Amendment to the Motion

Anaesthesia Associates and Physician Associates Order 2024 - Motion to Approve – in the House of Lords am 8:00 pm ar 26 Chwefror 2024.

Danfonwch hysbysiad imi am ddadleuon fel hyn

Baroness Bennett of Manor Castle:

Moved by Baroness Bennett of Manor Castle

As an amendment to the above Motion, to leave out from “that” to end and to insert “this House declines to approve the draft Anaesthesia Associates and Physician Associates Order 2024 because it represents a significant constitutional change in regulation of healthcare professionals by omitting parliamentary oversight and approval for regulating anaesthesia associates and physician associates; and fails to address concerns within the medical profession about the supervision and titles of the roles.”

Photo of Baroness Bennett of Manor Castle Baroness Bennett of Manor Castle Green

My Lords, I rise to move what the Minister has correctly identified as a fatal amendment that the House do not approve this order. This is on two primary grounds: the lack of democratic oversight and the concerns of the medical profession.

Before I begin, I want to make it clear that I am not opposed to the existence of physician associates or assistants, or their anaesthetist colleagues. I am not opposed to their regulation—indeed, I am keen to see them regulated—and I respect the efforts of current and future PAs and AAs who complete their studies and have the student debt to prove it.

I also want to be clear that, unless I get an indication from the House that it wishes me to do so, it is not my intention to put this amendment to the vote. My intention in tabling it was to ensure that the many hundreds of voices of concern that have reached me personally and the more than 21,000 doctors and patients who wrote to their MPs opposing this order are heard, and that the Government consider—seriously, I hope—whether they should go forward to regulate PAs and AAs in this manner, with this order.

I will first address the second part of my fatal amendment, about the views of doctors and patients. Sir Robert Peel invented the concept of policing by consent. I want to adapt that for these circumstances by saying that we must have regulation by consent. I am sure that all noble Lords engaged tonight are aware that the British Medical Association, the Doctors’ Association UK and the EveryDoctor group are opposed to this statutory instrument, for reasons on which I am sure we will hear much more from the noble Baronesses, Lady Finlay and Lady Brinton, with their regret amendments.

One of the very serious concerns is about clarity for patients and the confusion introduced by the title “associate”. On that I turn to a report from the BBC, an interview with Marion Chesterton, the mother of Emily, who tragically died after being seen twice by a PA and misdiagnosed. Marion said that her daughter

“didn’t know she hadn’t seen a doctor”.

Marion added—and this is something that I think people should focus on:

“Physician associate sounds grander than a GP”.

I pick up a point made by the Minister about PAs and AAs having been around for 20 years, an often-cited statistic. If we look back to 2014 and 2015, there were fewer than 50 PA and AA graduates. There were literally handfuls in the system. It is only when you get to 2018 that you start to see the figures leaping up to 400 graduates, and the Government’s aim is to head towards the figures that the Minister cited. So we may not have seen much confusion, but there were few people to be confused about within the system. This is a situation that is arising now, and that demands a reconsideration.

However, I will largely leave the arguments about titles, and the General Medical Council as regulator, to the regret amendments. What I want to focus on is the word “consent” and the concerns of doctors and patients in the context of the state of our medical system.

We debate as junior doctors are in the middle of their 10th strike action. We debate as one in seven British-trained doctors is working overseas. We debate after a BMA poll found last year that around 40% of junior doctors plan to leave the NHS as soon as they can find another job.

We need to make changes to the system. That is something on which the Minister and I, and I think pretty well everyone, are agreed, but we can make changes to the system only with the consent of all those involved. There is a moral argument for that, but also a very powerful practical argument. The Government need to work co-operatively and sensitively, and to listen to our medical professionals rather than ride roughshod over their serious concerns—concerns that are shared by many patients and that have filled my social media feed in recent days.

The first part of my amendment is about democracy. The order got virtually no scrutiny or consideration in the other place. We, of course, have no opportunity to amend it to tackle the issues that the noble Baronesses will focus on in their regret amendments. We have only the extraordinarily rarely used option of rejecting it. I have not had any indication from the Labour Party that it would support that, and I assume that its silence on the Order Paper means that it supports the Government’s path, but I ask the Labour Front Bench to consider whether we have to take this back to the drawing board. That is a question I put to it directly.

The Minister raised the report of our hard-working and, I fear, underappreciated Secondary Legislation Scrutiny Committee, which makes it very clear that this is not just about PAs and AAs but is meant to be the model for broad and widespread changes to medical regulation in the future. The committee’s report says that this is

“the first use of powers inserted into the parent Act by the Health and Care Act 2022 to give the GMC direct powers to make and amend standards and procedures for these associates”,

while, as it says in bold,

“removing the process from Parliamentary oversight”.

It is interesting that the Committee says:

“The Explanatory Memorandum should have been more explicit on this point and on what safeguards remain”.

In testimony, under questioning from the committee of your Lordships’ House, the department confirmed that

“changes in registration processes etc will no longer be laid before Parliament in any form, they will just be posted on the GMC’s website … however members of either House can respond to consultations if they wish”.

I am glad about that.

This has really not been made clear through the process, as the committee highlights. I think it is worth focusing on the fact that had it not been for the amendments from the noble Baronesses and me we would not even be doing this in the main Chamber. We would be in the secondary Chamber, getting, as we all well know, very little attention at all.

I particularly want to highlight, in case noble Lords did not receive it, the briefing from the Professional Standards Authority, which has responsibility for overseeing the GMC’s activities. It said, in what I think one would describe in bureaucratic terms as a carefully worded briefing, that we

“need to keep under review as the reforms are rolled out the accountability framework proposed to balance the increased autonomy for regulators with greater accountability”.

I wish to make a final point to address the fear and concerns of many patient groups and communities—which the Minister alluded to—that their communities and their families will lose ready or perhaps any access to doctors and be relegated to a second tier of NHS services, with PAs with two years of medical training versus GPs with 10. In the letter following up the very useful briefing that he arranged last week—and I think him very much for that and for the letter—the Minister makes reference, as he did in his speech, to the Government’s aim of doubling the number of medical places in England to 15,000 by 2031-32.

The Minister gave, I believe, the same figures as were reported in the Observer on Sunday. These were in a leaked letter from the Health Minister and the Minister for Skills, Apprenticeships and Higher Education to the independent regulator, the Office for Students. The figures in that letter have been interpreted as significant back-pedalling on the Government’s final aim and total. I ask the Minister whether he remains confident and can guarantee to the House that we are on target to achieve that final figure, given that we do not seem to be taking very strong steps in that direction.

The way those figures came out can only amplify the fears of many communities that those who can pay can go private, as increasing numbers of Britons feel they are forced to do. Patients at the centre of well-serviced areas where doctors can supplement their NHS pay with private work will keep access to a service like that now available, while other areas—the kinds of areas that are often talked about as being in need of levelling up—will get a second-class service.

We have to think about the context of this. Our NHS is battered by privatisation, with nearly 10% of services, including more than half of under-18 inpatient psychiatric services, now provided by for-profit providers. We have seen the disaster of PFI schemes, now set to cost £80 billion for the original £13 billion investment—the equivalent of £1,200 for everyone in the UK. We have seen this jewel in the British crown worn away by austerity—a decade in which investment in infrastructure and new technology collapsed and the pay of junior doctors and midwives in particular plummeted in real terms.

Please let us not deliver another blow. Please withdraw this order either tonight or afterwards. Take the path of consensus. Take the path of democratic oversight. Bring this forward as legislation that can be debated, amended and properly scrutinised. Please listen to the fear of communities. I ask everyone in this debate but particularly the Labour Front Bench to consider that approach and the wisdom of it. I beg to move.

Photo of Lord Young of Cookham Lord Young of Cookham Deputy Chairman of Committees

I should inform the House that if this amendment is agreed to, I will be unable to call the amendments in the names of the noble Baronesses, Lady Finlay of Llandaff and Lady Brinton, by reason of pre-emption.

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Deputy Chairman of Committees, Deputy Speaker (Lords) 8:15, 26 Chwefror 2024

My Lords, I declare that I am a doctor registered with the General Medical Council, a member of the BMA and a fellow of the Royal College of General Practitioners and the Royal College of Physicians.

We have physician associates and anaesthesia associates seeing patients, examining them and advising them, who are as yet unregulated. All responsibility for their behaviour rests with the doctor who is their supervisor from whom they have delegated responsibility. The professional scope of practice for these associates can vary widely across the country. It is determined at a local level and patients have no idea about the variation.

There is a golden thread in clinical care that the most experienced person delegates down. They delegate down tasks that they know the relevant team member has the skills to undertake. A key skill in medicine, gained with extensive experience, is the integration of all the relevant information, evaluation of risk and prioritisation. Currently a problem in the whole of the NHS is that we expect staff to refer upwards and the boundaries are unclear.

A case of non-accidental injury in a child has been brought to my notice where the expert evidence was provided by a physician associate whose relevant experience is unclear at best. This blurring is misleading to non-medical professionals, including the police, judiciary and legal professionals. Supervision must be mandatory and stipulated in the GMC’s Good Medical Practice.

The junior doctors’ discontent, which we have heard about already from the noble Baroness, Lady Bennett, is boiling over. After training, medical graduates emerge with huge student debts to work a 40-hour week for just over £32,300, only to find that after a two-year postgraduate programme a physician associate typically earns between £3,000 and £11,000 more, for only 37.5 hours a week. All this has inflamed tensions—although I would say that direct verbal attacks on physician associates and anaesthesia associates, who have trained in good faith and with good intent, are not appropriate and I would not condone them.

Doctors are the only healthcare professionals who must undergo extensive, nationally stipulated postgraduate training before being appointed to a permanent senior role. Without long-term job security, these juniors rotate through departments, sometimes commuting many miles. They find that they do not belong and do not feel part of the team or valued, while patients miss out on continuity of care.

Very importantly, patients seen by a physician associate sometimes think that they have seen a doctor. The term “physician associate” gets muddled with the specialty and associate specialist doctor, who often has years of experience. Can the Minister clarify whether the term “physician associate”, which is so misleading, will become a protected title after this order passes? How can the name then be changed to revert to the more accurate “physicians’ assistant”? Currently, no medical titles are protected: “doctor” is not and grades up to and including consultant are not, which is another source of confusion. How is that going to be cleared up?

The cost-efficacy basis for these posts has been questioned in a recent paper, showing how the cost of one consultant anaesthetist supervising two operating theatres with an anaesthesia associate in each—that is, three staff—is more expensive than having two consultants doing one list each. The risk is higher if a problem arises in both theatres, especially in an anaesthetic emergency, when deterioration and brain damage can happen in minutes.

This crisis has been 20 years coming because we failed to expand medical school places or to register these new healthcare roles and define their scope of practice. What is the solution?

I fear this order will not solve all the problems. Yes, physician associates and anaesthesia associates must be regulated. It seems an outrage that people with such responsibility have been around for 20 years, unregulated, and a decade after that was recommended. The General Medical Council, in taking responsibility for regulation, must keep the register completely and clearly separate from that of medically qualified doctors. Can the Minister confirm that this clarity will be a legal requirement?

I tabled my regret amendment because it must be clearly on the record that the concerns exist, that some current regulation around the Medical Act needs updating urgently and that the GMC must be held accountable to Parliament, as has been explained by the Minister. Regulation is essential, but it is not the end of the issue; it is only the beginning.

The GMC must tackle the inappropriate way that some courses are advertised, which state that they train PAs

“to work as a safe and competent medically trained healthcare professional” or to

“be a medically trained, generalist healthcare professional”

—which sounds awfully like a GP to me. Some courses describe working under a senior physician, but others say nothing about supervision. The anaesthesia associate courses differ slightly. They make it clear that, at present in the UK, only doctors who have specialist training in anaesthesia can administer anaesthetics and that the anaesthesia associate works as part of the anaesthetic team.

Next, the scope of practice must be clearly defined and agreed at national level, so that any employer is aware of what the associates should be doing and how the senior doctors must supervise them on site. Employers must also ensure that all patients know the qualification level of the person seeing them. Seven-day services are essential for patients.

Medical postgraduate training itself is in crisis. The royal medical colleges, the Academy of Royal Medical Colleges and the GMC must get together urgently to address postgraduate training. Perhaps it could be shortened, with post consultant-level fellowships to develop highly specialised skills and bring innovation to healthcare. Lifelong learning is essential; it is the essence of growing a good medical workforce in the long term. Medical schools, as they welcome the increased numbers, must look at how those who might wish to convert to a medical degree can be credited with their prior learning and experience, and tackle regulatory blocks in funding and timing.

Importantly, the title must be reviewed. The terms “physician assistant” and “anaesthesia assistant”, in use until 2014, clearly denoted the role as having delegated responsibilities from a supervisor. If “physician associate” and “anaesthesia associate” are to be protected terms, then we need a designation of medicine that clearly identifies a medical degree—similar to the American MD designation, for example. Patients must know who has seen them.

To summarise: patients must know the level of training of the person whom they have seen. Physician associates and anaesthesia associates must be regulated with appraisal and ongoing learning, including revalidation. The scope of practice of this new workstream must be defined to ensure that they have clear boundaries and supervision must be defined as being closely supervised on site to ensure patient safety. People must not be misled into believing that they are completely independent practitioners.

Photo of Baroness Brinton Baroness Brinton Democratiaid Rhyddfrydol

My Lords, I am grateful to follow both the noble Baronesses, Lady Bennett and Lady Finlay of Llandaff, and I have been crossing out large chunks of what I was going to say, which I hope will be helpful to Members of your Lordships’ House.

As both of the other noble Lords have, I want to start by saying that this is not an attempt to discredit the many PAs and AAs who do an extremely good job. We need to understand that, and we need to understand that our health system must change and modernise. The issue is what is happening in our NHS and how the role of PAs and AAs is impacting not just on patients—I will come to the detail of that in a minute—but on the working of supervising doctors and junior doctors. All of those groups are in crisis, and this just seems to be adding further problems.

I echo the points made by, I think, the noble Baroness, Lady Bennett, about the Secondary Legislation Scrutiny Committee, which the Minister referred to in his introduction. In the committee’s report to us, it says three times that the Explanatory Memorandum assumed understanding and that it was not good enough. I ask the Minister if he will work with his officials to ensure that any more Explanatory Memorandums that come forward, not just on this issue but on others, are very clear and do not assume prior knowledge.

All of us have said that PAs and AAs—I am not going to keep saying physician associate and anaesthesia associate because it takes too much time—are not a replacement for doctors, though not one of us believes that that is the case. I am going to start with the title. The Royal College of Physicians and the Faculty of Physician Associates, which sits within the RCP, has guidance on the associate title and introduction guidance for PAs, supervisors, employers and organisations. What it says is in complete contradiction to what is happening on the ground:

“It is our view that, when a PA introduces themselves to a patient or staff member, they must make it clear at the start of the interaction that they are a physician associate, as well as explain the use of the term ‘PA’ … PAs must correct patients and staff if they refer to them as a … doctor, nurse or other professionally protected role title. This includes verbal, written and other forms of communication”.

Like other noble Lords, I have been inundated with letters from doctors and patients saying that they have been misled—not in the deliberate sense, but that PAs have not been correcting the record when someone has called them a doctor. The BMA, in its very helpful briefing, said that:

“To patients, PAs and AAs and doctors may look the same and appear to be doing a similar job”.

The problem, as the noble Baroness, Lady Finlay, said, is that the title is confusing. “Physician associate” perhaps implies that they have the same level of expertise as doctors. Unfortunately, as the noble Baroness, Lady Bennett, said, this has already led to a tragedy. Emily Chesterton died, aged 30, after two appointments with a PA who she believed was a GP, where mistakes were made.

A further difficulty, particularly in GP practices, is that GPs are beginning to worry that they are going to spend their entire time supervising PAs, as well as seeing patients with chronic diseases, and will not see ordinary people at all. Trainee GPs are worried about how they are going to be supervised. How is the Minister going to ensure that the issues of supervising and training, which are very serious, will be dealt with after the passage of this SI—because I do not think any of us are planning to call a vote today?

We have heard that, across acute trusts and GP surgeries, doctors have reported 70 instances of avoidable patient harm and near misses caused by PAs. That includes fatalities, missed diagnoses resulting in terminal diseases, missed DVTs, sepsis, heart attacks and haemorrhages. Missed cancer diagnoses in primary care has therefore emerged as a significant issue. In England, 74 acute trusts have replaced doctors with PAs on the doctors’ rota. Even if those PAs are supervised, that means that doctors who should be seeing patients are supervising more and more people. It is not a zero-sum game. One trust—I think it was Leeds, from memory—had a paper on how much more beneficial PAs were on the rota because they were much cheaper than doctors.

Doctors at 24 trusts reported witnessing PAs illegally prescribing medications, including controlled drugs. That is a particular worry because they are not permitted, under their current training and qualifications, to prescribe any drugs. That must be done by the doctor. The PA can recommend to the doctor what they think, but it should be signed off by a doctor. In addition, 42 acute trusts in England have witnessed PAs introducing themselves as doctor or failing to correct errors.

We have heard about a number of issues. I conclude by saying that, earlier on today, on the Victims and Prisoners Bill, we were talking about the duty of candour, which the NHS introduced nearly a decade ago. One issue related to this is that every regulated member of staff must report whenever they believe that something has happened that either possibly will cause damage or has caused damage. One of the good things about regulation for PAs and AAs is that they will come under the duty of candour. However, in all the cases that we have been told about where things have gone wrong, there is no evidence that there were reports to the CQC by the supervising doctors about things going wrong. Therefore, yet again I say to the Minister that my real concern is about current practice inside our extremely pressed and busy NHS, to make it safe. Just providing regulation for PAs and AAs will not in itself do that. I hope that he can help your Lordships’ House to understand.

Photo of Lord Hunt of Kings Heath Lord Hunt of Kings Heath Llafur 8:30, 26 Chwefror 2024

My Lords, I was a member of the GMC until the end of January, so at the council meetings I was involved in a number of discussions about the responsibilities of the GMC in the lead-up to this order being laid. Unsurprisingly, I strongly support it.

I listened to the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, and clearly they raised issues that the Minister will need to respond to. However, the combination of statutory regulation by the GMC and a proper governance framework within each employment body seems the most appropriate course for us to take. Therefore, I say to the noble Baroness, Lady Bennett, that passing the order is the best way to secure the safety of patients, which is why I hope the House will give it resounding support tonight.

My second point comes back to the noble Baroness, Lady Bennett, on democratic accountability and legitimacy. The Minister mentioned that a combination of the Health Act 1999 and the Health and Care Act 2022 has brought this order before us. Since I took the 1999 Act through this House, I feel some responsibility to stand up for what it essentially aims to do. The whole problem of regulation of the professions in the health service is that it has never had the priority it deserves from the Government. The Law Commission reported in 2014, and here we are 10 years later, just about getting round to the first tranche of orders that we need to modernise the regulation of our health professions.

If you rely on primary legislation to make this kind of change, nothing will ever change. It is slow enough with secondary legislation, but with primary legislation it becomes almost impossible to get sensible change made. All the regulatory bodies are utterly frustrated that they have very old-fashioned processes and procedures, because they do not have the discretion needed to make changes that would be to both the public’s and the professions’ benefit. Therefore, I am glad we have this order and I hope we can follow it through.

My third point is about the noble Baronesses saying that they do not like the campaign of what is essentially vilification that has been going on over the last few months against the physician and anaesthetist associates. I wish they had paid a little more tribute to the members of those professions and the fantastic work they do. I have met physician and anaesthetist associates, and they are going through a torrid experience. They have been subjected to a nasty campaign and, even in their own employing body, there have been reports of bullying at work and they have been subjected to rude and antagonistic comments from colleagues.

What is the context in which we are to judge this litany of mistakes that they have made? They seem to be isolated examples and, to my knowledge, there is no comparative data on errors by consultants, principal GPs or postgraduate medical trainees. I would not like to see a list of all their mistakes. What would happen if we asked people to report mistakes made by F1 medics each August? The BMA is playing with fire in the campaign it has adopted of putting these poor professionals, who are doing their best, in this frame. I protest about this and the general lack of medical leadership from the profession when it should have been defending the associates. The way it has run away from this issue has been a disgrace. It will find that its lack of leadership and strength will bite it in future. I have not been impressed by the way in which employing authorities have dealt with this either; they have left individual AAs and PAs to withstand the pressure and bullying without the support they need.

The Minister needs to reflect on some of the points raised. First, in addition to declaring his confidence in physician and anaesthesia associates, he needs to set out a long-term plan for their contribution to the NHS, ensuring that the voices of those professions are heard. The Government’s ambitions on the numbers of AAs and PAs seem very modest. Why? Does he think we need to revisit that? Secondly, he needs to make it clear to NHS England and to employing authorities that bullying and intimidation of any healthcare professional in their employment must not be tolerated.

Thirdly, in response to the noble Baronesses, Lady Brinton and Lady Finlay, the Minister needs to ensure that each employing body adopts an appropriate local governance framework to deal with some of the issues that they have legitimately raised. Fourthly, we need research on the clinical outcomes of physician and anaesthesia associates and, frankly, comparative data with other health professionals. That is the only way to deal with the toxicity of these lists of mistakes that have been circulated. Finally—here I agree with the noble Baronesses, Lady Finlay and Lady Brinton—there clearly needs to be a plan of communication to the public to explain the role of the associates and the contribution they can make in future.

The order is important. Some legitimate issues have been raised, but equally we need to defend the associates, uphold the work they do and give them confidence about the future.

Photo of Baroness Watkins of Tavistock Baroness Watkins of Tavistock Deputy Chairman of Committees

My Lords, I declare my interest as a NED of the NHS Executive. I support this order, for many of the reasons that the noble Lord, Lord Hunt, has just explained, but stress that I am extremely unhappy about the division between the reports from various medics and the associates that are planned. One of the big problems is that we do not value junior doctors enough. The phrase we use is inappropriate. I have been married for 43 years to a doctor who has been called a house officer, a senior house officer, a registrar and a senior registrar—those things would now be referred to as a junior doctor. I want to put that on record.

I also support what the two noble Baronesses have said, which is that we need a distinguishing factor for a qualified doctor, be that “MD” or whatever else is selected by the medical profession. I am a nurse, and I am proud of being a nurse. We have nursing associates, but I know that I am a registered nurse and I know that I have a doctorate, but I would never refer to myself as a doctor in the clinical area. These issues are difficult to deal with because we need to value people’s different experience and training.

I was appointed by a previous Secretary of State to chair the grandfathering of the paramedics on to the new register, when it came into being, and look at the success that that has been.

Photo of Lord Winston Lord Winston Llafur

My Lords, I regret to say that I totally disagree with my noble friend speaking from the Front Bench, a person for whom I have the greatest respect, both as a colleague and as a previous Minister of Health in an earlier Government. He is not medically qualified; he is not a doctor who has been in practice. I speak simply as a fellow of the Royal College of Surgeons of Edinburgh and—it seems a bit immodest to say this—I was the triennial gold medal holder at the Royal College of Surgeons in London for innovative research. I never know quite how I got that award, but I did, and it hangs in my lavatory—I probably should not say that either.

There is a very serious issue here: anaesthesia. I do not want to frighten anybody, but I am not exaggerating when I say that there is no point at which a doctor has a patient closer to death than when the patient is anaesthetised under a general anaesthetic. It is then that things can happen which are completely unexpected, and there are all sorts of ways that the qualifications of that anaesthetist are incredibly important. Doing anaesthesiology is, most of the time, deadly dull; nothing goes wrong, you sit there quietly while the surgeon carries on acting out his wonderful role leading the operating theatre and controlling everything. The person who is really at risk is the person who is under anaesthesia, and that is something we should never forget; it is really important.

We do not even understand fully how anaesthetics work. It is true to say that even though we use gas and other agents, how they work exactly on the brain is not certain and we are still learning, years after the first anaesthetics in Victorian times. We have to recognise that this is quite a strange area of medicine, and that is why I am making this speech.

I want to tell a story about an anaesthetist friend of mine with whom I worked. Before I was doing regular in vitro fertilisation, I did a huge amount of reproductive surgery—surgery in the pelvis and telescope examinations, including laparoscopy. He and I worked as a team regularly on a very large number of patients, with complete success. On one occasion, I had a young woman, who was only 19, as my patient. She had severe abdominal pain, and I wondered, for somebody that age to have that pain, whether she had some unusual condition, and I thought she should have a laparoscopy.

My anaesthetist, as he always did, went to see the patient before the surgery and examined her to make certain she was well. He took her into the anaesthetic room and started with the anaesthesia, while I was waiting in the operating theatre. Then, quite suddenly, my anaesthetist friend wheeled the patient in on a trolley and said to me, “Robert, I think we have a spot of trouble here”. That was all he said, but there was something in his tone of voice and I thought, “This is really a weird thing for him to say”. The patient was unconscious and not intubated, and she remained unconscious. Her heart went and she had, in effect, died. We got her on to the operating table and I, as the surgeon, had a decision to make: what do I do? Do I, as the person leading the team, interfere, or do I leave it to my anaesthetist, in whom I had complete trust? I asked him whether he thought I needed to do heart massage or various other things. He said, “No, hang on for a bit”.

My colleague struggled with the unconscious unmarried young woman for almost 50 minutes. Sometimes, there was almost complete panic in the theatre—apart from my anaesthetist. There was one point when the nurse ran in with a drug she felt should be injected into the heart of the patient. My anaesthetist simply said to her, “Nurse, do not bring me what you think I need, just bring me what I ask you to bring”, in a very gentle voice. The young woman survived. My anaesthetist brought her round and she recovered completely; she walked out of hospital without any loss of memory.

We had no idea what had happened. It was extraordinarily puzzling. Only later did we realise that it was a rare and unusual effect of the drug, which had not been widely used at this stage. We put in a red card, and it was flagged up. Eventually, the drug was withdrawn. It was, in effect, an allergic response to the drug and was completely out of the blue. I have no doubt that had I had a different anaesthetist—or an assistant—in the theatre at that moment, the patient certainly would have died. If she did not die, she would have been severely brain damaged. As it was, she did not suffer lack of oxygen or have any other problem.

My other story is a difficult one that still preys on me more than 30 years later. A friend of mine—another doctor—went in for an abdominal procedure. I felt it was unnecessary and told him, “I do not really know why you are doing this”. To cut a long story short, he was put to sleep with general anaesthetic and as he was recovering, the anaesthetist saw that he was conscious and left the premises. He was left there with someone looking after him and his airway. My friend died. He died because he had a rare and unexpected deformity of the trachea and the trachea had perforated, so the airway was not what we thought it was. It would have been recognised by somebody really experienced with the trachea. It could not have been seen by an assistant who did not have the kind of anatomical knowledge that only somebody who is medically trained would have.

The House must understand that I have nothing against anybody, but I am very concerned that we might be giving associates or assistants more responsibility than they really deserve. I think it is very important to understand that no matter how safe anaesthesia is—and it is safer now worldwide than almost any other medical treatment that is generally used—it is still a procedure we need to be extremely cautious about.

I ask the Minister to think very carefully whether or not we should be blurring the notion between those who are medically qualified and those who are not. By giving those who are not medically qualified some idea that they are, we are running the risk that this sort of accident can happen. These accidents are rare, but they are completely unexpected and unpredictable. An anaesthetist has to recognise the unexpected. That is not something that most individuals can do; I, as a different kind of doctor, could not do that. I had no idea what had happened to the young woman. I was prepared to do open-heart surgery while there was nobody else in the theatre, which would have been ridiculous. But my anaesthetist was there to hold my hand—metaphorically—and rescued the young woman. We must recognise this is a very serious issue: what you call the doctor or the assistant is extremely important.

Photo of Lord Lansley Lord Lansley Ceidwadwyr 8:45, 26 Chwefror 2024

I am very glad to follow the noble Lord, Lord Winston, because he directs us to the central issue, of how we seek to ensure the safety of patients in all circumstances. What he was describing illustrates the essence of the relationship of a physician associate—or, for that matter, an anaesthesia associate—to the supervising doctor. That is a central issue as well. In the circumstances that we were just hearing about, the responsibility of the doctor or the consultant in charge of the patient is the central responsibility. It would be wrong to think that the devolution of tasks to an associate removes the responsibility of the doctor in charge of that patient.

I hope we agree that proceeding with the order is necessary because we want to bring physician associates and anaesthesia associates within the scope of regulation. This process has been very useful, not least because my noble friend and his colleagues have given us considerable time and energy in discussing the order and how it is to be implemented.

I confess to the House that when I was Secretary of State back in 2010 to 2012, and as the noble Lord, Lord Markham, made clear, there were relatively few physician associates. I remember them as physician assistants. I remember the desire on the part of physicians to have additional resources available to support them in that role. It was never to replace doctors; it was always to enable physicians to focus on where their responsibilities lie. That is still the purpose and the point of physician associates. I am less familiar with anaesthesia associates, and in those days, I do not remember understanding that they were there in the form in which we now have a number.

None of this debate is about trying to criticise physician associates, anaesthesia associates or the profession as a whole. We are setting out to make sure that as they are brought into regulation, that regulation works most effectively. From my point of view, the simple fact of being brought under the regulation of the General Medical Council was not a problem, because the General Medical Council was clearly addressing all the issues very efficiently and professionally. However, because the GMC regulates doctors, I confess that there is a worry about the idea of another profession being regulated by it. If one says, “I am GMC registered”, what do people assume by that phrase? They assume that one is a doctor. The distinction that needs to be made between the medical register, the specialist registers and the register that is to be established for physician associates and anaesthesia associates is critical.

As for myself, I am perfectly clear in my mind and would have started out by assuming that PAs and AAs would be regulated by the Health and Care Professions Council. That clearly was not the route that was chosen. In my view, it is too late to revisit that. However, the distinction in the registers under the GMC must be very clear.

Equally, the scope of practice and what the noble Lord, Lord Hunt of Kings Heath, said about the governance of the trusts and the bodies responsible needs to be absolutely clear. In particular, the scope of practice is the essence of how we can ensure the safety of patients, so that the whole multidisciplinary team understands what their respective roles are. I am not sure that there is any merit in trying to understand which professions are responsible for which mistakes. Let us look at outcomes. The outcomes are the product of the multidisciplinary team and a group of professionals working together—they are not the results of individual professionals. Let us put that slightly to one side.

The only other thing that I feel very strongly about—which has been referred to in a number of respects—is that patients and the public need to understand who the professionals responsible for them or providing the service to them are. Let us be clear: we start from a point where I suspect that most patients in most circumstances where they are looked after by PAs or AAs do not know who they are and how they fit into the professional scene. It is not that we are looking to ensure that everybody needs to be educated about that—that is probably too hard a task—but I urge my noble friend the Minister, the regulators and the professionals involved to recognise that PAs or AAs do themselves and patients the greatest service by being absolutely clear at any moment—including proactively—that they are not the doctor in charge of that patient but that they are providing care under the supervision of the doctor for the given purpose. If anybody appears to be in any confusion whatever, it is important that that confusion is remedied. For patients, understanding who is doing what to them and why is an essential part of “no decision about me without me”.

While the order enables the regulation to proceed, I hope that our debates on it are not “fire and forget”. This is about a process that we should be looking at very carefully to understand whether the problems that we have referred to, and the difficulties and worries that we entertain while the order goes through, are dealt with in the subsequent regulation.

Photo of Lord Harris of Haringey Lord Harris of Haringey Llafur

My Lords, I declare my interest as the chair of the General Dental Council. It is not for me to comment extensively on matters affecting a fellow healthcare professional regulator, but I will say one thing directly in response to what the noble Lord, Lord Lansley, said about the substance of the order. Unlike the GMC, the GDC is responsible for all dental professionals, including dentists, dental nurses, dental technicians and so on in the four nations of the UK. I believe that it is helpful to the public to be assured that all the professionals they encounter when they enter a dental surgery will be registered as professionals by the same regulator and that they will have equal levels of assurance about the training and standards they can expect—and within a framework that indicates what the limits are of each of their professional responsibilities, what can and cannot be done, and how they are appropriately supervised.

My reason for intervening, however, is separate. The DHSC has made it clear that this order is the first step in the reform of the way that all the healthcare professionals are to be regulated. Indeed, it told the Secondary Legislation Scrutiny Committee that the intent is to provide all regulators with “broadly equivalent powers”. While the GDC is some way down the queue—it is after the NMC, the Health and Care Professions Council and so on; although it is still helpful to get in early—this is potentially a template that will apply to all the regulated professions.

I make it clear that regulatory reform is welcome and long overdue. The GDC’s framework was set out in the Dentists Act 1984—that legislation is 40 years old, with only limited updating since then; somehow, the GMC is slightly more prominent and gets more updating than some of the other professions. The Government first consulted about the scope of reform in 2017, following Law Commission recommendations three years earlier. It has taken a decade to get even to this stage, and we are still a very long way off from orders being prepared to cover the dental professions. By the time the orders for all the other professionals are agreed, the model in today’s order may be outdated.

The GDC welcomes the intention to give the regulatory bodies more authority to update their procedures and processes without recourse to Privy Council approval and the delays inherent in waiting for the DHSC to draft regulations and lay them before Parliament. Such updating would of course be subject to full consultation in each case by the regulators concerned and would be only in the framework laid out in orders such as the one we are debating. We need such reforms to enable regulators to operate as effectively as possible to protect the public better in the light of changes in the way the professions deliver their services.

My concern, therefore, is whether tonight’s order is going to be a rigid framework for all subsequent orders. Is the template used here for anaesthesia and physician associates going to be used for nurses, midwives and dentists, as well as all the other healthcare professionals? One size will not fit all. Differences between the various healthcare contexts lead to different sorts of public protection risks, and that must be reflected in the way in which the different regulators regulate.

I will give three examples. First, in the order there is quite properly a requirement for periodic revalidation, but that will be different for associates covered by this order operating in a medical setting, often as part of larger organisations with well-developed clinical governance mechanisms, from what it would be for dental professionals, for example, many of whom work in single-handed practices or exclusively in private care. A different approach to revalidation and continuous professional development will be necessary, and that will need to be reflected in the framework laid down by a future order.

Secondly, those different ways of working also apply in terms of complaints and fitness-to-practise concerns. Associates, and indeed most doctors and nurses, will mostly be subject to existing complaint resolution processes handled via the NHS. Fitness to practise is a separate mechanism for them that comes into play often after those complaints have been through an NHS process, but such arrangements will need to be designed differently for most primary care dentistry that may well be outside the NHS.

Thirdly, the order says an offence is committed by someone who uses the title of anaesthesia or physician associate with the intent to deceive. At the moment, for dental professionals this is a strict liability offence. Maybe it is possible—although, having listened to the noble Lord, Lord Winston, I doubt it—for someone to claim they are an anaesthesia associate without an intent to deceive, but I have to say it is difficult to see why and how that could apply to someone purporting to be doing that or, for that matter, to be a dentist. If this wording were used for a future GDC order, why impose an additional requirement of proving intent to deceive rather than leaving it as a strict liability offence?

The examples that I have given all relate to dentistry but, as well as the GDC and the GMC, there are eight other professional healthcare regulators, each of which will have examples of its own. My plea to the Minister is that the DHSC should not use this template without careful consideration of the very different circumstances of each of the other healthcare professions.

Lastly, can the Minister give an estimate of when we can expect to see a draft order covering dental professionals? That is urgent because the GDC is essentially using 40 year-old mechanisms and procedures that are no longer fit for purpose, and it is in a context where more and more new models of dental practice and cosmetic dentistry are emerging—for example, remote orthodontics, where professional oversight is ostensibly being provided remotely, or non-UK providers of services offering “initial consultations” in hotel rooms. Such practices are affecting patient safety now, but the regulatory tools to address them do not yet exist. Flexibility is needed, and we cannot wait indefinitely for regulations to be brought forward.

Photo of Lord Patel Lord Patel Chair, Preterm Birth Committee, Chair, Preterm Birth Committee 9:00, 26 Chwefror 2024

My Lords, I begin with a slight disagreement with the noble Lord, Lord Harris. I take his point about how dental professionals, not just dentists, are regulated by the GDC, but I agree with the comment from the noble Lord, Lord Lansley, about the impression it would give if other professions apart from doctors were regulated by the General Medical Council. Hitherto, the GMC has regulated only doctors, so it would have to be clear in the register how these people were differentiated. I am afraid that the solution of having a prefix on a register would not mean anything to patients.

In the past, if you walked around a hospital, it was easy to know who was a doctor, as they mostly wore white coats; who were the nurses, because they wore different uniforms, including the matron’s uniform, which was a different colour; and who was a trainee nurse, because they wore a pink uniform, which is why junior doctors referred to them as “pinkies”. Physiotherapists wore yet another colour of uniform. However, nowadays everyone wears suits or jackets or jerseys, so you cannot distinguish from that which profession is looking after you.

I take the point that the noble Lord, Lord Winston, made, that for all of us who have done surgery, a qualified, competent anaesthetist is our friend. But sometimes—as he and I have no doubt done—we operate on pretty vulnerable patients for whom the surgery is necessary but they are not a safe bet for anaesthesia, unless by an extremely competent anaesthetist. But I interpret the anaesthesia associate as someone who does not induce anaesthesia but only maintains anaesthetic under strict supervision by a qualified anaesthetist. And that is quite distinct from what a physician associate might do, because they might be involved in different ways in assisting the physician. The point made by the noble Lord, Lord Winston, is important because it is an example that shows up the importance of the scope of the practice of physician associates and anaesthesia associates.

It does not help—and this debate is an example of why so much concern has been expressed—when the NHS health careers website says, in relation to physician associates, that they will be trained in

“taking medical histories … performing physical examinations … diagnosing illnesses … seeing patients with long-term chronic conditions … performing diagnostic and therapeutic procedures … analysing test results … developing management plans”— which I presume means patient management plans. If you see that, you can see why there are concerns and confusion over what their responsibilities will be and the limitation of the scope of their practice.

I absolutely appreciate the need for physician associates —I keep calling them assistants—and anaesthesia associates and the need for regulation, but I think this crosses the Rubicon since it is the General Medical Council that will regulate this. It is important that what it defines as the scope of the practice is understandable to patients and professionals clearly.

The noble Lord, Lord Hunt of Kings Heath, commented that he took the legislation through this House in 1999, and that Act will subsequently be the vehicle for SIs to be used for future regulation. I am sorry that some of us were not here at the time because some of us might have opposed it. An Act from nearly 25 years ago cannot be the one that continues to be used. If we are going to have further reforms of the regulation of doctors and nurses—where we are talking about 1.5 million health professionals, not 3,000 physician associates or anaesthesia associates—I hope we are not going to have an SI to do that, because there are lots of issues of regulation.

Photo of Lord Hunt of Kings Heath Lord Hunt of Kings Heath Llafur

My Lords, to be fair, I said that that Act had been subsequently amended by the Health and Care Act 2022. If you do not have flexibility through regulation, you will never get anything done in relation to modernising health regulation. Governments simply do not find time in primary legislation to update regulation.

Photo of Lord Patel Lord Patel Chair, Preterm Birth Committee, Chair, Preterm Birth Committee

I hope they do find time, because that allows for better scrutiny and better ability to amend, which we always claim to be our key role—to scrutinise and amend. It is a major piece of legislation to go through using SIs, and it is inappropriate to do so. Maybe we must consider how else we could do it in a way that maintains flexibility.

Moving on from that, as the noble Lord, Lord Harris, already mentioned, if this legislation is going to be the template for future legislation to regulate all health professionals, some issues will need to be discussed. This order does not require that health is considered as a category in the regulation of physician and anaesthesia associates. The statistics show that, when the GMC or, I presume, any other regulator investigates, it is a very stressful situation for the person involved. Some statistics suggest that one in three considers suicide; they are depressed by it. If the category of health is removed as a consideration when a person is investigated, as this order does, it is a backwards step. I need to ask the Minister why health has been removed as a consideration. If this is the template, I presume that this will also apply to other regulations in the future.

Photo of Baroness Fox of Buckley Baroness Fox of Buckley Non-affiliated

My Lords, the noble Lord, Lord Patel, just said many very important things, with which I agree, far better than I would. I thank the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, because this debate has revealed the importance of this order: it is not a minor regulatory matter that can be put through by an SI, in a back room. That it has created so much debate outside the Chamber indicates why it is important that we discuss this and that it is not nodded through behind the public’s back. I am glad of that.

I have been embroiled in discussions about this for some time. The noble Lord, Lord Hunt of Kings Heath, made a good point when he said that the discussion has become quite toxic. I thought it was perfectly reasonable to be worried about PAs and AAs; I did not anticipate this kind of savage attack on them. There has been a real scapegoating of these individuals, which is not how we should resolve this issue. We should also remember that doctors can be guilty of clinical negligence. We do not want to wander around pointing the finger at who is more negligent.

However, if there are preventable never events as a consequence of people not being fully equipped for the roles that they are asked to do—by the way, they are being asked, very often told, what to do when they are not really up to it, through no fault of their own—it is a matter for public concern. That is the way that accountability works and why we need to be very clear and have no muddle over what somebody is supposed to be doing, what they are not supposed to be doing, and what they can and cannot do.

There were a couple of things that confused me in the arguments made in the briefings we received. I lost the will to live in the rows going on about the differences between physician associates and physician assistants, as though “associate” or “assistant” was the key difference. I think the difficulty is when people think that any of them are physicians, because that means that they think they are doctors. That is the confusing bit and it shows that people can get lost in the midst of this.

It is also worth bearing in mind some context when it comes to the public. Most patients would prefer to see anyone at a doctor’s practice than wait for two weeks in pain. That makes the public vulnerable to having a lesser service. I understand that. I also thought that the noble Lord, Lord Patel, was absolutely right about a big team: when you are in hospital, you are surrounded by people wearing a million badges, different colours and lanyards. They all introduce themselves to you in great detail, but you do not care because you are ill. You want to lie back and trust them, and assume that a division of labour is going on.

Sometimes, when I was reading the briefings, it felt as though there might be a bit of vested interest about who was regulating who and what numbers were on the badges. This seemed to miss the point of the real concerns, which are whether there is sufficient clarity about the scope of PAs or AAs, or whatever we call them; that there is not too much mission creep; and that we have a clearly defined set of protocols and specific tasks allocated. I think it important that PAs in GP surgeries have a different set of protocols and scope than in hospitals—they are not the same, even though in both instances they are called PAs.

It is also important that there is a clear sense of what is taught on those courses. People talk about the training courses, university courses and two-year courses as though they will be the solution. As an aside, I worry about the credentialism that has led to too many people doing nursing degrees and not wanting to do any nursing, but I am also concerned about the fact that degree courses are being trusted in this way when, if you talk to anyone who is a lecturer, or works in a university, they will tell you about the problems of dumbing down, grade inflation and not being sure of the product you are getting. So I am not sure that I trust that.

Finally, in the NHS we definitely need a shake-up. We know that we need new members of staff. I do not want to be somebody who says only the old roles count, but I came across something I refer the Minister to: the notion of medical assistants, put forward by Maureen Baker in July 2014 when she was chair of the Royal College of General Practitioners. Having visited the United States with Jeremy Hunt, she described this new group of people—medical assistants—which basically described what I think we need. I do not know why we cannot have them and why we have come up with this idea. I work with a lot of young people and there are plenty of bright young people desperate to enter medical school and become doctors and they are not able to. Why is that? That is the kind of situation that needs to be solved, rather than just making up PAs or getting into a row about the pros and cons of them.

Photo of Baroness Harding of Winscombe Baroness Harding of Winscombe Ceidwadwyr 9:15, 26 Chwefror 2024

My Lords, I support this Motion and, not for the first time in a debate on health, I find myself in almost complete agreement with the noble Lord, Lord Hunt, and the remarks he made earlier in an extremely powerful speech. We are exemplifying the right debate here, in that this is a subtle and important issue.

I do not wish to suggest that I challenge the esteemed clinicians from a number of the different clinical tribes who have spoken this evening. I speak as a non-expert, as a manager of people, and as a patient. Non-experts in healthcare would find it completely baffling that we have 3,000 people working day in, day out in clinical roles who are currently unregulated. It cannot be right, and I have not heard any argument this evening that suggests that anyone in the Chamber thinks it is right. I think we are all united in our agreement that these hard-working, brilliant people need proper professional statutory regulation.

I hope that, therefore, the order, as it stands, passes. But it is worth dwelling on why this has created so much controversy. Fundamentally, it is because change is hard—and people change is hard and scary. There is a real danger that we underestimate how important it is to look after the people who care for us, and that what we are really hearing from a number of the different clinical tribes is fear, frustration and hurt that they are not being looked after. The real tragedy is that, as the noble Lord, Lord Hunt, said, in the process we have made 3,000 more people feel hurt, unloved and uncared for in the awful debate out in the Twittersphere or X-sphere or whatever it is called.

I will not talk for very long. I just want to register that this has been far too long unfixed, that 20 years is too long for people to be practising without regulation, and that other countries around the world are far ahead of us on this. We should be discussing how we properly define the scope of practice and how we then extend that scope of practice, with the appropriate training for prescribing rights and the ability to order X-rays, just as happens in many other countries in the world. We are all in this Chamber rightly proud of the NHS, but we must not stick our heads in the sand and convince ourselves we are brilliant when others fixed this issue 20-plus years ago.

I finish by saying that regulation is clearly not enough. I completely agree with the noble Baroness, Lady Finlay: we have to recognise that our health and care workers feel unloved and uncared for. There are far too many stories of people unable to get a hot meal when they are working night shifts or having to cancel their own wedding because they are not rostered to be allowed to take the time off. None of that requires professional regulation; that requires professional management. We need both of those.

Photo of Lord Bethell Lord Bethell Ceidwadwyr

My Lords, I hope that my noble friend the Minister will not mind if I say that I am very grateful to the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, for the regret amendments and this debate today. Secondary legislation comes through the House and too often we overlook it. Every now and again we need to put a spotlight on some of the important measures that go through.

I regret two things. I deeply regret the way in which the professions of associate physician and associate anaesthetist have been denigrated in the press, in the lobbying material that has been sent around, and, frankly, in aspects of this debate. I agree with my noble friend Lady Harding and the noble Lord, Lord Hunt, that the feelings and sentiment of these hard-working contributors to our healthcare system have been overlooked. I was sent a very robust briefing by the Royal College of GPs. I replied: “Is there nothing positive you can say about these hard-working healthcare professionals?” The reply came back—the noble Baroness, Lady Finlay, was copied in on it—that there was not: there was nothing positive it could say about them. I greatly regret that tone, and wish it had not happened.

I am not a clinician and I do not have anything to rival some of the comments made by the clinicians. However, I point out that our hard-working healthcare professionals are incredibly stretched. Take GPs, for instance: 350 million appointments were conducted in primary care last year, 160 million of which were by GPs themselves. That was 50 million more than in 2019, so 44 more appointments per practice. That trend is going up. Britain is getting less healthy, and there is a large amount of immigration. The number of full-time equivalent GPs—although the number of GPs has gone up, a lot of them are working fewer hours—has decreased from 28,000 in September 2015 to 27,000 in October 2023. The complexity of many people turning up to these appointments is very high.

We have to find people from somewhere to do some of these appointments, and there are going to be people who have a lot to contribute who do not necessarily go through the 10 years of qualification to become a GP. We should be embracing them. That is what is happening in every other professional walk of life—it is happening with the astronauts who fly to the moon, the people who fly our planes, and the lawyers who run our courts. The modernisation of workforces is happening everywhere; we should embrace that. My noble friend the Minister alluded to 12,000 AAs and PAs by 2036; that would be just 8% of the number of doctors. That is not a revolution or a threat that the doctors of Britain should be worried about.

If these regulations do not go through—the noble Baroness, Lady Bennett, has said that they will—then it would be difficult to enforce standards, there would be years of delay to regulate the professions, there would be a reduction in the number of healthcare professionals to support our healthcare system, and training programmes would be on hold. I support the passage of this legislation, so that we can modernise the workforce, increase primary care capacity, improve the lot of our hard-pressed GPs and make it easier for a wide range of talents to make a difference to the British healthcare system.

Photo of Baroness Bloomfield of Hinton Waldrist Baroness Bloomfield of Hinton Waldrist Ceidwadwyr

My Lords, I will speak very briefly in favour of these regulations. I am absolutely in favour of any way in which we can leverage the ability of our doctors to concentrate on what they want to do, and what they have been highly and expensively trained to do, which is to take responsibility for seeing, diagnosing and treating patients who are ill and in need of medical help. I am also in favour of trying to reduce the exorbitant cost of locum GPs, which bleed resources from the National Health Service—resources which could be much better spent elsewhere. Some of the Government’s initiatives, such as allowing pharmacists greater and more extensive advisory and prescribing powers, are also very welcome.

I have no philosophical objection to the concept of physicians or anaesthetists being supported by assistants, whether they are senior nursing staff or others, but I share the concern that the very term “associate” implies a greater degree of qualification than is actually the case. Two years’ training post a science degree does not a doctor make. Of course they should be regulated by an organisation which enjoys public confidence, so long as that in itself does not imply a greater medical qualification.

It is easier to prevent overreach in a hospital environment, where supervision in anaesthesia should be routine, but it is much harder in general practice. The reason I rise now is because my husband was seen by a physician associate when his throat failed to heal weeks after he burned it with a hot cup of coffee. After the young man had taken a photograph and disappeared up the corridor with his phone, allegedly to see a GP, he reappeared with an ominous pamphlet entitled “Suspected throat cancer” and suggested an urgent appointment at the John Radcliffe Hospital. I am pretty sure he was not trained to be the bearer of such bad news. So undoubtedly physician associates need to be regulated, though I acknowledge it was better this way round than ignoring something and saying that there was no issue to be dealt with when there might have been.

We have 14 GPs in our local practice, in a small town in Oxfordshire: 11 work three days per week, none of them works full-time and one of them works one day per week. Perhaps we should also address the loss of 40 working days per week from any similar team, as well as putting in place things that make doctors’ working lives more rewarding and meaningful. If physician associates are part of that then I am fully supportive, so long as they are properly regulated. The Faculty of Physician Associates code of conduct, produced with the GMC, says that physician associates will always work under the supervision of a designated senior medical practitioner and that they must work within the limits of their experience. Let us make sure that these regulations will help make that happen.

Photo of Lord Scriven Lord Scriven Democratiaid Rhyddfrydol

My Lords, I have listened to the debate very carefully. My professional experience as a former health service manager over many years is that we have had this debate about people taking on different roles in health and always the same arguments come. Whether it be physiotherapists taking on roles, nurses becoming nurse practitioners or pharmacists coming into this, the same argument always happens: that somehow this dilutes patient care and safety. The answer is that it does not if it is properly regulated, there is proper training and there is proper monitoring of what happens to patients.

I understand that there is some anxiety, but I have to say to the BMA, in particular, that its language in the briefings it has given has driven the bullying and ostracisation of colleagues in hospitals who are valued members of a clinical team. That is the word: “team”. It needs to be led by a senior doctor, normally the consultant, without ostracising people within that team. I gently say to the noble Baroness, Lady—I have forgotten.

Photo of Lord Scriven Lord Scriven Democratiaid Rhyddfrydol

The noble Baroness, Lady Bennett of Manor Castle—I remembered the Manor Castle because of Sheffield, but I could not remember the Bennett bit—that, twice during her contribution, she used the term “a second-rate service”. These people do not provide a second-rate service; they provide and augment the team service, to ensure that patient outcomes are as good as they can be.

On the whole, I support the fact that these orders are being laid, although there is one issue that I think needs to be thought through carefully: if the GMC is going to regulate, there is an issue about the way that the distinguishing of the registers is dealt with. I see that as a potential trip-up point if not thought through very carefully; I hope the Minister can give the House some assurance on that.

On the whole, I support the regulations. This is just a continuation of many years of different people in the team taking roles. With the correct regulation and the correct training and supervision, this will improve patient outcomes and service.

Photo of Lord Allan of Hallam Lord Allan of Hallam Liberal Democrat Lords Spokesperson (Health) 9:30, 26 Chwefror 2024

My Lords, this statutory instrument has triggered a debate that I think is happening on multiple levels. There are two meta questions around the structure of the medical professions, writ large, and the legislative process for establishing professional regulations and updating these over time. This is something on which the amendment from the noble Baroness, Lady Bennett, focuses, and around which the noble Lord, Lord Hunt, has helpfully provided some extra history.

There is one question, which I would call an adjacent question, around the treatment of junior doctors and their frustration at the moment, which they are expressing largely through industrial action. That has been mentioned, quite rightly, by a number of noble Lords, but I do not think that is core to the debate around associates; it is an adjacent question spilling over into this debate.

We have to recognise that the Government have got themselves into a mess over the junior doctor situation and that unhappiness is now having these knock-on consequences. The noble Lord, Lord Bethell, interestingly pointed out that the BMA was unable to come up with examples of the positive use of associates. I thank the Minister for bringing some associates here so that we could hear from them. I thank the consultants in emergency medicine at Leeds hospital who wrote to me and, I suspect, to other members, describing how associates work on the ground and full of praise for the work they do, which has rightly been echoed in the debate today.

There are three questions around the associate roles themselves, which are touched on more in the two regret amendments. The first is whether these roles represent a valuable innovation for the NHS and, importantly, for the patients of the NHS, and so have a long-term place in the system. I hear broad support for the answer to this question being yes, qualified by some questions around the name and the scope, which I will come to shortly. Broadly, I have not heard anybody say that they disagree with the development of these associate roles within the NHS.

The second question is whether they should be regulated by the GMC, as proposed in the statutory instrument. Here I hear a more grudging “Yes”, but still a broad acceptance that the GMC is the only game in town and that it will do a good job. I was interested to hear from the noble Lord, Lord Harris, about the role of the GDC; the comparisons between the GDC and GMC are helpful for us to consider. Certainly, there is a broad sense that the GMC will do a good job if it is the regulator; I am inclined to agree with that.

A particular benefit of the regulation is that it will provide a clear and well-established route for any issues to be investigated. Again, people have raised particular instances in the debate about where things have gone wrong. They will go wrong from time to time with any group of professionals—including politicians, dare I say? It does not matter which group of professionals it is, things will go wrong. What is important for a member of the public is that there is someone they can go to who has a clear and well-established procedure for getting to the bottom of what happened and finding a resolution. I have every confidence that the GMC will provide that for physician and anaesthetist associates and that this will add to any complaints mechanism that exists within individual trusts, which is all there is today so long as these professions are outside of a regulated entity.

Again, importantly, it has been mentioned in the debate that the GMC will provide for a regular review of these professionals to ensure that they continue to remain fit to practise. I think we all can welcome that. I hope the Minister will be able to commit to there being full transparency from the GMC about the activity that takes place on the new associates register so that we can understand how many are coming on and going off it and understand any issues that have arisen, such as the reasons they might have been taken off the register.

The Minister referred to annual reports to Parliament. In 2024, we expect a little more real-time information so I hope he will be able to commit to there being full transparency about associates coming on to that new GMC register and that we should be able to see that much more frequently than simply a report to Parliament.

The third question that has arisen and the one I want to spend the most time on—not too much given the lateness of the hour but enough to try to elaborate the point—is whether the roles are properly defined to avoid confusion and whether they are being used appropriately. Some of this is in the name, which we have discussed already, and I hope the Minister can point to some evidence about there being a lack of confusion.

It seems to me instinctively that there is confusion, partly because “physician” is not common parlance in British English—it is something we more typically associate with American TV shows. The noble Baroness, Lady Watkins, made the point about how we now talk about junior doctors. If you said to somebody, “Do you think a physician associate or a junior doctor is more highly qualified?”, I suspect a lot of people would opt for the physician associate because “physician” has a grandness.

We should be honest enough to test this with ordinary people, not people in the medical profession. That is the test we should apply and if it is true that people think that the physician associate is more highly qualified, we need either to help people understand that that is not the case or change the name. It is really important that we go out there and talk to ordinary people about how they experience those names to understand what is going on. I hope the Minister can commit to that.

More significant is the scope of the role as defined in national guidance and how that is exercised within health organisations in both the NHS and the private sector. The noble Lord, Lord Hunt, and others rightly raised the scope of practice. I think my most significant concern is not about individual physician associates presenting themselves wrongly but the decisions that will be made by their employers about how to deploy them. We need to look at general practices and large NHS trusts separately. With GPs, in many places we are already operating in a commercial market and in some cases physician associate roles have been growing quite significantly under the additional roles reimbursement scheme which has been operating over the last few years. I thank whoever in the department who is responsible for coming up with a scheme whose acronym is ARRS, which brought a smile to my face when reading the briefing notes late at night.

This issue was brought home starkly to me when I, along with thousands of other people, received a note from my practice telling me it is being sold by a large US corporation called Centene to a British private company, owned by private capital, called T20 Osprey Midco Ltd—very catchy. GP practices are bought and sold en masse between these corporations. I looked into the business of the Centene corporation and found that in 2022 “Panorama” did an investigation specifically into its use of physician associates and came up with some quite disturbing data around the preponderance of physician associates in practices being operated by this US corporation.

I am not a raging anti-capitalist but I do not think it is crazy to think that private businesses will try antod find whichever ways they can to reduce their costs and increase their margins. I would like the Minister to explain how the Government will make sure that these roles are not misused in general practice, especially where they are owned by corporates rather than being operated by some part of the NHS structure. In particular, I would like him to explain how we ensure that practices follow the Royal College of GPs’ position that the physician associates must work under the supervision of GPs and not be used as substitutes. That was something the Minister said in theory. I would like him to clarify in practice how he is going to make sure that happens in this multiplicity of individual contractors who are not NHS employees but operate independently of it.

There is a real concern that if there is a shortage in GP recruitment, that will clearly add to the pressure for practices to think, “I’ll hire the physician associates because I can’t get the GPs”. Again, if we follow the RCGP guidance—I hope the Minister will agree with this—if a practice cannot hire a GP, it has no one to supervise the associate so it should hire fewer physician associates, not more. The hiring of physician associates is contingent on practices hiring sufficient trained general practitioners.

When it comes to NHS trusts, the concerns relate to the decisions that the management may take. This is not intended to be NHS manager-bashing, particularly not with my noble friend Lord Scriven sat behind me; it is more a bit of Government-bashing. If the Government leave trusts with constrained budgets, managers will naturally look again at ways to keep the services running, including using less expensive staff where they can. The risk will be compounded again if the more expensive fully trained staff are not available because there is some shortfall in the Government’s training programme.

I know that the Minister will have to say, “The Government will meet their targets for training doctors and GPs”, but in the real world we have to imagine a scenario where, sadly, they fall short. Again, I want to hear assurances from him that where trusts start heading down the route of thinking that they can hire associates because they cannot get the doctors, the levers will be in place for the NHS centrally to stop that happening and to ensure that associates, who are valued and valuable members of teams, will not be left by their managers to do all of the job, rather than being part of a team with a trained medic leading it.

I hope the Minister can reassure us on the scope in both GP practices and NHS trusts. Again, the SI and this regulation are welcome but there are some questions to answer around how these measures present to people. However, the most significant questions that we may come back to in two, three or four years’ time will be around how individual trusts and general practices have decided to use these roles, rather than any questions around the professionalism or effectiveness of the individuals doing that work, whom we value.

Photo of Baroness Merron Baroness Merron Opposition Whip (Lords), Shadow Spokesperson (Health and Social Care)

My Lords, the point that the noble Lord, Lord Allan, has just made about respect for the professionals we are speaking about is a very good one for me to follow on from, because I believe we are at our most vulnerable when we are in the care of the NHS. We have a right to expect to be seen and treated by a competent and regulated professional, in whom we have confidence. This debate has highlighted the sensitivities and practical challenges in trying to get that right. I am sure the Minister will take note of the many valid points that have been raised.

I start by associating myself and these Benches with thanking physician associates and anaesthesia associates for their professional and continued service. I feel particularly strongly about saying that in view of the points raised by my noble friend Lord Hunt and other noble Lords on the considerable toxicity that has been generated about this issue. That has brought bullying and intimidation to these very valued members of the NHS team. I am sure that all of us in your Lordships’ House believe that this is just not acceptable.

In the debate tonight, I feel that I have heard broad agreement that regulation is important—indeed, crucial —to maintaining high standards of patient safety and care, and providing clarity around the boundaries of the functions that can and cannot be performed. Yet, as we have heard, there has been significant delay in getting there when it comes to PAs and AAs, even though regulation needed to come alongside workforce planning. Can the Minister tell your Lordships why this regulation has taken so long?

I want to say from this side of the House that, if we are in government after the general election, we do not want regulation to take as long as it has under this Government. This is not least because, as technology advances and health needs change and expand, we need a bigger and better skill mix across the NHS. We want to work to ensure that new professionals supporting the NHS will be registered and regulated with thoroughness and speed. I will turn to the points in the amendments to the Motion before your Lordships’ House.

First, this is not a new issue. The term “associate” is one that these professions have used for many years in their education, training and deployment within the NHS. It pre-dates the decision to bring them into regulation. Just like doctors, PAs and AAs are responsible for clearly communicating who they are and what their role is in the team. I take on board the points made by the noble Lords, Lord Patel and Lord Lansley, and others, that this should not be the sole responsibility of patients. I am sure the Minister will have heard this point too.

On the regulator, the Secondary Legislation Scrutiny Committee reported that

“The proposal to register and regulate Associate Physicians and Anaesthetists is entirely in line with previous practice”.

It confirmed that, in its view,

“the GMC is experienced in that role”.

Therefore, the committee did not express any concerns about the policy intention, and neither did the Academy of Medical Royal Colleges.

On the proposal to decline to approve this order, I hope that by now it is clear to your Lordships’ House that AAs and PAs provide much-needed capacity in supporting doctors and other front-line staff as part of a multidisciplinary team, and that their numbers are to increase as part of the workforce plan. Declining to approve this order would not just send the wrong message but would set back the long overdue reforms required to provide assurance and safety standards to patients, and to help the NHS deal with ongoing pressures.

In the Adjournment debate in the other place on 7 February, Minister Stephenson said:

“The role of a physician associate is to work with doctors, not to replace them … The role of physician associates is in no way a replacement for that of any other member of the general practice team.”—[Official Report, Commons, 7/2/24; cols. 338-41.]

Those are welcome comments. Could the noble Lord the Minister give a reassurance that the expansion of PAs and AAs will not impinge on medical speciality training expansion and, most crucially, on opportunities?

Noble Lords, as we have heard throughout the debate, have heard much from those concerned about this order. It is also fair to say that we have also heard from those who support it. I understand the strength of feeling, as I heard about the life-and-death implications described so painstakingly by my noble friend Lord Winston.

I have a few questions for the Minister. Could he give an assurance that all stakeholders will be fully consulted by the GMC on the details of the draft order? What measures will be taken to ensure that patients have both clarity and improved awareness of who they might speak to and deal with in a medical setting? This was highlighted in the regret amendments in the names of the noble Baronesses, Lady Brinton and Lady Finlay. Could the Minister also indicate what support will be available to PAs and AAs? What level of supervision will be suitable and how will the Government ensure that it is in place, given how stretched staff already are on the front line? Has the Minister had discussion with the GMC about defining scope of PAs and AAs?

It would be helpful to hear the Minister’s thoughts on how the order might impact on career progression in the NHS and help with retention. To follow up on the points raised by my noble friend Lord Harris, will the Minister explain how the order fits in with the wider regulation reform to be undertaken in the next year or so?

I know we all agree that patient safety must always be our number 1 priority. Can the Minister provide any assurances about the measures in place to review this legislation over the two-year transition period, particularly given the expansion of the role of PAs and AAs in the NHS?

Some have expressed concern about the safeguards around the fitness-to-practise decisions taken by regulators, including decisions to remove or reduce regulatory restrictions on a registrant who has been found to present a possibly serious risk to the public. What assurance can the Minister give on that point? If the legislation is deemed not suitable to improve patient safety, what measures will the Government take to remedy that and keep on top of the situation?

We support this order. It is vital that all those who treat patients in the NHS do so with patient safety and quality care at the fore. I hope this debate and this order will make a significant contribution to that.

Photo of Lord Markham Lord Markham The Parliamentary Under-Secretary for Health and Social Care 9:45, 26 Chwefror 2024

I thank all the noble Lords for their contributions. The wide range of views and experience shows the House at its best. On the serious point of the noble Baroness, Lady Bennett, about making sure that there was a full debate, I hope noble Lords feel that this is a good example of where we have had a full and thorough debate.

I am glad to say that, within all those contributions, there was a general agreement on the importance of these roles and the vital contribution that they can make. They can allow doctors to work to the top of their profession—my noble friend Lord Bethell made that point. As the noble Lord, Lord Scriven, rightly said, they are a supplement to doctors. I hope that, when you have support and allow people to work to the top of their professions, that will cover some of the points that my noble friend Lady Harding and the noble Baroness, Lady Watkins, made about good management, making general practitioners and doctors feel valued in their roles, and making them feel that they are being offered these support service. That is very much within the scope of practice here. Oh, I now see that the noble Baroness, Lady Watkins, is on the Woolsack; I was looking all over for her and thinking, “Surely my speech is not so boring that I have lost her already”.

I hope noble Lords feel reassured by all this and that, as drawn out in the numbers referenced by my noble friend Lord Bethell, this represents only 8% of the GP workforce, so it is very much a supplemental role rather than a substitute.

All speakers echoed the point made passionately by the noble Lord, Lord Hunt, that PAs and AAs play a valued role—one always grounded, as my noble friend Lord Lansley said, in the central role: the doctor or the anaesthetist themselves.

As my noble friends Lady Harding and Lady Bloomfield said, this seeks to regulate them properly, with much clearer regulations, a defined scope of practice and the flexibility to adapt. The noble Baroness, Lady Merron, asked the very fair question of why this has taken so long; the honest answer is that I do not know, but the whole point of this is to build in flexibility. With all the will in the world, as we have seen, if it required primary legislation then, for whatever reason, there would not be time available in Parliament to make the changes quickly enough for the required flexibility. That is what we are trying to do with this order.

The noble Baroness, Lady Bennett, said that she wants to make sure all voices have been heard. I hope those voices have been well heard. During the 18 months that I have been in this role, I have had more correspondence on this than on anything else. She mentioned the Observer article on the long-term workforce plan; I assure her that there is no back-pedalling on this. The target is for incremental increases in the numbers each year. Funnily enough, the frustration expressed to me by Minister Stephenson today is that we are not only hitting the targets for this year but exceeding them. There is definitely no back-pedalling; rather, we are exceeding our targets.

I assure the noble Baroness, Lady Merron, that we do not intend to impinge at all on specialisms. Following on from the Oral Question today, the next stage is to try to get into the detail of the specialisms.

On the points raised by the noble Baroness, Lady Finlay, there is some confusion around the protected titles. As we all know, “doctor” and “consultant” are not protected titles today; you can call yourself a doctor if you have a PhD, and I called myself a consultant once when I worked as a strategic consultant. There is confusion. On the point raised by the noble Baroness, Lady Watkins—I see that she has now popped up by the Throne; it is like “Where’s Wally?”—we need to look at an overhaul of titles, full stop, and at some of the acronyms, such as AAs, as mentioned by the noble Lord, Lord Allan. The idea is that all of this will be part of a full GMC consultation process over the next couple of years on this reformed legislation; we will look at all these points there.

There are separate registers. As mentioned, it is intended that there will be separate prefixes of PA and AA in the registration numbers, but I fully accept that it will not mean anything to a member of the public that a serial number is PA1234. It is a good point that there should be a more thorough consultation on the use of titles, because it is absolutely a confusing picture.

The noble Lord, Lord Harris, with his experience of the GDC, showed that having one regulatory body looking after everything provides clarity. That is valuable, but, as the noble Baroness, Lady Brinton, said, our Explanatory Memorandum needs to be clearer, and so I make that commitment.

As my noble friend Lord Lansley, said, this needs to be an ongoing process policed by the CQC. As part of that, I take the point made by the noble Lord, Lord Harris, that you should not need the caveat about the intent to deceive. The fact that you are not using your correct title in the right place is enough in itself.

Photo of Lord Markham Lord Markham The Parliamentary Under-Secretary for Health and Social Care

That is something I will pick up on. On the point raised by the noble Baroness, Lady Fox, I say that the GMC, with the CQC, should be able to give the ongoing quality assurance.

The noble Lord, Lord Hunt, said very well that the discussion on mistakes has not been useful. We are all aware that, regrettably, mistakes happen in all areas, and we need to make sure that we understand and learn from them, rather than using them to point fingers. Moving into the regulated space, where there is duty of candour, is useful.

I do not think anyone could be failed to be moved by the passion with which the noble Lord, Lord Winston, spoke about his experience. It was a very telling story. As reassurance I cite the noble Lord, Lord Patel, on the scope of the practice: it is one anaesthetist to two AAs, and the role of the AA is very much to maintain, as he explained well. In a similar way, the PAs really do need to work under GP supervision. The numbers are set out in the long-term workforce plan. We have a foot on the throttle for those training places, particularly in regulating them. We will make sure that things are properly managed so they cannot get out of control.

I absolutely agree with the points made by the noble Baronesses, Lady Watkins, Lady Harding and Lady Bloomfield, that this is a people management issue, and a lot of the heat from this debate is a feeling from junior doctors and others that they are unloved and uncared for. I freely admit that there is a wider issue that we need to look at, concerning things like hot meals; clearly, it is something trusts need to look at it as well.

I echo the points made by the noble Lord, Lord Hunt, that passing this order is the best way to ensure the safety of patients. As we develop, there is perhaps scope to be more ambitious, but let us try to do this step by step, to make sure we really are happy and that the scope of practice works. As ever in a debate as long as this—it has been a very thorough one—I will write to fill in any details that I have not managed to cover. At this point, I hope and trust I have provided sufficient answers to the questions, and have demonstrated—

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Deputy Chairman of Committees, Deputy Speaker (Lords)

I hesitate to rise because the House clearly wants to end the debate, but I am not sure whether the Minister, in summing up, said whether the titles of physician associate and anaesthesia associate will be protected titles when the order goes through. Are they negotiable? I ask that question specifically because I had a lot of discussions with different people involved in this, particularly the GMC, and I have been concerned that if those are the only protected titles of all the grades registered by the General Medical Council, we may be storing up further problems for the future. If this is to be a protected title, can the Minister provide assurance that further statutory instruments could be brought forward if, in the light of the consultation advised by the noble Lord, Lord Allan, a different title is suggested? Could it then be changed?

Photo of Lord Markham Lord Markham The Parliamentary Under-Secretary for Health and Social Care

It is a protected title. The point I was trying to make about the general overhaul and understanding of the titles, however, is that there will be the scope to do this, as doctors and consultants are not protected titles today. I think we need to develop clarity on that, which is why the further reforms and SI changes will set out to protect other titles as well.

Photo of Lord Patel Lord Patel Chair, Preterm Birth Committee, Chair, Preterm Birth Committee

Sorry about prolonging the debate, but is that the only protected title of all healthcare professionals?

Photo of Lord Markham Lord Markham The Parliamentary Under-Secretary for Health and Social Care

My understanding is that currently none of the titles is protected. These are the first set of titles that will be protected as a part of the secondary legislation that we are passing. The idea is to understand the hierarchy of titles and start to introduce the protections. I am happy to follow up in writing in more depth on all of this. I thank the noble Lord for his intervention.

Hopefully, this order will provide a standardised framework of governance and assurance for clinical practice and professional conduct for AAs and PAs. It will enhance patient safety and enable AAs and PAs to make a greater contribution to patient care. I beg to move.

Photo of Baroness Bennett of Manor Castle Baroness Bennett of Manor Castle Green

My Lords, I am acutely aware of the hour, but I am also aware there are a great many people—so social media tells me—watching this debate. There are a couple of things I need to say.

First, I thank everyone who has taken part in the debate, especially the noble Lords, Lord Patel and Lord Winston, for bravely telling us about the detail of their rich experience.

I will pick up on the comments made by the noble Lord, Lord Hunt, and the noble Baroness, Lady Merron. If you look back at my speech—I have handed over my notes now—I used the word “respect” talking about the PAs and AAs, and I talked about their study and student debt. I make it clear to the noble Lord, Lord Hunt, that I have not made any listing of incidents where things have gone wrong. I cited one case relating to the issue raised by the noble Lord, Lord Allan, of the difficulty patients have in understanding what the term “physician associate” actually means.

I highlight the words of the noble Lord, Lord Patel: using an SI to do a major piece of legislation is inappropriate. That is the whole reason I put down this fatal amendment. The noble Lord, Lord Hunt, and others said we cannot get the parliamentary time for it. Well, we have talked about reform a lot tonight, so maybe we ought to look at reform in Parliament as well. I will refrain from suggesting some of the Bills that we could not be doing so we could be doing this as a Bill instead.

There are a couple of points that need to be answered. The noble Baroness, Lady Bloomfield, questioned part-time GPs. If GPs are working, say, theoretically four days a week, it is more than a full-time job in terms of the stress, pressure and time involved. If we are going to keep people in the profession, we have got to allow them to contribute as much as they can. That is an issue of sustainability.

The noble Lord, Lord Scriven, referred to me talking about a second-rate service. I was talking about a possible experience a few years in the future; if there is the situation of whole regions, areas and practices—like the noble Lord, Lord Allan, said—having only PAs, effectively that would be a second-rate service. That was the future context I was talking about.

Given the time, I will make one final point. The noble Lord, Lord Bethell, said the Government are looking for the number of PAs and AAs to be 8% of the total of doctors. The question, of course, is not just about the total but about the distribution. There is the point about private hedge fund owners of GP surgeries and what they might choose to do. There is also the point which I have been driving at all the way through, having for more than a decade been visiting northern cities and towns in particular, where people really feel that they are struggling to get a decent NHS service and struggling to get the staff, and they fear that they might not get enough doctors.

Again, I thank everyone. I thank the noble Baroness, Lady Fox, for stressing how vulnerable patients are. My final point is that in making sure that patients understand they are being seen and treated by a PA or an AA, there has to be an attempt to understand that when people are ill, vulnerable and desperate, they may not absorb something just being done to them by rote. That is really important.

With that brief summing up, and in the circumstances, I beg leave to withdraw my amendment.

Amendment to the Motion withdrawn.