Study Questions Safety and Effectiveness of PAs and AAs

The evidence supporting the safety and effectiveness of physician associates (PAs) and anaesthesia associates (AAs) in the UK is “sparse and of variable quality,” according to a new study published in The BMJ. 

The researchers warned that the lack of safety incidents in a few small studies does not prove PAs and AAs are safe to deploy. They called for urgent research “to explore staff concerns, examine safety incidents, and inform a national scope of practice for these relatively new and contested staff roles.”

While some studies have suggested that PAs could support hospital ward teams and emergency departments when appropriately deployed and supervised, “the number of individuals and settings studied was small, and those findings should be considered preliminary,” stated the researchers from the University of Oxford.

Trisha Greenhalgh, lead author and professor of primary care health sciences, stressed the need for stronger evidence. “At present, we simply do not have the data to support claims that these roles improve efficiency or maintain patient safety,” she said.

No Evidence of Added Value

PAs and AAs are graduates, typically with a health or life sciences degree, who complete 2 years of extra training. However, the effectiveness and safety profile of these roles have been heavily scrutinised and debated.

The researchers analysed 29 studies on PAs and AAs. They found that the total number of PAs studied was small, especially in primary care. No studies directly assessed AAs. 

Only one study involved a doctor directly observing the clinical competence of PAs, and none examined safety incidents. Some research indicated that PAs seemed to struggle in primary care because the role was more autonomous, the case mix more diverse, and decisions more uncertain. Also, institutional support was more limited, and supervision arrangements more challenging. 

Overall, the researchers found no evidence that PAs improved primary care or that AAs added value in anaesthetics. Some findings suggested they did not. The researchers also found no proof that these roles improved efficiency or reduced costs. Instead, the need for senior doctors to supervise PAs and AAs may make them more expensive than employing doctors, the authors suggested.

Concerns Over Patient Safety

There are more than 3500 PAs and around 100 AAs working in the NHS in England, with plans to recruit more. Most work in general practitioner surgeries, acute medicine, and emergency medicine under the supervision of doctors. 

Recent reports have raised concerns that many patients are unaware of being seen by a PA rather than a doctor. Some patient deaths have also been linked to misdiagnosis by PAs.

The study warned that assuming a lack of reported safety incidents equates to an absence of risk is “an error of logic that is likely to cost lives.”

Professor Phil Banfield, British Medical Association council chair, criticised the decision to recruit for these roles despite the lack of evidence on safety. This should have “set off a chorus of alarm bells” for policymakers. Instead, they “seem content to charge ahead, having ignored the genuine concerns of doctors, as well as warnings from coroners,” he said.

Calls for Regulation and Oversight

Professor Kamila Hawthorne, chair of the Royal College of General Practitioners, said it was the College’s position that PAs “do not have a role in a general practice setting.” However, as around 2000 PAs already work in general practice, the College has developed guidance on induction and preceptorship, supervision, and scope of practice. 

The Royal College of Physicians had also published guidance. It states that PAs should “never function as a senior decision maker,” should not determine hospital admissions or discharges, and should not prescribe medication. Additionally, resident doctors should not be responsible for supervising PAs; that duty should be the responsibility of senior doctors.

In November, the government launched a review of the role of PAs and AAs, led by Professor Gillian Leng, president of the Royal Society of Medicine. A spokesperson for the Department of Health and Social Care said regulation of PAs and AAs by the General Medical Council, which began in December 2024, would “ensure patient safety and professional accountability.”

Martin McKee, co-author of the study and professor of European public health at the London School of Hygiene & Tropical Medicine, warned in a statement that the enthusiasm for these roles and the lack of rigorous evidence “should be a red flag.” 

He added: “Workforce shortages are a real challenge, but they cannot be addressed by replacing doctors with people whose training maps poorly to the duties expected of them, and who may be inadequately supported, without a clear, evidence-based strategy.”

Dr Rob Hicks is a retired NHS doctor. A well-known TV and radio broadcaster, he has written three books and has regularly contributed to national newspapers, magazines, and online. He is based in the UK.