RCS England Council Discussion on Physician Associates

At the February 2024 Council meeting of the Royal College of Surgeons of England, Council members discussed the role of physician associates in surgery.

Non-medical members of the surgical team include roles that have existed for some years such as surgical care practitioners, surgical first assistants and advanced nurse practitioners. Professionals in these roles have tended to come from nursing backgrounds and are often embedded members of the surgical team before undertaking structured training based on a curriculum, skills, and responsibilities. Similarly, in dentistry there are well-established non-medical roles such as dental hygienists, dental therapists and orthodontic therapists all with a very clear scope of practice regulated by the General Dental Council.

Physician associates have played a more limited role in surgical teams prior to the proposed expansion of numbers across the NHS, and there is not anticipated to be a role for physician associates in dental teams.  Nevertheless, there was a shared view in Council that:

• Physician associates must not replace surgeons or surgical trainees. On 7 February 2024, NHS England wrote to the Royal College of Physicians to confirm its view that physician associates cannot and must not replace doctors.
• There is an urgent need to define a national scope of practice and training curricula because of concerns about the variability, and in some cases inappropriateness, of clinical activities within individual NHS Trusts. Patient safety must be paramount. Urgent regulation is therefore also required.
• Training time for surgical trainees must be protected and enhanced. Where physician associates are employed, their responsibilities should enable doctors in training to leave the wards to attend learning opportunities in clinic or theatres.
• The role of surgical care practitioners, surgical first assistants and advanced nurse practitioners must not be undermined.

In addition to the Council discussion, RCS England recently responded to the Skills for Health Medical Associate Professions (MAPs) Career Development Framework. We strongly disagreed with the proposals in this document and we expressed our particular concerns about career development proposals for MAPs working in Tier 3 and 4 roles, described as clinical leadership roles, and which would overlap with roles that should be reserved for doctors. The consultation provided no context around roles and responsibilities within the team, how MAPs progress beyond their core skillset, what is reserved for a doctor and should not be undertaken by a MAPs, and where each member of the team sits in terms of responsibilities. We encourage Skills for Health to reconsider its proposals.

Next steps

RCS England is working with the other surgical colleges to define the core scope of practice for physician associates joining a surgical team as well as principles which individual surgical associations should use to determine the scope of practice specific to that specialty. This joint work includes representatives from ASiT, BOTA, the Federation of Surgical Specialty Associations, patients, MAP professional groups, Confederation of Postgraduate Schools of Surgery and the NHS. Surgical specialty associations are best placed to know what role, if any, physician associates can play within their specialty.

However, there is currently no guarantee that a nationally defined scope of practice for each specialty will be used by trusts to inform the parameters around the role of physician associates. Therefore, we will be taking the following additional actions:

1. Following their letter to the Royal College of Physicians, we will be discussing with NHS England how they plan to communicate their position to individual trusts to ensure physician associates are not performing duties that should be done by doctors and doctors in training, and to avoid scope creep.
2. We will discuss with the General Medical Council how they plan to reflect surgical specialty scope of practice in their intended regulation of physician associates. Our expectation is that this must be referred to in their regulation including through the education framework and approval of training, standards, revalidation and fitness to practise processes.
3. Local consultants are responsible for agreeing how physician associates are used in surgical teams. Through our communications with members we will continue to make clear to consultants that they should exercise this role responsibly and cautiously while national scope of practice and professional regulation are pending.