In China during the Cultural Revolution, “barefoot doctors” would be trained in the basics of healthcare, and then sent off to work in rural areas where fully trained urban doctors would not settle. For obvious reasons of quality control, this isn’t an idea that has ever got much traction in developed countries. To be a doctor in this country, you need six years of training, followed by two years of clinical work in hospitals, plus a final year as a trainee intern and then maybe four to six years of training in your chosen area of specialisation.
Any way you cut it, that’s roughly 14 years of training and on the job experience. If all of those skills are necessary – and no one is saying they aren’t – then the government’s sudden announcement in April that it aims to expand the deployment of “Physician Assistants” (PAs) in the public health system gave the public every reason to feel uneasy. The scope of the work to be done by PAs still hasn’t been clearly defined.
Regardless, it seems that many patients will be being seen by PAs in future, and PAs will be empowered to prescribe medicines and to order lab tests. To patients, PAs will look and act much like the doctors who will be expected to supervise the quality of their work, and double check it – in addition to the workloads that doctors currently face.
Despite the misgivings, PAs are on track to becoming a recognised part of the landscape of public health. To practice here, PAs currently need to have graduated from an accredited PA programme in the US, the UK or Canada and have clinical experience – but as yet, there is no recognised training pathway for PAs in New Zealand. The NZ Medical Council has been assigned the role of regulating PAs in this country- even though n 2022, it declined a previous invitation to do so. This monitoring role will include overseeing PA registration and practice standards in order to ensure that, as the Council says, “physician associates are competent and fit to practice.”
What would the Medical Council like to see in place before the expansion of the PA role? Probably, this sort of thing :
1.The need for clear information for patients on what physician associates do, and how the service they provide will differ from that delivered by other health professionals, such as doctors and nurse practitioners.
2.The importance of ensuring physician associates can provide culturally safe care, and have received robust induction to the nuances of practice in Aotearoa New Zealand. This should be a necessity for any foreign – or locally trained – PAs, given that they will be treating Māori or Pasifika patients whose current health outcomes are demonstrably worse than those of pakeha New Zealanders.
3. The need to ensure that the PA role supports equitable healthcare access, and does not create confusion in the system. The concern here is to avoid a two tiered system of public health whereby (a) some classes of low income patients or (b) those living in rural areas are treated by PAs, while GPs and other scarce health professionals provide superior healthcare to the more advantaged living in urban areas.
Going for broke
This is still a work in progress. The full and final details of how PAs will operate in the context of the New Zealand health system, their required level of qualifications, extent of prior clinical experience and the feasibility of providing adequate oversight have yet to be worked out. Here’s some recent UK evidence as to why we should be worried:
A new survey, conducted by the GP magazine Pulse, found that 21 per cent of 425 GP networks in England said they had reduced PA numbers in the last year. It comes after the Government-ordered Leng Review found PAs have been used as substitutes for doctors, despite having significantly less training.
One of the 18 recommendations in the review was that PAs be banned from seeing patients whom a medic has not reviewed to prevent the risk of “catastrophic” misdiagnoses.
This UK’s Leng review was not an over-reaction. More than 3,500 PAs and 100 AAs (Anaesthesia assistants) are currently working in Britain’s NHS. As in New Zealand, there have been calls for an expansion in their number.
But their roles were reviewed following high-profile deaths of patients who were mis-diagnosed by PAs, with six patient deaths linked to PAs recorded by coroners in England. They include 30-year-old Emily Chesterton, who died from a pulmonary embolism after being misdiagnosed by a PA on two occasions and told she had anxiety. In her report, Professor Gillian Leng concluded there were “no convincing reasons to abolish the roles of AA or PA” but there was also no case “for continuing with the roles unchanged”.
So….Britain (which has had more extensive experience with PAs) is backing off and re-evaluating their role, in order to better protect patient safety, while we are pressing onwards. Yet as this very recent article in NZ Doctor indicates, key details of the picture are still missing. How, for instance, the work of PAs will relate to ACC claims remains unclear:
Because physician associates aren’t currently covered by ACC, a GP who is acting as a supervisor of their practice can be liable for any medical error by the physician associates.
NZ Doctor ‘s Stephen Forbes posed pertinent questions :
We asked ACC what work it is doing to assess any potential increase in projected claims costs following the registration of physician associates, and how much it expects to pay out in the first 12 months from 2026 to 2027. We also inquired whether the agency has any concerns about a possible rise in claims because of the change.
For now ACC won’t, or can’t, throw much light on these matters:
ACC is refusing to say whether the Government’s decision to allow physician associates to become a regulated workforce will affect claims. Until now, the agency hasn’t covered physician associates for medical error because they aren’t a registered profession.
By next year though, PAs will be. What we do know is that the expansion of PAs will add to the oversight and regulatory demands on the existing health system. More to the point, the public has barely been consulted over what is a key change in the delivery of their GP healthcare. Basically:
Are physician associates a much-needed extra source of safe hands for stretched general practice? Or are they an imported, unproven workforce being used to plug gaps in the sector at the expense of putting more resources and time into homegrown solutions?
Good questions. Answers pending.
Two state, deluded state
Chances are, anyone whose family is dying of starvation would not be looking for New Zealand to have a prolonged debate over how they deserve to be defined. Yet a delay in making even the symbolic gestures seems to be all that we have to offer, as hundreds of thousands of Palestinians continue to be systematically starved to death by Israel.
Could be wrong, but I doubt whether anyone in Gaza is waiting anxiously for news that New Zealand government has finally, finally come to the conclusion that Palestine deserves to be recognised as state. So far, 147 out of 193 UN member states reached that conclusion ahead of us. Some of the last holdouts – Canada, the United Kingdom, France and Australia – have already said they will do so next month. So far, none of that diplomatic shuffling of the deck has stopped the Gaza genocide. Only significant economic and diplomatic sanctions and an extensive arms embargo (one that includes military-related software) can force Israel to cease and desist.
You don’t need to recognise statehood before taking those kind of steps. Last week, Germany – which does not recognise the state of Palestine – imposed a partial arms embargo on Israel that forbids sales of any weaponry that might be used to kill Palestinians in Gaza. Not much, but a start – given that (after the US) Germany has been the main foreign arms supplier to the IDF.
Meanwhile, the Luxon government has yet to make up its mind on Palestinian statehood. Our government repeatedly insists that this recognition is “complex.” Really? By saying so, we are embarrassing ourselves on the world stage. While we still furrow our brows about Palestinian statehood, 76% of the UN’s member nations have already figured it out. Surely, our hesitation can’t be because we are as mentally challenged as we are claiming to be.
The more likely explanation is that we are trying to appease the Americans, in the hope of winning a trade concession. Our government must be gambling that an angry Donald Trump will punish Australia for its decision on Palestine, by lifting its tariff rate, thereby erasing the 5% advantage over us that Australian exporters currently enjoy. By keeping our heads down on Palestine, we seem to be hoping we will win brownie points with Trump, at the expense of our ANZAC mates.
This isn’t mere conspiracy talk. Already, the Trump administration is putting pressure on France over its imminent decision to recognise Palestine statehood. A few days ago, Le Monde reported that the US ambassador to France, Charles Kushner – yes, Ivana Trump’s father-in-law –blundered into France’s domestic politics by writing a letter of complaint to French president Emmanuel Marcon. In it, Kushner claimed that France wasn’t doing enough to combat anti-Semitism:
“Public statements haranguing Israel and gestures toward recognition of a Palestinian state embolden extremists, fuel violence, and endanger Jewish life in France,” [Kushner] wrote. “In today’s world, anti-Zionism is anti-Semitism – plain and simple.”
Simple-minded is more like it. People who oppose the criminal atrocities being committed in Gaza (and on the West Bank) by the Zionist government of Israel are not doing so on the basis of racial prejudice. They’re doing so because Israel is breaking every rule of a civilised society. Any number of UN conventions and international laws forbid the targeting of civilian populations, homes, schools, ambulances and hospitals…not to mention the deliberate killing of hundreds of medical staff, journalists, aid workers etc Not to mention imposing a famine on a captive population. Day after day, the genocide continues.
For Kushner to claim the global revulsion at Israel’s actions in Gaza is motivated by racism is revealing. To Israel’s apologists within Israel, and in the US (and New Zealand) only Israeli lives really matter.
Footnote: New Zealand continues to bang on about our support for the “two state” solution. Exactly where is the land on which Christopher Luxon thinks a viable Palestinian state can be built, and what makes him think Israel would ever allow it to happen? Thirty years ago, Israeli settlement expansion fatally undermined the Oslo framework for a Palestinian state situated alongside Israel. Since then, the fabled “two state solution” has become the tooth fairy of international politics. It gives politicians something to say when they have nothing to say.
Songs for the UN
It is hard to appreciate just how optimistic a world that was emerging from the shadow of a world war felt about the founding of the United Nations nearly 80 years ago. Check out these cheery songs about the work of the UN, and its humanitarian agencies:
And then there’s this wavering hymn: