Physician Associates
Our stance
The NZRDA has long been sounding the alarm bells about the risks with Physicians Associates (PAs) practising in New Zealand. Chief amongst these are the significant risks to patient care and safety.[1] Regulation alone cannot eliminate these risks, and the rush to do so simply embeds these practitioners and the risks they pose into our health system.
Evidence of this failed experiment
We have mounting evidence of the failure of this PA model overseas. Amongst a “catalogue of errors”[2] by PAs in the UK, this includes several recent examples of misdiagnoses such as:
- A 79-year-old patient who suffered a serious brain bleed after being reassured by a PA that his painful headaches were “nothing to worry about”.[3]
- A 30-year-old patient death from a pulmonary embolism after being twice misdiagnosed with a “sprain” and “anxiety”.[4]
- A 34-year-old pregnant patient death from breast cancer which was misdiagnosed as a “blocked milk duct”.[5]
- A 77-year-old patient death resulting from a PA leaving an abdominal drain in for too long and directing the drain to be clamped, which increased the risk of infection.[6]
Locally, we’ve seen a similar case reported earlier in 2024 of a patient being misdiagnosed by a PA, which was later diagnosed by a doctor as a serious health condition that could have led to blindness if left unchecked.[7] Other instances of PA misdiagnoses in a Gore clinic has led to a brain bleed and vision loss, as well as a patient receiving treatment they had not agreed to.[8]
These are all instances of very avoidable patient harms resulting from the use of PAs. A common element in all these cases was the patient’s belief that they were being seen by a doctor.
There are also numerous reports of PAs practising outside their remit across multiple NHS Trusts, including:
- Being used to fill gaps in medical rosters and cover doctor shifts at over half of NHS hospital Trusts, despite not being medically qualified to do so.[9],[10]
- Illegally prescribing controlled medications – including opiates and sedatives – to hospital patients on at least 22 occasions.[11]
- Illegally ordering more than 1,000 hospital tests including X-Rays and CT scans, unnecessarily exposing patients to radiation.[12]
- Undertaking child forensic medical examinations, despite not being recognised as a professional legal witness, jeopardising the integrity of this evidence in court.[13]
These risks aren’t anecdotal. Empirical evidence suggests PAs frequently practice defensive medicine to compensate for their lack of medical training and that they tend to prescribe inappropriately.[14],[15]
Why do these risks arise?
These adverse incidents are happening not because PAs are bad people. Nor are they simply cases of human error. Instead, risks are inherent within the PA model of training and practice.
PAs are not doctors, despite intentionally misleading claims of being “highly trained medical professionals”.[16] Entry requirements into overseas PA programmes can range from a degree in homeopathy, computer science, or English literature, meaning in some cases PAs receive at most two years of medicine-adjacent postgraduate training before they are let loose on the public.[17] In contrast, it takes more than 10 years of medical training to become a general practitioner in New Zealand.
Risks also arise through the fragmented model of PA care. Since they are not qualified medical practitioners, they are (with good reason) limited in the scope of what they can and cannot do. This means the supervising doctor is often allocated only the most complex or difficult patients, with PAs tending to see younger and less medically complex patients.[18]
However, our ageing population’s health needs are becoming increasingly complex, meaning risks to patient safety arise not in cases of simple diagnoses – such as a cold or sprain – but where underlying conditions present in a seemingly innocuous way. Identifying, diagnosing, and treating such complex cases requires the specialised skillset and clinical judgement that doctors have taken years to hone. The abridged and variable training requirements to become a PA mean they will simply never have the breadth and depth of medical training nor clinical competence to safely underpin the work they currently do nor what they propose to do independently, if regulated. This is to say nothing of cultural safety and the risks to patients arising from a wholly imported workforce, whose training has occurred outside the scope of Te Tiriti o Waitangi and the Medical Council’s cultural competence standards.[19]
Regulation locks in these risks
We are not alone in this assessment of risk. In the NHS, where PAs have already been employed, 87% of doctors believe the way PAs practice pose a risk to patient safety, and in another survey of surgeons nearly half (46.9%) reported negative impacts of PAs on patient care.[20],[21] The British Medical Association (BMA) and Royal College of General Practitioners (UK) have staunchly opposed their regulation and expansion, resulting in the government recently commencing an independent review of the scope and safety of PA roles.[22],[23],[24]
Similarly, across the ditch, the Royal Australian College of General Practitioners has recommended that “Australia should learn from the UK… on what not to do”.[25] Yet, our own policy decision makers seem single-mindedly determined on charging down this fundamentally flawed path to regulation.
The Ministry of Health’s line remains that PAs have already been allowed to practice in Aotearoa, so we must regulate them. But if this is genuinely about safety in clinical practice, we already have well-established training and regulatory pathways in New Zealand. Why not support this small overseas-trained PA workforce of around 30 to retrain as nurses, paramedics, allied health professionals, or even undergo medical training?[26]
The rush to regulation indicates our decision makers’ failures to appreciate the complex and valuable work that our doctors, nurses, and AST practitioners do. And it fails to acknowledge that the future sustainability of our health workforce relies on training and retaining our local health professionals.
What should we be doing instead?
Let’s be clear about what this is – a cost cutting exercise being packaged as a solution to the longstanding underinvestment in growing our local health workforces. Yes, our health system has a workforce crisis, but this is about a shortage of health professionals not health professions. Nowhere does our Health Workforce Plan 2023/24 identify PAs as an essential workforce in addressing our nation’s future health needs.[27] This is because there is nothing that a PA can do that an existing regulated health professional cannot.
All regulation will do is cause further problems down the track and cement in risks to patient safety, when what New Zealand really needs is more qualified doctors, nurses, and AST practitioners. It is unfathomable that public safety would be jeopardised, at expense of regulating an imported and medically untrained group of PAs in Aotearoa. And it is striking that decision makers who claim to wield a ‘disproportionate’ influence[28] in government would choose to be selective about when to ignore evidence, and when to question this – such as when investment is needed to grow our local medical workforce.[29]
[1] D’Souza, N., Powell, D., & Dalton, S. (2024). Caution ahead: the risks with regulating physician associates in Aotearoa. New Zealand Medical Journal, 137(1602).
[2] Boyle, J. (2024). Survey unearths catalogue of errors by unregulated medics. The Sunday Post, 7 January 2024. Retrieved https://www.sundaypost.com/fp/physician-associates/
[3] Ennals, E. (2023). GP chiefs call for a crackdown on NHS physician associates following a string of life-threatening blunders. The Daily Mail Australia, 15 October 2023. Retrieved https://www.dailymail.co.uk/health/article-12630607/NHS-blunders-prompt-call-stop-physician-associate-recruitment.html
[4] BBC News. (2023). Call for physician associate clarity after misdiagnosis death. BBC, 16 July 2023. Retrieved https://www.bbc.com/news/uk-england-manchester-66211103
[5] Ennals, E. (2023). Why did our daughter have to die? Family’s anguish after cancer death of mum misdiagnosed by medic with two years’ training. The Daily Mail, 12 November 2023. Retrieved https://www.dailymail.co.uk/health/article-12739005/Why-did-daughter-die-Familys-anguish-cancer-death-mum-misdiagnosed-medic-two-years-training.html
[6] Clegg, R. & Shoesmith, I. (2024). My wife died because the NHS used cheap labour. BBC, 13 November 2024. Retrieved https://www.bbc.com/news/articles/czxvww97pleo
[7] https://www.rnz.co.nz/news/national/506989/he-could-have-gone-blind-concerns-unregulated-physician-associates-may-put-patients-at-risk
[8] Shaw, R. (2024). Doctors quit amid patient safety risk disagreement. Otago Daily Times, 25 November 2024. Retrieved https://www.odt.co.nz/southland/doctors-quit-amid-patient-safety-risk-disagreement
[9] Hill, R. (2024). ‘He could have gone blind’: Concerns unregulated physician associates may put patients at risk. RNZ, 18 January 2024. Retrieved https://www.rnz.co.nz/news/national/506989/he-could-have-gone-blind-concerns-unregulated-physician-associates-may-put-patients-at-risk
[10] British Medical Association (BMA). (2024). Widespread use of physician associates on doctors’ shifts is “appalling” says BMA. 24 October 2024. Retrieved https://www.bma.org.uk/bma-media-centre/widespread-use-of-physician-associates-on-doctors-shifts-is-appalling-says-bma
[11] The Telegraph. (2024). Physician associates ‘illegally’ prescribe opiates to hospital patients. 22 February 2024. Retrieved https://www.telegraph.co.uk/news/2024/02/22/it-blunder-physician-associates-illegally-prescribe-opiates/
[12] Price, O. (2024). ‘Cut-price’ physician associates illegally ordered more than 1,000 NHS hospital tests including X-rays and CT scans despite not having any formal medical training – as doctors slam ‘direct threat to patient safety’. The Daily Mail, 3 February 2024. Retrieved https://www.dailymail.co.uk/news/article-13038173/Cut-price-physician-associates-illegally-ordered-1-000-NHS-hospital-tests-including-X-rays-CT-scans-despite-not-having-formal-medical-training-doctors-slam-direct-threat-patient-safety.html
[13] Waters, A. (2024). Child protection medicals must be carried out only by doctors, not PAs, say safeguarding experts. BMJ (Clinical Research Ed.), 387, q2172. Retrieved https://www.bmj.com/content/387/bmj.q2172.full
[14] Walia. B, Banga. H, & Larsen, D.A. (2022). Increased reliance on physician assistants: an access quality tradeoff? J Mark Access Health Policy,10(1):2030559. doi: 10.1080/20016689.2022.2030559.
[15] Park, W. (2024). Physician associates would be a major loss for the Aotearoa New Zealand healthcare system. The New Zealand Medical Journal, 137(1590), 106-108.
[16] New Zealand Physician Associate Society. (n.d.). What is a Physician Associate? Retrieved https://nzpas.org.nz/whats-a-pa/
[17] Donnelly, L. & Moore, A. (2024). Physician’s Associates qualify for courses with degrees including homeopathy and English literature. The Sunday Telegraph, 30 March 2024. Retrieved https://www.telegraph.co.uk/news/2024/03/30/physicians-associates-qualify-courses-degrees/
[18] Drennan, V. M., Gabe, J., Halter, M., de Lusignan, S., & Levenson, R. (2017). Physician associates in primary health care in England: A challenge to professional boundaries? Social Science & Medicine, 181, 9-16. doi: 10.1016/j.socscimed.2017.03.045
[19] Medical Council of New Zealand. (n.d.). Cultural competence. Retrieved https://uat.mcnz.org.nz/our-standards/current-standards/cultural-competence/
[20] British Medical Association (BMA). (2023). New survey shows “shocking scale” of concern from doctors over use of physician associates. 12 December 2023. Retrieved https://www.bma.org.uk/bma-media-centre/new-survey-shows-shocking-scale-of-concern-from-doctors-over-use-of-physician-associates
[21] The Association of Surgeons in Training (ASIT). (2024). The physician associate role and its impact on surgical training and patient care. ASIT report, January 2024. Retrieved https://www.asit.org/media/gb3g3z0m/asit-physician-associate-report-2024-v2.pdf
[22] British Medical Association (BMA). (2023). BMA position statement on physician associates and anaesthesia associates. 18 September 2023. Retrieved https://www.bma.org.uk/news-and-opinion/bma-position-statement-on-physician-associates-and-anaesthesia-associates
[23] British Medical Association (BMA). (2024). GPs vote in favour of phasing out physician associate role in general practice. 18 October 2024. Retrieved https://www.bma.org.uk/bma-media-centre/gps-vote-in-favour-of-phasing-out-physician-associate-role-in-general-practice
[24] Department of Health and Social Care. (2024). New review of physician and anaesthesia associates launched. UK Government, press release, 20 November 2024. Retrieved https://www.gov.uk/government/news/new-review-of-physician-and-anaesthesia-associates-launched
[25] Royal Australian College of General Practitioners (RACGP). (2024). RACGP submission to Unleashing the Potential of our Health Workforce – Scope of Practice Review – Issues Paper 1 (2nd consultation), March 2024. Retrieved https://www.racgp.org.au/getmedia/b74435f5-236c-46a2-88c5-5b7a8420ad0b/RACGP-Sub-Scope-of-Practice-Review-Issues-Paper-1-2nd-consultation-FINAL.pdf.aspx
[26] Health New Zealand | Te Whatu Ora. (2023). Health Workforce Plan 2023/24. Retrieved https://www.tewhatuora.govt.nz/publications/health-workforce-plan-202324
[27] Health New Zealand | Te Whatu Ora. (2023). Health Workforce Plan 2023/24. Retrieved https://www.tewhatuora.govt.nz/publications/health-workforce-plan-202324
[28] Smith, A. (2024). ACT wielding ‘disproportionate’ influence in government – David Seymour. RNZ, 26 November 2024. Retrieved https://www.rnz.co.nz/news/political/534800/act-wielding-disproportionate-influence-in-government-david-seymour
[29] RNZ. (2024). ‘We need more doctors’ – Support for new Waikato medical school. RNZ, 22 November 2024. Retrieved https://www.rnz.co.nz/news/national/534504/we-need-more-doctors-support-for-new-waikato-medical-school