023 Commons Chamber

[Barbara Keeley (Worsley and Eccles South) (Lab)]

I applied for this debate to discuss the use of physician associates in the national health service and I am grateful for the opportunity to bring this important subject to the attention of the House today.

This issue was raised with me following the very sad death of Emily Chesterton, the daughter of my constituents Marion and Brendan Chesterton, who are in the Public Gallery today. Emily died in November 2022 after suffering a pulmonary embolism. She was just 30 years old when she died.

Emily was a budding actor in musical theatre. She studied at the Liverpool Institute of Performing Arts and performed in numerous productions. She was also a winner of the Hammond House poetry prize in 2018. Emily’s mother, Marion Chesterton, describes Emily as active and always willing to help others.

Emily and her partner, Keoni, moved to London from Boothstown in my constituency to pursue their careers in the arts. They registered with their local GP surgery, the Vale Practice in Crouch End, north London. Emily had been diagnosed with polycystic ovary syndrome and had also contracted covid-19 late last summer.

My constituent, Marion Chesterton, said that Emily had been feeling unwell for a few weeks before she made an appointment at the Vale Practice on 31 October 2022 as she had calf pain and was breathless. Emily believed that this appointment was to see a GP, but the person she was booked to see at the practice was a physician associate.

A physician associate does not have the depth of training that a general practitioner would be expected to have, as they are not a doctor. A physician associate can practise after just two years of training. Importantly, physician associates are intended to supplement more qualified staff, not to replace them.

After a short appointment, the physician associate diagnosed Emily with a sprain and possible long covid. She was told to rest and take paracetamol. At no point during the appointment at the GP surgery was Emily made aware that the person who had diagnosed her was not a doctor.

A week later, on 7 November, Emily began to feel very unwell. Her leg was swollen and hot and she struggled to walk a few steps without becoming out of breath. She made another appointment at the Vale Practice and saw the same physician associate. It appears that this was a short appointment and that Emily’s legs were not examined.

The physician associate suggested that Emily’s breathlessness was due to anxiety and long covid and prescribed propanolol for the anxiety. In messages Emily sent on this day, she described seeing “the doctor” and it appears that she was never told that the person she was consulting for medical assistance was not a fully qualified GP.

In its serious incident report, the Vale Practice states that patients should not see a physician associate twice for the same condition, and guidelines make it clear that physician associates cannot currently prescribe, with any prescriptions needing to be signed off by a supervising GP. It appears that the oversight of prescribing medication was missing and that this system failed in Emily’s case.

Later in the evening of that same day, 7 November, Emily’s health deteriorated while she was out for a meal with her partner and parents. She took a propanolol tablet as advised by the physician associate. Emily’s mother, Marion Chesterton, told the coroner’s inquest into Emily’s death that Emily immediately became drowsy and that they all soon left the restaurant, with Mr and Mrs Chesterton driving Emily and Keoni back to their home in Crouch End.

On returning home, Emily became very ill. Her partner, Keoni, recalled to the inquest that she lost her pulse and he had to perform cardiopulmonary resuscitation on her, which recovered the pulse. Keoni then called an ambulance.

Mr and Mrs Chesterton then returned to Crouch End to be with their daughter. Marion Chesterton recalled that, when she saw Emily, she was squatting on the stairs. She sat with her daughter as they waited for the ambulance. Marion said:

“Emily asked me in a quiet voice to please help her, and I tried my absolute best to keep her calm, stroking her hair, holding and supporting her on the step as best I could, reassuring her that all would be well, not to panic, that I loved her…I noticed that she had lost some responsiveness, that she was extremely clammy, and her lips were turning blue. Her breathing had become very laboured, and she was rasping.”

Mrs Chesterton recalled that the ambulance arrived not long afterwards, around 45 minutes after Keoni made the first phone call. Emily suffered a cardiac arrest on the way to the hospital. Her family had to say their goodbyes while she was still on the machine which was pumping her heart for her.

Keoni recalled that staff at the A&E department at Whittington Hospital, where Emily died, told him that the propanolol tablet “definitely wouldn’t have helped” Emily’s condition. Staff had to give her an antidote to the drug.

The circumstances that led to Emily Chesterton’s death were investigated by a coroner, with a hearing at St Pancras Coroner’s Court on 20 March 2023. The coroner heard from representatives of the Vale Practice, Emily’s mother, Emily’s partner and the physician associate who had seen Emily.

Messages from Emily to her partner and family at the time of her appointments were also shared with the inquest. These messages evidence Emily’s belief that she was seeing a doctor. They also evidence that the appointments with the physician associate were short and that Emily was not examined fully.

The conclusion of the coroner was:

“Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”

That is a heartbreaking statement, making clear the failings in the health system, which should have supported Emily with appropriate care.

Further failings were evidenced in the incident report from the Vale Practice, which was provided by the practice to the coroner. Failings of the physician associate identified by the GP practice include not introducing herself to Emily during the appointment, not allowing Emily’s partner to accompany her into the consultation room despite this request being made and despite Emily being vulnerable because of her illness, not exploring the potential causes of Emily’s breathlessness, not documenting the severity of covid-19 that Emily had suffered from a month earlier, not exploring why Emily felt “clammy”, not documenting whether oxygen saturation readings after exertion or respiratory rate readings were taken, in line with clinical guidelines, and not referring Emily for an electrocardiogram, blood tests or other clinical investigations, also in line with clinical guidelines.

Crucially, the physician associate did not seek medical advice after seeing a patient who had presented twice in one week with significant risk factors for pulmonary embolism, such as polycystic ovary syndrome, recent contraction of covid, calf pain and breathlessness, and she sent Emily home without consulting a doctor. The practice later raised concerns about the physician associate’s knowledge and understanding of what appropriate investigations she should perform in a patient presenting with symptoms post covid, about her ability to recognise an unwell patient and escalate such concerns to a doctor, and about her over-confidence and lack of insight into the limitations of her own clinical knowledge and practice.

Two weeks after conducting the serious incident review, the practice made a collective decision to terminate the contract of the particular physician associate, as she appeared to be unable to co-operate with the practice’s supervision requirements. Then

“a decision was made not to employ physician associates going forward”.

Despite that, Mrs Chesterton tells me that the particular physician associate is still practising medicine in the NHS in London as a locum. She asks, “How is this possible?”

This case raises serious questions about the wider use of physician associates in the NHS, and particularly about allowing the provision of unsupervised one-to-one consultations in general practice. NHS information says that physician associates are graduates who have undertaken relevant postgraduate training and that they work under the supervision of a doctor. They will have been educated on a medical model with basic medical skills, but they lack formal professional regulation and they do not have prescribing rights. Most physician associates work in general practice, acute medicine and emergency medicine.

The physician associate role was introduced into the UK 20 years ago—I have to say that before looking into this case I had never heard of the physician associate role, but it appears it has been around that long—in an attempt to address workforce shortages in underserved primary care practices. The role was based on the physician assistant role in the United States, which dates back to the 1960s.

Physician associates are expected to be under the supervision of a designated medical practitioner, but that does not appear to have been the case with the lack of supervision that occurred in the case of Emily Chesterton. When qualified medical professionals such as GPs are already stretched, it is easy to see how tasks such as checking the notes and work of a physician associate could be missed.

There is also the problem of the title of the role, which Marion Chesterton told me sounds

“extremely grand, even grander than a General Practitioner”.

She suggested that the name should change to “doctors apprentice”, “learner doctor” or “probationary doctor” to avoid confusion, and it should be made very clear who patients are seeing.

Marion Chesterton also told me:

“We only discovered that the medic treating Emily was not a doctor the week before the inquest. This caused us extreme distress.”

She asks:

“Could something be put into place to keep families fully aware earlier on in the process?”

Crucially, it is very concerning that there is no statutory registration system for physician associates. There is only a voluntary register. In July 2019, the Department of Health and Social Care announced plans for the General Medical Council to regulate physician associates, pending the passing of new legislation. After a consultation in 2021, the timetable for regulation has been beset with delays. The Royal College of Physicians and the Faculty of Physician Associates have called these delays “frustrating and disappointing”. It was not until February this year that the draft legislation was published and put out to a public consultation.

When will the Government respond to the consultation and when does the Minister expect the legislation to regulate physician associates to be debated and approved? It has been, as I said, 20 years since the role was introduced. In 2018, as the Minister may know, the hon. Member for Newton Abbot (Anne Marie Morris) promoted the Physician Associates (Regulation) Bill, a private Member’s Bill. In 2019, the Government committed to regulating physician associates. That was four years ago now.

The Royal College of Physicians and the Faculty of Physician Associates have led the RegulatePAsNow campaign since May last year. The Faculty for Physician Associates said:

“We believe that regulation is fundamental to ensuring that physician associates remain a safe and effective workforce in the future.”

We also know that regulating physician associates has public support. A petition calling for the statutory regulation of physician associates was signed by nearly 6,000 members of the public.

It is clear that the legislation underpinning the regulation of medical practitioners is now in urgent need of reform. The Medical Act 1983 is now 40 years old, and the General Medical Council has described it as

“complex, overly prescriptive and slow to adapt to change.”

It has taken the Government too long to recognise that, and progress is happening at a snail’s pace.

What will the Minister do, from today, to ensure the safety of patients being treated by physician associates? What measures will he introduce to ensure that patients know the role and qualification of the person they are seeing when attending appointments in general practice settings? Those questions are becoming increasingly pressing as more people enter the physician associate role. There are currently more than 3,000 qualified physician associates working in the UK. Although the numbers look relatively small at the moment, the General Medical Council expects them to grow steadily in the next few years, with one study estimating a projected growth of 1,000% per year.

Growth in the number of physician associates will be turbocharged by proposals in the Government’s recently published NHS long-term workforce plan. The plan aims to more than triple the number of physician associates in the NHS workforce in the next 12 years. By 2037, they will total 10,000, with around 1,300 trained annually from this year, and 1,500 trained each year in 10 years’ time. In response to the Government’s long-term workforce plan, Latifa Patel of the British Medical Association said that the proposed wider use of physician associates

“must come with clear boundaries around expectations, and not impact on the training of medical students and doctors.”

The coroner concluded that the poor quality of care given to Emily Chesterton by the physician associate at Vale Practice contributed to her death. That concerns me deeply, and it should concern the Minister, too. The Government must now move quickly to regulate physician associates and learn from the events that led to the sad and tragic death of Emily Chesterton.

I want to finish with the words of Emily’s mother, Marion:

“We feel extremely let down by the care provided by the GP practice. We have lost our precious, beautiful, kind, loving, talented and irreplaceable daughter, and this must not be allowed to happen to any other family.”

--- Later in debate ---

[Barbara Keeley]

I take what the Minister has said about the training and voluntary registration aspects, which I did speak to, but could he comment on the situation we seem to have been in? The GP practice had concerns about the physician associate’s knowledge and understanding of what investigations she should perform, her ability to recognise an unwell patient, and her overconfidence and lack of insight into the limitations of her own knowledge. Those are the issues that the GP practice itself reported. Does the Minister share my concern that it is a very serious thing to have had a system like that, and, surrounding that, to have the fact that the reception function in that practice did not realise that it should not refer an unwell patient to a physician associate twice within a short period of time? If these are meant to be safety measures, they are not working, are they?

[Will Quince]

I hear what the hon. Lady says. In response to her questions, we very much need to look into the exact details, and I hope I will be able to respond to her with full answers when I have received both the coroner’s report and further information from NHS England regarding the practice itself. On the face of what she has just said, the situation is concerning and it certainly adds weight to her calls for the register to be non-voluntary and for regulation and legislation in this space. I will come on to that issue in a moment, because it is a case well made.

The physician associate role is in no way a replacement for any other member of the general practice team—that is an important point to make. They work in conjunction with the existing team, and are complementary to it. Physician associates can help broaden the capacity and skill mix within the practice team to help address the needs of patients in response to the growing and ageing population faced by constituencies up and down the country, including the hon. Lady’s constituency and, indeed, mine. However, let me be clear: the employment of a physician associate does not in any way mitigate the need to address the shortage of GPs, nor does it reduce the need for other practice staff.

I will talk, not about the specific case that the hon. Lady described—I do not have those details—but about the generalities of the responsibilities of a supervising doctor, which may be relevant in this case. Physician associates are dependent practitioners: they are working with a dedicated consultant or GP supervisor. They are able to work autonomously but, vitally, with appropriate support, and the General Medical Council has published guidance for doctors who supervise physician associates. The supervision of a qualified physician associate is similar to that of a doctor in training or a trust-grade doctor, in that the physician associate is responsible for their actions and decisions. However, the medical consultant or GP supervisor ultimately retains responsibility for the patient.

The hon. Lady has called for regulation. As she alluded to, the General Medical Council is well advanced in developing regulatory processes for physician associates once the necessary legislation is in place, and regulation will give the GMC responsibility for, and oversight of, physician associates and anaesthesia associates in addition to doctors. That will enable a more coherent and co-ordinated approach to regulation and make it easier for employers, patients, and of course the public to understand the relationship between the roles. The hon. Lady asked specifically when that legislation will come forward. We intend to lay legislation before the House at the end of this year, which will allow the GMC to commence the regulation of physician associates by the end of 2024—legislation by the end of this year, and then a year for it to be put in place.

The General Medical Council has published future professional standards for physician associates. Among other things, that includes working within the bounds of professional competence and knowing when to refer, or indeed to escalate, to a colleague within the practice. Those standards also cover communication with patients, including the importance of physician associates explaining what they do and how their role fits in with other members of the medical team. Once regulation commences, the GMC will be able to investigate concerns raised about physician associates, and in serious cases will be able to prevent a physician associate from practising, either on a temporary or a permanent basis.

[Barbara Keeley]

I want to go back to the point I made to the Minister about the title of physician associate, which I have used a lot and so has he. The point is that it does sound rather grandiose as the name of a role in clinical practice for a person who has trained for only two years, and it is confusing. I have been steeped in health and social care matters in this place—I have been a member of the Health Committee and had Front-Bench responsibility for it—and I had never heard of physician associates, so it does seem confusing. The title itself is confusing.

[Will Quince]

I thank the hon. Lady for her intervention, and I gave careful thought to the point she raised in her speech. Although the terms she used were doctors in training or trainee doctors, physician associates are not doctors in training and they are not doctors. They are very different, but they are a part of a multidisciplinary team. I will take away what she says. She is right that they have been in place for well in excess of 10 years, but nevertheless there is still a relatively small number of them. However, there are plans to significantly grow their number, so I will take that away.

Personally, as part of my own experience of the NHS, I have never seen a physician associate, but when I have been in general practice, I have often seen a paramedic, a physiotherapist or a pharmacist and they have made their position very clear at the outset of the appointment. I think we need to ensure that, regardless of the title— I will take that away and look in some detail at whether it needs to be changed—they are properly introducing themselves and their role, making it very clear to patients that they are not a doctor but are working under the close supervision of one, and making it very clear that they are not able to prescribe but a doctor can. I think that is the most important point, but the hon. Lady raises a very good point about the title and I will consider that very carefully.

[Barbara Keeley]

I think this is actually related to the confidence one has or does not have. The Minister says he takes advice from pharmacists, as do most of us, but we tend to know in that circumstance that it is a pharmacist we are talking to. There are receptionists, physios and all these types of people working in GP practices, but this was a person who to all intents and purposes looked like a doctor. That knowledge of the short period of their training, and of what they can actually do and not do, really ought to be more visible.

[Will Quince]

I hear what the hon. Lady says, and I will certainly take that away and give it considerable thought. If she has any particular ideas in this regard, given her experience on this matter, I would of course be very happy to meet her to discuss this further. It is really important, certainly ahead of legislation, that we get this right.

Before I close, I would again like to reiterate my deepest condolences to the family of Emily, and I thank the hon. Lady once again for bringing this debate to the House. As we develop and progress with changes to the NHS workforce, it is absolutely vital that robust governance and supervision sit at the heart of the multidisciplinary model, because at the heart of everything we do must be patient safety.

Question put and agreed to.