Rising NHS physician associate use questioned after Oldham death

A man whose wife died after a drain was mistakenly left in her abdomen for 21 hours has condemned the increased use of physician associates (PAs) within the National Health Service.

Susan Pollitt’s inquest concluded her death at Royal Oldham Hospital in July 2023 had been caused by an “unnecessary medical procedure contributed to by neglect”.

Roy Pollitt did not know his 77-year-old wife was being treated by a PA – who are only required to have two years’ medical training – and believes “she would have lived if the NHS had not used cheap labour”.

The coroner who examined Mrs Pollitt’s death highlighted the lack of a national framework covering PAs’ training, supervision and competency assessment.

Associates were introduced in the NHS 21 years ago with the expectation they would support doctors by delivering basic care.

Over the past two years the number of associates has more than doubled to 3,000.

According to the NHS Long Term Plan, there will be 12,000 physician and anaesthetic associates by 2036.

Health Secretary Wes Streeting said there were “legitimate concerns” about the role of PAs before the expansion.

Fears have been expressed that some have been acting beyond their original remit.

BBC News has seen evidence that in the month of Mrs Pollitt’s death, the NHS trust which oversees Royal Oldham used PAs to cover nearly 20% of doctor shifts in elderly care.

Several organisations, including the British Medical Association (BMA), have voiced concerns about the blurring of professional lines between doctors and associates across NHS trusts and primary care.

Anaesthetists United, a group set up by concerned doctors and consultants, has filed a legal claim against the General Medical Council (GMC) for not, in its view, properly defining associates’ roles and responsibilities.

One of the group’s founders, consultant anaesthetist Richard Marks, said patients were “being put at risk” as a consequence, something that “strikes to the heart of you” as a doctor.

BBC News has also learned that PAs have exceeded their remit in several NHS trusts, including by:

• Covering doctors’ shifts
• Prescribing medicines
• Ordering X-rays without supervision

From December, associates will join doctors in being regulated by the GMC.

Significant concerns remain, however, from some within the medical profession.

Susan Pollitt originally went to Royal Oldham Hospital with a broken arm after suffering a fall at her home in nearby Failsworth, Greater Manchester.

Initially treated in a corridor, the great-grandmother was also diagnosed with an acute kidney injury.

Due to a lack of gastroenterology beds, she was taken to a respiratory ward.

Her daughter Kate Pollitt said staffing levels seemed “very low”, adding that on the night her mother died “it took nearly four hours to find a doctor in the whole of the hospital”.

At Mrs Pollitt’s inquest, dozens of issues with her care came to light.

Not only did the PA leave an abdominal drain – used to remove excess fluid from her body – in for 15 hours longer than permitted, but he also told colleagues to clamp it, increasing the risk of infection.

It has also emerged that, in the previous year, a liver nurse only approved the associate’s competence in using the equipment because she assumed he was a doctor.

Kate Pollitt said: “He thought he was doing right… but he was in a situation where he wasn’t supported.

“There was too much confusion and not enough supervision.”

The Northern Care Alliance (NCA) NHS Foundation Trust, which runs the Royal Oldham, found Mrs Pollitt would probably have survived had the drain been removed earlier.

Its chief medical officer, Dr Rafik Bedair, said: “We’re saddened Mrs Pollitt didn’t receive the standard of care that she should have done and we remain deeply sorry to her family for this.”

He said the trust owed it to them to “learn from what went wrong and make things safer for patients in the future”.

The NCA serves more than a million people across Salford, Oldham, Rochdale and Bury, as well as providing more specialist services to patients from Greater Manchester and beyond.

Following Mrs Pollitt’s inquest, North Manchester Coroner Joanne Kearsley issued a Prevention of Future Deaths notice due to her concerns about PAs.

The GMC agreed patient safety was at risk without effective safeguards.

Its chief executive and registrar, Charlie Massey, said next month’s regulatory changes would be “a vital step towards strengthening both patient safety and public trust in these professions”.

And he stressed it was down to employers to clearly define roles and, like “all regulated professionals, [associates] will be expected to work within their competence”.

But consultant anaesthetist Dr Marks warned the lack of a national scope of practice – with clear limits and standards – would still put patients at risk.

He said a lack of supervision for PAs had been a “key feature” in recent high-profile cases, including the death of 30-year-old woman from Salford.

“In each one of them, had a doctor been more closely involved and seen what was going on, they would have made changes to that patient’s care,” he said.

“What we’re most concerned about is that you’ve got a big increase in numbers of PAs who don’t have the depth of understanding because of their background, and who are going to be let loose on the public without adequate supervision.”

Mr Marks was also worried about the fact that while doctors receive seven years of training, PAs receive two.

“What you don’t know, you don’t know,” he said, with PAs “not having the skills or experience” to diagnose patients with varying levels of complexity.

The Academy of Royal Colleges has also called for an independent review into the use of associates because of an “increasingly acrimonious and destructive debate”.

A Department of Health and Social Care spokesperson said: “Our deepest sympathies are with Susan’s family and friends.

“Patient safety is our top priority. We are urgently working with the NHS to ensure that physician associates are supporting, not replacing, doctors.”

NHS England said it had issued “updated guidance on the appropriate deployment of medical associates” and would provide increased clarity about their roles.

Streeting told BBC Breakfast he felt PAs “do have a role to play” in freeing up doctors’ time, but he had concerns about transparency.

But the health secretary said patients “should know who we’re seeing, who’s in front of us and why, and we’ve got to take those issues seriously”.

The Pollitts stressed they did not want to blame the PA for what happened, saying he had been the “only one who showed Susan – and us – any empathy”.

Kate Pollitt said she only wished he had received more supervision.

“You do get angry and upset,” she said. “But there’s nothing we can do for my mum now, so there’s no point in being angry and having that bitterness for the rest of our lives.

“We just want change – it won’t mean things like this won’t ever happen again but if we can help reduce the chances then it’s worth it.”