Minister supports ‘role for physician associates’ in HSE

Minister for Health Stephen Donnelly has told the Medical Independent (MI) he believes “there is a role for physician associates” (PAs) in Irish healthcare.

Responding to a question from MI at the IMO AGM on 5 April, Minister Donnelly said: “We already have physician associates working within the HSE, though not very many. I believe there is a role for physician associates. I am aware of the caution that has been sounded in the UK. What we cannot have is any healthcare professional who is not a doctor asked to work as a doctor.”

He added: “As with any role, be it an NCHD, consultant, nurse, or health and social care professional, there has to be and there must always be strong clinical governance in place, everyone needs to work within their licence, within their training.”

“What we are doing is supporting healthcare workers to work to the top of their licence, be it through advanced practice nursing and midwifery, enhanced pharmacy care, specialist roles… so I think there is a role for physician associates. They are already working within our service and we have to ensure, for them, as with every healthcare professional, that there is very clear oversight and clinical governance in place from a patient safety perspective.”

The issue of PAs was discussed at length at a number of sessions at the IMO conference.

A panel discussion on “valuing the role and expertise of the doctor” heard that the PA role is being “misconstrued” at individual hospital and Trust level in the NHS where PAs are being placed on doctors’ rotas in some locations.

Chair of the British Medical Association’s international committee Dr Kitty Mohan said initially PAs were
introduced in the NHS on the premise that they could free-up doctors to see more complex cases and for specialist training.

“It started off like that. They would take bloods, they would put in cannulas, they would make sure the house officers got their lunch. They would do those jobs that actually meant people could train. I think now what we are seeing is that at a local hospital level, as The Telegraph reported, that [role] is being misconstrued.”

IMO NCHD committee Chair Dr Rachel McNamara told the session that “we had a very worrying report into us” about an Irish hospital that had rostered a PA in an SHO on-call weekend shift. 

Dr Mohan advised the Irish health system to define the scope of practice for PAs “early and clearly with all the related parties”.

“We are 20 years down the line in the UK and our colleges are still saying they haven’t had time to define the scope… the scope is being defined at the individual Trust level and that is when it becomes really out of control.”

It is understood there are approximately 60 PAs working in public and private healthcare in Ireland. As of yet, the Department of Health has not formally recognised the role and PAs have not been assigned a regulator.

Several motions were passed at the IMO conference relating to PAs, including the need to ensure a clear and definite role for PAs appropriate to their training, that the role does not compromise specialist training and NCHD posts, and that PAs must not be rostered on medical rotas.

Dr John Duddy, Consultant Neurosurgeon, Mater Misericordiae University Hospital, Dublin, spoke in defence of PAs from the floor during a debate on motions relating to PAs on 6 April.

Dr Duddy said there has been “a lot of noise” about issues around the implementation of the PA role in the NHS.

However, he pointed out that PAs have been working “successfully” in the US healthcare system for decades.

Dr Duddy was involved in a PA pilot project in Beaumont Hospital, Dublin, in 2015.

He said that one of the outcomes from the pilot was the agreement that PAs would directly report to the supervising consultant.

“So if there are scenarios where a PA is leading a team or is reporting to somebody else or reporting to a registrar, that is absolutely inappropriate,” Dr Duddy said.

“…. The consultant is supposed to be responsible for the PA’s practice – that’s the North American model, and that’s the model envisaged here in Ireland.”

He added that it was also agreed that PAs were to act “as an adjunct to the NCHD role”, and “not to push them aside”.

Regarding the matter of regulation, Dr Duddy said that when the role was developed in Beaumont, the RCSI consulted with various healthcare regulatory authorities.

In 2017, the RCSI, which launched Ireland’s first postgraduate course to qualify PAs the previous year, evaluated the Beaumont pilot.

However, no regulator “wanted to take them on”, he added.

“My own view is that PAs are trained in the medical model by doctors,” Dr Duddy said.

“They are not trained in the nursing model; they are not trained in an allied health professional model. The most appropriate regulator would be the medical regulator. That’s my own opinion.”

A Department of Health spokesperson told MI that it is engaging with the HSE in relation to reviewing the current and future role of PAs in the public health service.

They said introduction of new grades requires consideration of issues including scope of practice; supervision and clinical governance structures; grade and salary scale; patient safety; and regulatory requirements.