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GPs buried under trusts' workload dump

Physician associates may be given prescribing powers, says DH

Exclusive The Government is considering whether physician associates should be given prescribing powers as part of its ‘new deal’ to relieve the pressures on GPs, Pulse has learnt.

The Department of Health has told Pulse this was one of ‘a range of issues’ it was considering ahead of recruiting 1,000 new physician associates to work in practices by 2020.

Jeremy Hunt promised the physician associates as part of a plan to recruit 5,000 new practice support staff over the next five years.

Giving them prescribing powers would add to their working role - as currently listed by NHS Careers - that includes taking medical histories; performing examinations; diagnosing illnesses; analysing test results and developing management plans.

But GP leaders have warned that adding prescribing to this list is unlikely to make much difference to the ongoing workforce crisis.

Mr Hunt recently watered down his committment before the election to recruit 5,000 more GPs saying that this was ‘a maximum’, but a Department of Health spokesperson told Pulse it was pressing ahead with plans for 1,000 more physician associates.

He said: ‘Together with NHS England and Health Education England we are considering how to ensure 1,000 physician associates will be available to work in general practice by September 2020. A range of issues and possible solutions have to be considered, including prescribing responsibilities and whether and how they need to be regulated.’

Physician associates are currently science graduates who have completed a two-year training course, however, it is not mandatory for them to be officially registered.

Research from Kingston University and St George’s University of London this year claimed that physician associates can take on some of GPs’ daily work without any harm to patients and at lesser cost to the NHS.

But Family Doctor Association chair Dr Peter Swinyard, a GP in Swindon, warned offering them prescribing powers could result in a ‘real deception pulled on the public’ if they thought they were seeing a medically qualified member of staff.

He added: ‘If they can also prescribe then we have even more of the potential mismatch of what people think they are getting and what they actually are getting.’

GPC prescribing lead Dr Andrew Green said he supported ‘in general’ the extension of prescribing rights, when used responsibly.

He added: ‘However it would be a nonsense to suggest that the promise of 1,000 PAs in five years, even with prescribing rights, will make any difference to the crisis we are in right now. The underlying reasons must be addressed as to why today’s young doctors are not becoming GPs. Improving skill-mix within primary care might help, but people can forget how difficult it is to do our job well, and complex and undifferentiated care needs the most highly trained professionals available.’

Amid the Government drive to boost numbers, Sheffield Hallam University will become the 10th institution to provide the course from January next year and last week Royal College of Physicians launched a new arm, the Faculty of Physician Associates, especially for the staff grade.

Meanwhile, NHS Leicester City CCG is spending £600,000 on bringing over ten US-trained physician associates to work in local GP practices, in a bid to address its recruitment crisis.

Readers' comments (39)

  • Who will pay the indemnity costs.

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  • This will be seen by medical students as a further round of undermining general practice . It will make Primary care seem - medicine lite . It may be that PA's are excellent prescribers but why bother with the slog through medical school. Perception and image is very important - that's why billions are spent on advertising . I predict there will be a massive drop in recruitment for gp's

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  • Having Physician Assistants will suit those holding APMS contracts. Already they employ a lot of Nurse Practitioners, and now with the introduction of Physician Assistants, they need not bother employing more GPs to run their businesses and thereby cutting their costs significantly - but all this at the expense of providing quality and safe care to its registered patients.

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  • I thought it was a given that prescribing was in their job description.Otherwise what's the point.They'll end up queuing outside your door with prescription requests and just adding to the workload.Indemnity is crucial.They prescribe,they're responsible.You can't have GPs combing through all their cases.We have neither the time nor the manpower.

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  • Bob Hodges

    I visited Worcester University a week or so ago, as they have a 2 year MSc course for Pas. I was very impressed with what I saw. This is not an underhanded way of replacing GPs, but one of the ways in which primary care teams can be augmented.

    Remember - hospitals not only get 80% of all the cash, they have 80% of all the junior doctors as well. Some of the functions of the old fashioned 'firm' need to replicated within the community. GPs can't do all that on their own.

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  • If Nurse Practioners are going to need £4.5k of indemnity insurance what are these PAs going to pay?

    Don't see a lot of evidence based approach to this either, wouldn't it be better to get pharmacists involved, rather than Physicians Assistants.

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  • "Bob Hodges | GP Partner | 07 July 2015 10:29am
    This is not an underhanded way of replacing GPs, but one of the ways in which primary care teams can be augmented. "

    We know that it should be used to augment GPs but we all know that it WILL be used by the Govt as an underhanded way of replacing GPs.

    Please, nobody be naive about why JH wants this.

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  • this is what will happen. they write 'd/w GP' at the end of their consults. Liability back to GP when the brown stuff hits the fan. yet another nail in the coffin of this profession in the UK

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  • Leicester is re-inventing the (square) wheel. Heart of Birmingham PCT imported US "Physician's Assistants"; all but one left.

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  • @ Anonymous | GP Partner | 07 July 2015 10:26am
    "I thought it was a given that prescribing was in their job description...."


    Me too. PA will be of virtually no benefit if they do not prescribe and will actually increase our workload.

    If PAs will see and treat patients autonomously and their medical indemnity is funded then this should be a positive step.

    As others have said we need a team of autonomous professionals with GP supervising in a role similar to the consultant firm in hospital.

    The days of the GP acting as consultant, registrar, house officer will end soon (one way or another).

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  • "Anonymous | GP Partner | 07 July 2015 10:06am
    This will be seen by medical students as a further round of undermining general practice . It will make Primary care seem - medicine lite . It may be that PA's are excellent prescribers but why bother with the slog through medical school. Perception and image is very important - that's why billions are spent on advertising . I predict there will be a massive drop in recruitment for gp's"

    that's a good point. why spend 10 years of your life and 5 figures of money to be a glorified nurse.

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  • 2 years to do a diploma in physician associate. A lot are doctors who cannot get on the register. Let them help, it will be good.

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  • Bring it on. I've had 22 years of sweeping up after others. Let's see how the patients take to seeing the assisstant rather than the doctor.
    The main issue is that they are not addressing the real problem Dr/pt ratio is out of control as are pt/appt/year.
    A few PAs ain't going to help that.

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  • well its a 2 year fulltime post grad diploma AFTER a bioscience degree not JUST 2 years
    and the evidence shows that PAs can be effective members of the team supporting doctors
    they are dependent practitioners who will work much like ju7nior doctors do in hospitals currently, with consultants supervising and training and (yes) dealing with the more difficult cases.
    Anyone not feeling overworked? Anyone not want someone who you get to know over a period of time and who can see at least some of the patients for you?
    Jim Parle
    Declaration of interest: former full-time GP and senior partner, now academic and director of Birmingham’s PA programme

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  • Why is is that all of these other roles that are brought in to try and "augment" doctors, also seem incredibly expensive?
    I can remember being an FY1 on nights, being given work that the nurse practitioner "wouldn't do", only to find out they were on double my salary.

    Likewise whilst an A&E SHO, I remember the day light hours A&E Nurse Practitioner telling me what type of people he would and wouldn't see, and then finding out he was on more money than me as well.

    I'm all for diversifying and different roles but it seems every time we bring one of these roles in it highlights what good value an actual trained doctor (of any grade) is.

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  • 'Likewise whilst an A&E SHO, I remember the day light hours A&E Nurse Practitioner telling me what type of people he would and wouldn't see, and then finding out he was on more money than me as well. '

    I also remember being on with experienced nurses in A&E when an SHO, and they deserve all they get. I can think of several cases where they saved my bacon and were welcoming and helpful at all times.

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  • The GPs numbers would not have dwindled if GMC MPTS were given resilience training not take NHS complaints as sacrosanct and investigate them before torturing Gps to distraction and resignation.
    Four years ago there were more GPs than could be absorbed.It is mismanagement of bullying of GPs pointed out by prof Brian Jar-man ,David Hands,also cost effective approach to treatments by Tony Barnet that has led to our sad situation.

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  • I'm surprised it's taken so long to even consider introducing physician assistants into the UK.I've long argued that they should form the backbone of primary care.Let's be honest here:most of General Practice is crud.It is work that can be done alot cheaply by non GPs.

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  • The trick is of course spotting the serious problems amongst the " crud " . That takes training skill and experience . Not everyone can do it .

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  • Often people think of PAs in primary care as someone to do the unselected 'minors' or acute list.
    This is a mistake as the best clinicians to deal with undiagnosed, uncertain diagnoses rapidly yet safely are GPs.
    Our PA sees new patients but also spends a lot of time following up patients with known diagnoses, such as the housebound visits or those recently out of hospital, where their clinicial skills can be put to work yet there may be less time pressure to rapidly assess and prescribe.
    If you employ specialist nurses you should have no worries about working with PAs. Their medical knowledge and 'language' is much more aligned to the medical model doctors use than nursing training.
    A PA can take a history, examination, differential diagnosis and produce a management plan in a very similar way to a medical student or junior doctor. They are trained by doctors, including GPs.

    They are not GPs, but then nor are junior doctors in hospital specialties the same as their consultants.

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  • 1000 PAs - aren't there about 8000 practices in England alone? How on earth will this help? Even if extremely competent, I would imagine the buck would stop with the supervising GP and therefore increase workload. I am far happier to make decisions about people I have seen.

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  • If everything was so easy in GP then why do trainees have to go through the hardship of passing their clinical exams.I think RCGP is partly to be blamed for this chaos.

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  • Regulate them,allow prescbing,insure them and let them help us !

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  • @Anonymous | GP registrar | 07 July 2015 4:30pm who wrote "If everything was so easy in GP then why do trainees have to go through the hardship of passing their clinical exams"

    To make them look as clever as their MRCP and MRCS counterparts...but fails dismally!

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  • Third-world medicine in one of the most economically developed countries in the world. What a disgrace!

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  • Turkeys voting for Christmas. Ten years agoI remember as a public health registrar when the then FPHM opened specialty training to non-medics, with the promise it would 'increase the capacity of the public health workforce'. Many of us argued it would be a back-door way of ridding medics who were too independent and replacing them with non-medics who were cheaper to employ, and easier to corral, and simply a way of cutting costs not increasing capacity I read in a recent BMA news about how the BMA PH committee were worried now that many Local authorities were not employing medics (Why bother when a non-medic is £20K less per annum) to save money. This will happen in the UK now: the RCGP will be happy as long as they get to regulate and oversee PA courses and will open membership to all (just wait for the rebranding to the Royal College of Primary Care Practitioners). The DH will be happy as they can still claim to offer a "free at the point of primary care NHS" but it will not be staffed by doctors, and will be cheap and cheerful. This is the beginning of the end of GP land. I was right 10 years ago about PH; I suspect I will be right 10 years hence about GP land, and there will be no jobs for GPs, just PAs (of course, as a GP you would be welcome to apply for a PA post should you wish, on their terms and conditions of service).

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  • @above

    So what if there are no jobs for GPs.Doctors should be working in hospitals where the really sick are.That's where they add value.Not signing sicknotes or sorting out verrucas and fungal toes.It's a complete waste of the country's resources to have them dealing with the unadulterated crap that constitutes general practice.It's no wonder they end up becoming deskilled and demoralised.The only reason why the youngsters are still choosing it is that it offers the opportunity to work part time.Once you remove that there is nothing to commend it.And at the end of the day the British public will get the health service that it deserves.Now they always find something to complain about GPs.Well they've got their wish because most of us will have packed our bags and left.

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  • Well ok as long as no one in my family has to see one. Im sure they will be helpful to us but I'm not keen on taking responsibility for them or the nurses(who didn't work out cheaper either).

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  • looks like anyone who wants to see a Doctor in the UK is going to have to go private soon.

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  • @Chris Kent | GP Partner | 07 July 2015 5:07pm
    Regulate them,allow prescbing,insure them and let them help us !

    That's fine but why should we have to pay our own extortionate insurance and they get it free with the same risks involved?

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  • Hundreds of qualified doctors were released from GP training making their and their families lives miserable. Millions of tax payers money gone down in the drain. Not to mention that those doctors spent 5-6 years in Medical school, passed PLAB exam which is a medical knowledge and language proficiency exam conducted by the GMC, passed competitive GP recruitment selection exam in three stages(examined by GP examiners), under gone three years of GP training under a qualified GP trainer endorsed by annual ARCP panels confirming progression, passed AKT, passed work place based assessments yet failed repeatedly by ONE examiners skill to judge in 10 minutes of those doctors suitability to do a job, a PHYSICIAN ASSISTANTS POTENTIALLY CAN DO IN REAL LIFE GP LAND!!!!!
    LAUGHABLE AND DISGRACEFUL!!!!
    “Every clique is a refuge for incompetence. It fosters corruption and disloyalty, it begets cowardice, and consequently is a burden upon and a drawback to the progress of the country. Its instincts and actions are those of the pack.” ―Chiang Kai-shek
    -LWT

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  • Hopefully they will help and not just be asking questions all the time. Al least they may be able to do all the des les qof stuff like anplanned admissions and we can see patients

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  • Half-way through the process of jumping ship to Oz, cant wait

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  • Great ...dirt cheap GPs!
    Smashing...you know you want it...you know that's just who you want to take your sick baby to...a cut price bargain basement 'stack 'em high' 'train em quick' Dr impersonator ....marvellous ...can we get them flying planes on Ryan air too please.

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  • Damn. Wasted all those years in hospital when I could have done the same job with a 2 year diploma!!

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  • Oh no! They now have the power!!

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  • 2 sides to this one.

    I do see that PA's may appear threatening to GPs, and if government seriously thinks they can do GP's entire workload then the whole service will indeed go tits up.

    However, we have long had nurses managing all our long term conditions patients (can't remember when I last saw a routine review of COPD for example, and have to ask our nurses advice these days as so deskilled on chronic COPD). PA's seem to be essentially a similar proposition - not to be doctors but to work a bit like our senior nurses do.

    So, to take a proper history, do the jobs, come up with a differential and management plan (like a F! doctor) to discuss if it's complicated, or to sort out the UTIs and coughs etc if it isn't. And of course to do some chronic disease stuff, and the kind of thing we had telehealth in for (that's another whole story of wasted money).

    There aren't enough nurses around to do all this work, and they have to be trained mostly in house, so why not train some other people up specifically for this role?

    I think we should welcome them with open arms, and think of them more like specifically trained nurse practitioners.

    (Not in any way denigrating nurse practitioners who have a wealth of experience on top of their training which will certainly give them a big advantage until the PA's have a few years experience under their belts).

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  • Just to try and answer a few questions
    PA's work under the supervision of a qualified doctor but they have their own professional indemnity, the fee for one of the PAs in my pratice is >£2000 and we pay it. They earn from £20,000 to £40,000 dependant upon experience.
    They are trained on a medical model, have a broad breadth of experience (but maybe not the depth of a doctor), they are trained in decision making, they are not protocol driven (unless that is what you require of them)
    HEE and DH have decided they are going to be an integral part of general practice. They are coming whether you like it or not.
    This is a new (for the UK) type of healthcare professional and general practice has the opportunity to help mould this role into something that complements our needs.
    We are being battered from every direction (money, workload, workforce crisis etc) but PAs could be the silver lining to that big black cloud we are forced to be in - just a thought!

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  • Just a quick comment from a PAs perspective. I have been working in general practice for nearly 9years now and I work exactly the same list as our GPs.

    My indemnity is through the MPS and I pay the same as a GP and am held clinically responsible for my decisions. Yes I have to knock on a GPs door to get a script signed but this is not as much of a big deal as people are making out.

    I have my own patient base that prefer to only see me and are quite insistent on seeing me over some of the GPs. We are not replacement GPs, how could we be with the breadth and depth of experience that a GP has? However there are now two of us in my practice and the workload that we take on is equivalent to that of a GP each. Our practice has high ratings on NHS choices and we work all day from 8am-6pm apart from an hour off for lunch. We do not just do 3hr surgeries AM and PM and we work to 10min appointments.

    We are part of the solution, not the problem. general practice still needs more GPs and people are correct that the government needs to address why GPs are leaving but until (if) that is sorted we need people to help address the ever increasing demand for appointments. patient education could go a long way to reducing the pressure on GPs rather then people feeling they need to see a GP for every sniffle or mild cough.

    If we work together then hopefully we can help each other and make work enjoyable and not the chore it has become for many

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