A sorter version of this article was published in our print-version of Vital Signs and circulated at the BRI and Southmead hospital. Feel free to give us a hand or donate to the project.

There’s too many different job titles in the NHS, and it’s hard to keep track of what they all mean. If you’re not plugged in, a Nursing Associate, a Staff Nurse, a Healthcare Support Worker and a Nurse Practitioner all sound pretty similar. It doesn’t help that they always seem to be making up new job titles that seem to overlap with other ones that already exist but are somehow on wildly different wages. Some of these newer roles have been catching some heat recently, in particular the Physician Associates (PAs). We think that this is a particularly interesting one, and since there is a lot of noise around it at the minute that it would be useful for us to look a bit more deeply at what is going on here.

PAs aren’t actually a new thing. They’ve been around in the NHS since 2003, and are based on similar job roles in the US, France and Germany. In 2024, there were around 3,000 PAs working in the NHS. Just for reference, there are around 140,000 doctors, 377,000 nurses and around 401,000 healthcare support workers. Why is it such a big topic then? The point here isn’t to add to scandal or come out for or against PAs, but to look at what this argument tells us about health work more broadly.

The crux of the matter seems to be the “Long Term Workforce Plan” that was launched by NHS England in June 2023. In it, there was a commitment to increasing the number of PAs in the NHS to 10,000 by 2037. It seems that anecdotally, PAs are being used more and more though, and that they are taking on more of the work that doctors would historically do. When they were introduced, they were imagined to be sort of supporting roles for doctors, doing a lot of the work that stopped doctors from focusing on patients. Mainly, they are employed in Primary Care, such as in GP practices, but there has been a steady increase in how many are working in hospitals as well. With the increase in their use, doctors in particular have been very vocal in opposing the increased use of PAs across the NHS. There has also been a slurry of scandals relating to PAs apparently overstepping boundaries and “acting outside of their clinical capabilities”. 

Doctors’ opposition

A lot of the doctors’ opposition is framed in terms of patient safety. This is obviously a legitimate concern, and there have been instances where a PA working “above and beyond their capabilities” has led to harming a patient. This concern over safety is a legitimate one, and doctors’ focus on providing the “best quality” healthcare is one that we should support.How we understand “best quality healthcare” isn’t so much of a straightforward question though. There are so many inputs from so many workers into providing healthcare, from cleaners ensuring a sanitary environment, catering workers providing the correct diets to patients to workers on assembly lines constructing hospital beds or medication. Even in the case of deciding what treatment a patient needs to be given at any time, this might involve the input of doctors but also of nurses who’ve worked in a given area for years. It might involve taking into account something that an HCA has observed during a long 1:1 shift, or something that the patient has said to a domestic while they changed the bins in the patient’s room. If we want to seriously think about how we develop a better healthcare system, and society, we need to pay attention to and build on the day to day cooperation between workers of all levels of experience and expertise. The problem that we have is in how we view this.

In the way that it is being framed, doctors are the only possible fount of medical knowledge because of their long training and studying. The perspective is quite paternalistic really; only us as experts should be making decisions because nobody else has the know-how. It’s in the interest of doctors to keep things this way. The consultant becomes a gatekeeper to scientific and medical knowledge that is locked away in universities and pharma company research departments. Instead of defending the concentration of medical knowledge into a relatively small number of hands, we should be looking for ways to socialise this knowledge; breaking down barriers between health workers, and between health workers and other workers. The insistence of doctors that only they are in a position to make decisions over treatment and care, as well intentioned and logical as it might sound, only really builds these walls up more. We need to look at ways that we can do this on wards and in departments in our communities and neighbourhoods.

While we would definitely consider the concerns over quality of care and patient safety entirely sincere, there is also something else beneath the opposition to PAs. At the minute, the reliance of the health system and the NHS as an employer on the particular expertise of doctors creates a strong position for doctors to command a relatively high wage. Even though multiple governments have been trying to undermine this over time with pay stagnation, doctors are also reliant on this concentration of expertise to bargain and struggle for better wages. We saw this in the BMA strikes over the last couple of years, where doctors were able to use their privileged position in the work process to get a better deal than the rest of us. This isn’t a bad thing, doctors should be fighting for more. We all should! It does show us though that in order for doctors to have this kind of strength, they need to insist on the separation of themselves from other workers in the NHS. 

This special position of doctors is what is being threatened by the expansion of PAs throughout the NHS. The logic of the managers and bosses is pretty plain to see. “If PAs can do most of what doctors can, and they cost less in the long run, the more the merrier!” In general terms, a PA will be on Band 7 pay (£46,148 to £52,809 after 5 years). A doctor will start on £32,389 and only after 5 years of further training be on £55,329 (all based on 2024 pay rates). The thing is that doctors tend to stick around, and after 8 years or so you’re looking at a much higher relative pay rate. So, if you’re a wanky technocratic manager looking at ways to cut costs, having more PAs looks like a pretty good idea.The doctors’ trade union, the BMA, understands this. At the moment, it doesn’t look realistically like the government plans to replace doctors altogether. But it is an existential threat. 

Regulation and political weakness

Actual opposition to the expansion of PAs has only really taken a couple of forms. First is individual moaning on social media, endless arguments on discussion forums, and a slurry of articles in the media. The second, which is more interesting, is to push for regulation of PAs. 

The way it is currently supposed to work is that PAs only work under the direct supervision of doctors, and the doctor in charge will determine the “scope of practice”. With things how they are, all health workers being overworked and almost all departments being understaffed this is a recipe for disaster. The system is set up to be full of holes. Instead of being able to work through this collectively as health workers – which we could do if we were more united in wards and departments- in a way that we decide together on who is doing what, doctors are calling for an external body to sort it all out. The idea is that if they become registered that they will be accountable, and join the hallowed ranks of the “real professionals”. 

The question of legal responsibility is not one that we can shrug off. There are very real consequences to workers who fall on the wrong side of it. It is understandable that doctors don’t want to be held responsible for decisions made by “less qualified” colleagues, with the threat of being stripped of their registration and their job. We would have to work this out together. Accountability is useful, and is something that we would need to re-imagine in a transformed health system. Whilst it appears as necessary in the way things are now, we have to be able to develop forms of regulation and accountability that can’t be used as weapons against workers. We need to be accountable to each other, and this needs to be based on solidarity with colleagues and patients. To do this, we need the involvement of more than just the writers of Vital Signs, it is something we need to work out together in struggle.

The specific questions around what PAs should or shouldn’t be doing should be rooted in our concrete experiences, abilities and needs at work. We need to be breaking down these professional divisions rather than throwing up more walls. If we were able to do this, we would also undermine the bosses ability to pit certain sections of the healthcare workforce against each other. If there was more solidarity between doctors and PAs on the wards and elsewhere, there would be less chance that management and the government could use one to attack the other. This goes for every professional division in the NHS.

 

Physician Associates: An Interview

There are various new job roles appearing across the NHS, which seem to represent a dissolving of the traditional hierarchies of healthcare work. One such new role is that of the Advanced Practitioner (AP). To understand more about the function and background of the role, we interviewed a friend about his work as an AP. Comparing the roles of APs and physician associates (PA) gives a picture of two ways to respond to shortages in the medical workforce. On the one hand, you have the AP role that comes out of nursing and practical experience on wards and ‘encroaches’ on the role of the doctor from below. On the other hand, you have a position like the PA that comes out of academia with little immediate connection to the practical side of healthcare work. The PA seems more like a technocratic solution to the shortage of doctors by creating a ‘lean’ professional category from the top down. 

 

• Tell us a little bit about your job background. How does one become an Advanced Practitioner? What did you do before?

The Advanced Practitioner (AP) position comes from the role of nursing and how that role developed in the 1960s throughout Europe and North America. It all came from the process of expanding that role and the clinical scope of nurses. In Britain, it expanded in the ‘90s particularly when the first Nursing Practitioners came out of a course at university, and that was the part of the development of the specialist nurse role. It changed again in the early 2000s, where they opened up the possibility of becoming an advanced practitioner from different backgrounds in healthcare such as physiotherapists, paramedics etc. They all did a common masters programme, and the idea was that they were then able to be APs in their particular role. Nurses tended to have the widest scope, because of all the different jobs that nursing involves. But paramedics for example would go back to working in emergency or acute care in the ambulance service or in A&E, or increasingly in Primary Care. Physiotherapists would go back to being senior physios working in muscular-skeletal medicine etc. All these people would then be working in a high level of autonomous practice, so practicing without supervision, doing things like examining, diagnosing, treating, formulating clinical plans etc. 

There were a couple of things in the background that led to this all coming about. For example nurses pushing against the boundaries of nursing, and restrictions on what they could and couldn’t do. At the same time, there was also a shortage of doctors in lots of countries, so this new role was definitely used to plug gaps. There’s a bit of a contradictory element here, because there is arguably a need for a medical practitioner who’s a non-doctor. There’s a lot of common, reasonably simple medical problems that you could argue don’t need five years of medical school and all the specialist training to be able to deal with. But that’s a bit of a complicated area to get into.

It’s really difficult to look at these roles in isolation, without some understanding of, or figuring out how the health system might work in a better way. It’s hard to make sense of how these roles fit in individually without a kind of wholesale reevaluation of health and the health system, because at the moment it is really stuck in the framework of the particular professions.

• Was there a similar discussion around ACPs as there is now around PAs, where doctors say why are you taking away tasks from us? Or because there was a shortage, were doctors happy that some of the more menial tasks were being taken away from them?

What’s happened with the PA role is that it has expanded very quickly in even the last 10 years. Looking into the history of it a bit, it comes from the US, mostly. In WWII there was both a shortage of doctors and obviously a growing need for an expanded doctor workforce, so they shortened medical training. Out of that emerged this “Physician’s Assistant” role. This worked quite well for some time, particularly because of the geography of America where you have all these small, rural communities. You can see the logic where it makes sense to have a small clinic, with a PA running it and you don’t need to employ a doctor and then you can have a larger clinic nearby with a doctor in and more specialist services etc. So the PA thing in America actually existed quite happily for quite a long time in America. I remember meeting a PA  from the US years ago and being really impressed with how good they were, both clinically and just as a medical professional. 

After meeting this PA, I thought that I might like to do that role. I went to a few universities to have a look at the course in maybe 2015. They made it really clear that they didn’t want older professionals. They wanted younger people who had done a degree in a non-medical but tangentially related subject like biochemistry etc. I think that was right at the beginning of the expansion.

• Could one say that the ACP is like a career step for people who come from the medical sector, and PAs are people who come mainly from an academic background?

Broadly speaking, the AP role is aimed at people who are already qualified and very experienced in their field. They’re already a practitioner in their own rights, they’re already registered, they’ve worked in medicine for a number of years. Then, they do a 2 year masters course, then go back to roughly the area that they worked in before, but with advanced skills. There is also progression there as well. So, as well as being a practitioner in your own right and being able to work autonomously, without supervision from a doctor, you can move up various bands and there are different ways to expand your role. 

On the other hand, with the PA role, the job that you enter into is where you stay. They’re also not allowed to prescribe medicine, which is really severely limiting. They’re also always supposed to be working under some kind of supervision from a doctor, which is one of the big bugbears that some doctors have. I can understand, and see why that’s difficult. 

So the PA role massively expanded over the last five years, and in the last couple of NHS “Long Term Plans”, it has been mentioned specifically. The APs have also been mentioned and targeted for expansion, but the expansion of PAs has been more dramatic.

• In order to imagine where these jobs are situated, in a hospital for example, what would be a typical job that an AP does? What is the AP’s relationship to, say, nurses and doctors? And, what would be the role of a PA and their relationship to other more advanced health workers?

It’s difficult because of the fragmentation of the NHS into various care settings; everything from small GP surgeries in inner city areas through to massive hospitals with specialist areas. It also varies between trusts to the point that it’s difficult to come up with some entirely common picture. For instance, in the last hospital that I worked at, I worked in A&E as an ACP. I would be on the same rota as doctors, seeing patients that come in having not seen anyone before me. So for all intents and purposes I was doing pretty much the same job, albeit to a lower educational and skill standard, as a doctor. I wouldn’t have to go to a doctor to sort of check that what I was doing was alright. I just saw the patient all the way through from admission to discharge. Obviously, if I had questions I could go and ask a doctor or consultant. There were no PAs in A&E at the time, but there were PAs on wards. They generally spent time transcribing doctors’ notes, saw patients but then would have to go and discuss what they were doing with a doctor. At the same time it did vary between departments. Some of the stuff that has been in the news about PAs is because PAs have been doing procedures etc that have previously been reserved for doctors. So, I’m not sure I can come up with a common picture of what they do. It’s part of the problem of coming up with a way to pigeon-hole what non-doctors and non-nurses do in terms of their medical practice. 

As a nurse, a non advanced practicing or specialist nurse, you’re usually working as part of a ward team and there is quite a clear remit of what they can and can’t do. They don’t order tests, they don’t prescribe or interpret results, or diagnose – there’s a whole category of what is considered “nursing work” and that’s quite clear. Whereas in other roles such as Advanced Practice, Physician Associate and probably a fair few others, the scope isn’t really defined as to what you can and can’t do. It’s mostly down to what you’ve been trained to do, what you’re competent to do and what you are confident to do. So, ACPs and what has happened with PAs is that you’ve been trained to do a procedure, and you’ve been signed off as competent to do it and then you do these procedures which were previously much more the scope of doctors. There isn’t this simple thing where on paper you’re allowed to do A, B and C and you’re not allowed to do X, Y and Z. It’s more like, “you definitely can’t do A, but if you’ve had some training you can do B, C, Y and Z”. 

• Could you describe the situation in the A&E? Were there clashes of competency? Was there stress around it?

There weren’t clashes in the A&E that I worked in, but I imagine that it varies from hospital to hospital. Where I worked was good, there was no stress between the different roles, and because of the structure of A&E it tends to be much more of a horizontal structure than situations like on wards. In A&E there tends to be a much more collaborative environment between the various professions, so it is a much easier place to get on in a role like mine even though the pace is faster and there’s more time-critical decisions, sicker patients etc. Nurses there tend to be much more experienced and are doing things that nurses wouldn’t do in other areas of the hospital. It’s also a place where newer doctors tend to do a rotation, and you often have the situation where there’s an A&E nurse who’s been working there for maybe 15 years showing the doctors what to do and explaining how things work – even to the point of double checking what the doctors are doing. So in a way because of the nature of the workload you have this more flat structure which seems different to other areas. The cliché is that surgical wards are particularly hierarchical, and my experience of PAs in hospitals is PAs on surgical wards basically being the doctor’s dog’s body.

This happens all over the place though. In the same way that there is this growing space in medical care for diagnosis and examination between registered workers like nurses or paramedics and doctors, you now have Health Care Assistants and other medical workers doing jobs that only nurses would do traditionally. So everything’s kind of upscaled a bit in terms of scope of practice and responsibility.

• So why wouldn’t they fill the whole of A&E with ACPs, wouldn’t that save money? Is it that a lot of the doctors who are working there are relatively junior [resident] doctors and would be on lower pay? 

I don’t know, but I would guess that there is a sort of “best practice” number of doctor that you have in any given department of various grades which means that it’s really unlikely that staffing an A&E with just PAs and ACPs is going to happen. There would also probably be a fair bit of resistance to that generally from hospital management and senior consultants in most departments.

This is one of the things that I struggle with politically about my role [less with ACPs because of the background] is the nature of our work being historically what doctors were supposed to do. There’s a question as to how much this is undercutting the position and the pay of doctors. 

I definitely had one job, not as an ACP, but one where the NHS contracted an out-of-hours service and the people who ran the Trust were very clear that at some point instead of employing a load of GPs, they wanted to employ one GP to supervise 5 or 6 PAs because it would be loads cheaper. Again it gets complicated, because there is also the empirical fact that there aren’t enough doctors, so you can’t look at it in isolation. Doctors’ training is completely inaccessible to lots of people because of the cost and the kind of high bar of entrance.

• What band is an ACP?

You start at 7 and then go to 8 when you’re qualified. It’s a high wage.

• On the level of assessment, treatment plan etc, do you think that ACPs can cover most of the needed skills in A&E, for example, or were there things that it was still necessary to delegate back to the doctor because you didn’t have the necessary skills or knowledge?

Medicine and people are really complicated, and nobody can ever know it all. One of the main things in medicine is understanding the limits of your knowledge and competence, and it never being an issue to just say, “I don’t know what’s going on here.” That is pretty common, doctors are always going to consultants, even doctors with many years’ experience, and just say that they don’t know what’s going on. You also always get consultants saying the same. Just as commonly, you have people saying that they do know what’s going on but despite everything that they’re doing the patient is just not getting any better. This is just part and parcel of the vagaries of medicine and the human body. So, it’s not really a thing of ACPs being able to replace doctors, or not being able to.

Going back to the PA role, I do think that this is a problem. A 2 year training course is not very long, and you come to the role with no medical experience. It’s a cliché, but in medicine you don’t know what you don’t know, and I think that it is easy to be confident in a role that you don’t really have the necessary experience. There’s this whole area that you don’t understand and it becomes a bit of a blind spot for you. There’s something about medicine as well that sometimes attracts egos, or at least unhealthy dynamics around things like capacity and knowledge. This is probably a bit where the PA role has become a bit stuck – a mixture of work pressures that force them into situations or procedures that they don’t really have the experience to do, even if they have been ‘trained’, combined with a bit of ego.

• You said that your experience with PAs has mainly been in GP surgeries. How do you think that relates to the discussion here?

Where I work now, we have a PA and they do the same thing as doctors, they sit in their own clinic with patients and they’re fantastic. They’re not that experienced, but they are very very good. I would have no problems seeing them if I was ill or recommending seeing them to anyone that I know. There’s some things they can’t do, like prescribing though so that does limit them a bit.

I would controversially say though that primary care medicine isn’t really that complex. You mostly see common conditions and ailments, like people with low-level viral illness, low level infections, musculoskeletal stuff, headaches etc. A lot of this stuff is really quite easy to deal with or refer to a specialist. In the worst case, if they really are unwell you can just send them to A&E. This won’t be particularly popular with GPs, but the reality is that primary care is a really good area of medicine for people like ACPs and PAs to work in. 

• You mentioned that PAs can’t prescribe. Do they do the diagnosis and then make a recommendation on what they would prescribe, then a doctor or ACP has to just sign it?

Basically. It’s a bit of a confusing situation really. In theory their supervising GP would go through each recommendation with them and double check that they agree with it before signing off. In reality though, they just have a quick look and someone goes through the electronic prescriptions system at the end of the day and just signs them all off. So, at the end of the day, it is an area that is a bit peculiar, and I can see why doctors aren’t particularly happy with the situation. As a doctor, or a non-doctor prescriber, you are taking some level of extra responsibility for another health care worker without that really being reflected in anything else. The rest of your workload doesn’t get reduced, you don’t get paid more. It’s just something that you’re just expected to do. At the same time, within the role of a doctor or an advanced healthcare professional, there is an expectation that you take responsibility for training and mentoring more junior colleagues, but as people are under pressure and stressed it is something that people are going to get wound up about. There is also the added question if who is responsible if something comes back. 

• What is the content of the 2 year PA course? Compared to a doctor’s 5 years, what is left out, do you know? 

When I was looking into it, it was explained to me as a sort of condensed version of the full medical degree. In order to do that though you would have to strip out a load of stuff, so you probably don’t go into things like advanced pathology etc. you’re also not prescribing which would be a year of the course. Going back to the discussion of how the role developed, I can see how in a crisis where society is desperate for medical workers, you could definitely strip it down to a training course like this. So long as these workers know their limitations, I can see an interesting argument there.

It’s all connected to those fundamental questions though; given a clean slate, how would we redesign a healthcare system? Who would staff that? Would you have all these different roles like HCAs, doctors, paramedics, nurses etc, or would you have people with multidisciplinary skills across the whole system? Would you want the same person diagnosing you and talking to you about your palliative care treatment to be the one who bed-bathed you and brought you your meals? There’s some pretty good arguments that I can imagine for that being the best thing for patients. You build relationships with health workers instead of what we have now where it feels like people swan in, give a diagnosis saying you’ve got x amount of time to live and then you never see them again – and the nurse or the HCA has to come in and deal with the emotional fallout of that. Underpinning all this is the fact that we have medicine in a capitalist system where people are paid wages, and things are structured how they are now because they have been developed in fits and starts over the last 200 odd years. Even if you took capitalism and money out of the equation this is still a structural problem that we would have to deal with in understanding and dismantling how health is regarded and the system is structured. 

It’s not easy to take a political line in the dispute between doctors and PAs. On the one hand you can say that doctors are defending a workers’ point of view, saying that they don’t want to be undercut. At the same time, they are defending what is really quite a privileged position which aims at keeping people out of the positions of medical expertise that they currently occupy. It’s difficult to work out how to confront this politically and try to understand the interests of everyone and not just a particular section of workers. Similarly with the PA situation, on one hand, capitalism will always try to minimise the investment in education and it will always try to lower wages. On the other hand, it generalises medical knowledge to a layer of the population who would not be able to go and study medicine for 5 years with all the money that’s bound up with that. So, it is also a process of socialising knowledge. It’s a contradictory situation, that it is important we work out a position from a class perspective, in the interest of all workers and working class patients.