With the NHS in the grips of a staffing crisis[1], the strikes, retention and attrition of junior doctors in training is a pressing concern. In 2022, the rate of doctors leaving after Foundation Year 2, rather than continue training was 45%[2], nationally. Many attribute this to lack of flexibility, poor wellbeing and inadequate pay for the level of work and responsibility required in their roles. However, our recent research project – Care in Uncertainty shows the causes may run deeper.

Based on mixed-methods research featuring survey responses from more than 300 trainee doctors in Trusts across England and Wales and 23 in-depth interviews with trainee doctors), our study sheds light on a deep-rooted source of stress: uncertainty. This relates in part to rotation into new job roles every 4-6 months, and has been exacerbated by a perceived lack of government commitment to doctors’ careers. In our survey, 94% of trainee doctors expressed concern about the current state of NHS as a system, and 80% said they were concerned about their own professional future within it.

Some of the interventions to ease staff shortage can have unintended consequences. For example, the introduction and expansion of the Physician Associates (PA) role in the NHS to manage the current staff shortage crisis. PAs were introduced in the mid-20^th Century in the United States to address a crippling workforce shortage in Primary Care[3] and careful use of this resource offers potential benefits. Their addition to a team can offer cost-effective care by tasking fewer complex jobs and cases away from doctors, PAs offer a long-term continuity both for patient and trainee doctors due to the nature of rotation. PAs are currently reliant on the trainee doctors to prescribe, order radiology and other investigations, but often the starting salaries of PAs is more than the foundation doctors. Such pay disparity can breed resentment, particularly in the context of junior doctors already feeling undervalued and underpaid. Since the majority PAs in the NHS were ‘looted’ from world regions most affected by health workers shortage[4], there is a moral issue as well as potentially increased tension among different ethnic groups in the NHS workforce[5].

A number of junior doctors in our survey and during interviews perceived that PAs encroached on their already limited training opportunities with consultants and their role in the medical care team. This has recently been highlighted by Dr Salisbury’s post [6] and on twitter.  Professional regulation and well-defined responsibilities within PA role are therefore essential to resolving such uncertainties. In support of this our interviews illustrated that in places where PAs have clearly defined roles, trainee doctors truly appreciate their support.

Our data clearly show the benefit of regular, effective and open communication between senior clinicians and trainee doctors to address various uncertainties faced by this group during their rotations; we would recommend that this should include clearly defining the role of PAs, and their part in the wider team built to provide integrated care for the patient. More importantly, to recognise trainee doctors’ valuable contribution by improving their working/learning conditions-designated work/study space, protected study time, access to quiet study area with functional computers, access to online revision resources for postgraduate exams. However, to ensure safe and effective patient care, there is a pressing need for the government to demonstrate commitment to trainee doctors’ careers which should include a commitment to better define and regulate the PA role and its scope in practice and a commitment to facilitate their necessary professional development as a valued part of the multi-professional team.

[1] Morgan, B. ‘NHS staffing shortages: Why do politicians struggle to give the NHS the staff it needs?’ [blog post] The Kings Fund, 24 Nov 2022, https://www.kingsfund.org.uk/publications/nhs-staffing-shortages.

[2] NHS Digital – NHS Hospital and Community Health Services: Joiners to and Leaders from the NHS in Trusts and CCGs in England between 31 March 2021 to 31st March 2022.

[3] History of the AAPA, found at: https://www.aapa.org/about/history/

[4] Clark, H. L., Toshner, M., Physician associatites: a solution for healthcare staff shortages or a colonial throwback? The Conversation, 5Oct2023, https://theconversation.com/physician-associates-a-solution-for-healthcare-staff-shortages-or-a-colonial-throwback-214424

[5] UK Parliament, Expert Panel: evaluation of Government’s commitments in the area of the health and social care workforce in England. 15 July 2022

[6]  Salisbury, H.: Physician associates in general practice, BMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p1596 (Published 11 July 2023)