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GPs go forth

Should I employ a physician associate?

Ministers want 1,000 physician associates in primary care by 2020. Three experts explain what they do

Q Why is the Government promoting physician associates (PAs)?

There won’t be enough GPs even if the Government meets its commitment of 5,000 extra by 2020. Practices who have found physician associates a valuable resource have often employed them because they couldn’t find GPs.

Q What is covered in PA training?

The course is a two-year intensive postgraduate diploma in physician associate studies, with an equal balance of theory and clinical work. The course teaches adult medicine, mental health, obstetrics and gynaecology and paediatrics. PAs learn to see patients in much the same way as doctors do, but as ‘dependent practitioners’, working under doctors’ supervision. Students become proficient in history taking, examination, forming a differential diagnosis and initiating investigations and management plans. Training is shared between hospitals and GPs as it is with medics, and the national framework sets a minimum 180 hours in GP practices. Most entrants to PA training programmes already have either a bioscience degree such as human biology, or a health science degree, such as nursing. Most courses are not funded, with fees costing £9,000 a year, though a small number of trusts and local NHS bodies (for instance, Health Education North West) offer funding.

Q What is the standard PA qualification?

The qualification for entry into the managed voluntary register is a postgraduate diploma.

Q Is there a statutory professional body?

A There is currently no statutory professional body or regulator. The Faculty of PAs at the Royal College of Physicians is lobbying the Government for independent regulation. In the meantime, there is a managed voluntary register held by the RCP, which employers are encouraged to insist upon; this confirms a PA has passed a UK or US PA programme, has passed the national examination, has maintained CPD and has passed the recertification examination every six years.

Q How much do PAs get paid?

The majority are paid around £30-£35k per year. Don’t believe the £50k hype: this is part of a temporary fix to recruit experienced US PAs on short-term contracts.

Q What are their working and supervision arrangements?

Every PA must have a named clinical supervisor that is either a consultant or a GP. This doctor doesn’t necessarily have to be present, but must be available if needed. The supervision required depends on the experience of the PA, and how well the supervising doctor knows them, but it is likely that for an experienced PA, ‘review rates’ would be under 10%. Recent UK research on same-day appointments found PAs saw two patients for every three the GP saw.

Q What tasks can they typically take on? What can they not do?

PAs work in a similar way to doctors, seeing patients, examining, advising, organising follow-ups or investigations. The scope of practice is determined by their supervising doctor. They cannot prescribe or order X-rays, though they can ‘propose’, as nurses without prescribing rights can. In future they could become formally regulated and acquire limited prescribing abilities.

Q What will their indemnity be? Who is responsible for it?

PAs can get indemnity in the same way GPs do, costing as little as £1,129 per year from Medical and Dental Defence Union of Scotland but increasing depending on levels of responsibility and experience. PAs are responsible for ensuring they have indemnity to work and employers are responsible for ensuring clinicians are appropriately covered. Responsibility for paying is up for negotiation.

Q How can I employ a PA?

There are around 250 qualified PAs working in the UK. GPs can seek PAs through the Faculty of PAs at the RCP, but the best option may be to get involved in training.

Professor Jim Parle is professor of primary care at the University of Birmingham, chair of the UK and Ireland Board for PA education, and a GP in Northfield, Birmingham

Professor Martin Roland is professor of health services research at the University of Cambridge

Sam Cryer is director of communications at the Faculty of Physician Associates and a physician associate in London

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Readers' comments (18)

  • Cheap labour.Less money.why will I employ a GP who is expensive?
    The government will encourage this.The RCGP will have no option but to encourage PAs.
    Impotent RCGP!!!

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  • why bother being a GP if '99%' of your work can be done by someone else who is cheaper, needs less training, lower risk (cheaper defense fees).

    i'd be interested to know what medical students make of this.

    it's clear that GPs are viewed as expendable and replaceable.

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  • I think wait until medical indemnity fees will go up as the risk from this is very high. Wait until what happens when one cancer is missed! If the indemnity does not go up for the actual PA it will instead go up for the supervising GP. I mean for instance they weren't in the room and they did not examine the patient did they! Either indemnity increases or the MDU MPS or MDDUS pays. This cost will be passed on to the rest of us.

    I think that it is only ethical for the increased fee hike to be passed on to practices that risk patient care with PA's.

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  • Doctors employing PAs is like turkeys voting for Christmas.

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  • Completely agree with those commenting about using Advanced Nurse Practitioners and the fact they can prescribe. Its hard to see what a PA has to offer over an above a nurse practitioner. Added to which, very often practices have nurses keen to do an ANP course and because they are a known commodity it represents a reasonably safe investment for the future while creating loyalty and improving retention. We have a rolling programme of graduate nurses undergoing ANP courses so that we are building future resilience as we struggle to find GPs. Definitely one way forward.

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  • The ANP role only exists because the UK didn't employ PAs sooner. The advantage of PAs is that they have been trained using the medical model rather than the nursing model.
    The nurse role was never meant to be a diagnostic, treating role but a caring patient-centered advocate role but it's evolved into the ANP role.
    The nursing role wasn't designed to take responsibility for decision making but to refer to the doctor so there's a change in thinking that's required to do the ANP role whereas the PA has been trained this way from the outset.
    How much is enough training anyway? You could argue that Dr training is too much for 90% of the routine work but it's needed in those rare cases and don't underestimate experience either.
    A lot of PAs come from nursing, paramedic backgrounds too so they bring the experience from there too.
    Arguably 2 years is too short though but you see some incredible naivety from student or newly qualified nurses too.
    Could you say that GP is enough? Should you not have to be a professor first?
    Training has it's place of course but so does responsibility, personality, intellect etc.

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  • The way forward would suggest crown immunity for PA's to ensure government is responsible for any inherent shortcomings of their training.The support of an experienced Gp would be invaluable to mitigate any legal claims and this would inevitably need both training and remuneration - has this resource been costed in ? I seem to recall that savings on practice nurse wages were often limited by the extra time required for their assessments ( i stand to be challenged however!!)

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  • Advanced Nurse Practitioners (ANPs) in General Practice will have undergone a post-graduate diploma or Masters level degree course, which involves rigorous, supervised, training & assessment in diagnostic skills along with all other aspects of patient management. Please don't confuse their training with basic Nurse training. In addition where ANPs have previously been employed in General Practice as Practice Nurses they will often have undertaken training in a range of chronic disease management, minor illness, contraception, well-woman, prescribing & other courses relevant to different aspects of General Practice work, usually from providers with university accreditation. In addition, the vital "soft skills" a nurse will bring into the role of ANP, through their prior training & work experience are vital to the empathetic management of patients in General Practice. And they are regulated. Please start looking at the superb resource already operational in the UK before scrambling to snatch ideas from the US. For an overview of ANP training take a look at, for instance, South Bank University syllabus:

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