The chair of the British Medical Association says the draft national clinical protocols for PAs directly contradict the recommendations of an independent review.
Physician assistants are once again making headlines in the UK medical sphere, with the head of the British Medical Association penning an open letter lambasting a proposal which would allow PAs to treat undifferentiated patients.
The latest twist in the multi-year saga was the circulation of a new draft national clinical protocols for PAs.
It followed a lengthy review by Professor Gillian Leng, which was itself launched after PAs and Anaesthesia Associates became the focus of an “increasingly intense debate” around patient safety.
Professor Leng’s review concluded that PAs should not see undifferentiated patients “unless triaged into adult patients with minor ailments and within clearly defined clinical protocols as agreed by the Royal College of Emergency Medicine and the Royal College of General Practitioners”.
This was explicitly based on concerns around PAs making an incorrect diagnosis and sending patients down an incorrect treatment pathway.
While the BMA received a copy of the proposed clinical protocols for consultation, council chair Dr Tom Dolphin said the association was not included in the drafting process.
Writing to Professor Leng directly, Dr Dolphin called the direction of the draft protocols “unconscionable”.
“In November last year, we made clear we opposed the decision to allow the review team to select individual members of the medical and assistant professions as core members of the panel tasked with generating draft clinical protocols,” he wrote.
“The exclusion of those who formally represent the medical profession such as the BMA, as well as Royal College representatives, was a significant omission, one that dramatically reduced the usefulness and credibility of the group and has ultimately resulted in unsafe and highly flawed proposals.”
The draft protocols were not released for public comment and were only provided to a select group of stakeholders.
The Royal College of Physicians, however, has uploaded a copy of the document to the web.
“PAs working in a primary care setting should assess only limited groups of undifferentiated patients because primary care does not represent an environment where immediate in-person review can easily take place,” the draft protocol section on primary care said.
“Within these limitations and the PA’s experience, assessing undifferentiated patients may also involve in-person review by the clinical supervisor. PAs should not hold sole responsibility for making a final diagnosis.”
It also said that the clinical supervisor “should review and approve the list of undifferentiated patients with minor ailments assigned to the PA”.
Related
If a patient re-presents a second time with worsening or unresolved symptoms, the protocol said the PA should discuss the patient with their supervisor.
If the patient presents a third time, PAs are to give the patient an appointment with “a fully qualified GP”.
Dr Dolphin’s letter to Professor Leng called out what he saw as contradictions between her review findings and the resulting draft protocols.
“Regarding the content of the consultation, the document alarmingly seeks to substitute the issues that led to your report with a new narrative about the successful implementation of PAs in many NHS settings,” the BMA council chair wrote.
“For example, it notes ‘PAs played an important role in providing consistency and continuity for the healthcare system, supporting consultants and GPs in managing their patients.’ – a finding not included in your report.
“… A protocol which is based on an inaccurate and partial understanding of how the PA role is used in practice is one that is doomed to repeat the same mistakes.”
Overall, he said, the protocol document paints “a picture of safe working that is unrecognisable to most doctors” and will enable the NHS “to dangerously use PAs in a way that is little different to what was happening before” the Leng review.
“The BMA’s position is clear and without caveat – PAs must not assess, diagnose, or manage undifferentiated patients in any healthcare setting, and resident doctors (at any level) must not be responsible for their supervision,” Dr Dolphin wrote.
All has been quiet on the PA front in Australia for some time now; Queensland still allows PAs authorised under a practice plan to request some diagnostic procedures, but there are no university courses providing a pathway to the profession.
A study published in the Australian Journal of Rural Health earlier this year found very limited evidence of PA use in Australia.
