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A faulty production line

Physician associates won’t save time for GPs

A new breed of assistants for GPs will neither work in our system nor help to reduce current demand on practices, argues Dr Michelle Drage

The Government’s latest proposed solution for managing the spiralling demand it has created in general practice is to build a posse of US-style physician associates.

But as universally accessible UK general practice is vastly different to the insurance-based US primary care physician model, I don’t believe this role will be useful in Britain.

Care is so formulaic and compartmentalised in the US that physician associates are able to do aspects of the general physician’s job. US primary care physicians are essentially internal physicians following a medical model similar to that practised in our hospitals and outpatient clinics.

This is not the case in Britain, where we train GPs to be expert generalists to a registered population - preventing illness, dealing with the social and psychological components of ill-health, sorting undifferentiated symptoms, diagnosing and managing complex multimorbidity, managing uncertainty, and delivering continuity of relationship as a key part of care.

Slaves to protocol

US doctors deal principally in medical issues, while we approach the care of our patients more holistically. I envy their 30-plus minutes of consultation time, but not their pre-packaged, protocol-driven, ready-sifted, ready ‘clerked’, sterile processing of patients. It is an approach that turns patients into bit-part packages to be overtreated and pandered to.

Through our therapeutic relationships with patients, UK GPs are themselves the treatment as well as prescribers and gatekeepers - and physician associates would put this under threat.

There’s no reason why GPs should employ physician associates when we already have practice nurses and advanced nurse practitioners (features that don’t appear on the US primary care physician landscape).

Creating yet another new role is a distraction that we can’t afford, unless of course the intention is to drive down clinician costs and wages, in an approach similar to that adopted with teaching assistants or police community support officers.

What’s more, for physician associates there is at present no professional regulation; their membership of a register is voluntary. But this is being taken over by that veritable bastion of generalism, the Royal College of Physicians, which is setting up a faculty incorporating the UK Association of Physicians Associates (and is planning to accredit courses and hold the register).

This hardly bodes well for general practice, and neither does the plethora of such courses that are now springing up, funded by Health Education England grants, with the number of centres offering courses rising from two to eight this year alone.

Worryingly, these budding physician associates are not even necessarily placed in recognised GP training practices for the GP aspect of their clinical training.

Who pays?

I’m also concerned about what the indemnity costs will be and who will pay them. Physician associates need space and longer appointments, and it’s not clear what conditions they will be able to deal with as they cannot treat complex illnesses.

And to crown it all, there is at present no study or evidence to show whether employing a physician associate in a practice will actually save GPs any
work.

This initiative is a band-aid at best, rather than a concrete solution for reducing demand on general practice. That lies in the Government being honest with patients about what the NHS is for.

That, alongside creating strong incentives to enter and stay in the service to increase the supply of staff.

Dr Michelle Drage is chief executive of Londonwide LMCs.

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Readers' comments (25)

  • Took Early Retirement

    Gosh! Surely not? We all thought they would be the saviours of the universe.

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  • Bravo. More frank comments like this needed.

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  • I agree with the sentiments expressed above totally.
    However, it seems to me that the intention is to change the way general practice in this country works to mimic the way it works in the States.
    We are increasingly being driven by exactly the pre-packaged, protocol driven processing hat you describe. QoF, "care pathways" and NICE "guidelines" do exactly this.
    We should have stood up to this formulaic method of treatment and indeed performance management years ago and those who supported it in the RCGP and BMA should take the blame for the direction of travel.
    This is the intention, not an unintended consequence and started with proponents of Keiser Permanante etc.

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  • I disagree.It seems like you're just protecting your turf.A significant chunk of modern General Practice is following guidelines and algorithms which include red flag indicators of when to refer.All this can be done by Physician Assistants.Doctors are better served dealing with the really ill as in hospitals.PAs should replace GPs as the backbone of primary care.You can have the odd generalist "floater" to deal with any in-house queries from PAs or nurse practitioners but that's about it.

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  • Dear Anonymous,
    "I disagree.It seems like you're just protecting your turf.A significant chunk of modern General Practice is following guidelines and algorithms which include red flag indicators of when to refer."

    err no that's not general practice. General practice is knowing when to ignore the red flags and tear up the algorithms.

    English GPs who do slavishly follow all that rubbish and behave that way will easily be replaced by PAs but thankfully the vast majority think about what they are doing with their patients and step outside these externally applied constraints. That rols, as Michelle explains, can never be replaced by PAs.
    Regards
    Paul Cundy

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  • Well said Dr Drage ! So well argued and expertly put ! We have some amazing ANPs who add a whole level of holistic care to General Practice. As an ANP my role is varied and practical. I work across boundaries, I get a great of support from my GPs and the nursing team ! The PA role is new, expensive and unproven in the UK. Perhaps I am protecting my own turf here, but we do not necessarily need PAs when we have proven ANPs who are experienced, educated and competant.

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  • Well said Rachel and thank you Michelle!
    We have fantastic ANPs already providing this service already, it would make more sense to invest in what we already have rather than starting afresh. ANPs can also prescribe whereas PAs cannot - this will restart prescribing by proxy which we are trying to get away from! Nurses should be utilised to take the pressure off the GPs, their knowledge and skills should be used for complex patients allowing them more time with these patients.

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  • Anonymous | GP Partner | 29 May 2015 12:47pm


    Dear anonymous GP - are you doing the same job I'm doing? I am dealing day to day with patients with vague symptoms, complex medical and social backgrounds and heavy psychosocial overlay.

    Training those to follow protocol slavishly is like letting 111 take over OOH triaging. It generates more work, reduces quality of consultation and satisfaction.

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  • This Article is really poorly written and is just as bad as a Tabloid article denigrating GPs . All i can ascertain from this article is this is one person's opinion. There is no evidence that you have seen Physician Associates working in General Practice, spoken to GPs who currently employ Physician Associates. You have given us no evidence of these GP's assessment of this role. Also you give no real evidence for ANPs being a better alternative - whom in my experience have very variable skills and level of training.

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  • Anonymous | Other healthcare professional | 31 May 2015 12:13pm

    Are you a PA? Whatever the author has written, do PAs not also have variable skills and level of training? Also less years of training and a whole lack of regulation? (as compared to ANPs having NMC).

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  • The buck always stops with the doctor. UK GPs are partly themselves to be blamed for GP degrading.

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  • Well said Michelle;
    it needs careful analysis at least before committing to a complete change.
    We do need something though, perhaps more GPs - and that needs improvement in Terms and Conditions, and in respect from hospitals, politicians, an the media. Sadly, politicians see us as competing for the patients'/voters loyalty. I wonder why?

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  • It is important to look at the role of PAs. Seeing acute 'minors' problems is probably a higher risk, more expensive way to use PAs as GPs are good at doing this.
    For those with known diagnoses, using a PA for assessment and management of flare ups, including doing home visits, can be clinically and financially appropriate.

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  • Using PA, nurses, nurse practitioners to do all the 'Easy' work means GPs get to see all the completely mind draining and exhausting patients non stop - with no respite in between.

    Roll on burn out and retirement for the lucky few with gold plated pensions.

    The only way it could work is a switch to much longer appointments to deal with the complex, while the PA or AN other do the lower complexity work.

    Risk is clear, use 111 style cheaper options, and you just ramp up demand elsewhere in the system, as they don't have the decade+ knowledge GPs have even when they start their careers.

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  • I find the entire article is based on a rather flawed premiss - that Physician Associates (and yes, I am one) do nothing more than work to protocols and are not able to work though complex cases. That simply is NOT the case. I have worked in A&E, Acute Medicine and now General Practice as a PA and I don't recognise any of what you all say - I see an undifferentiated case-load of patients, I don't work by protocol and I certainly don't flounder the minute a case is complex. On the contrary, the very essence of my training is to develop my clinical decision making skills to use my head, not the protocol.

    So with the greatest of respect, I would say that this article is based on very little in the way of facts.

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  • In response to Anonymous | Salaried GP | 01 June 2015 9:53am,

    Actually, Physician Associates have a national curriculum and a national exam at end of the training, not to mention an annual professional development requirement and a 6-yearly recertification exam. This on top of being a life or health science graduate. In contrast, ANPs do not have any national requirements or standards, and some LETCs have only just started looking at developing these. So no, PAs do not have variable levels of skills and training.

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  • Neil Howie | Other healthcare professional | 01 June 2015 12:57pm

    I'm sure that there will probably be good PAs out there, but with respect, I would want my family to see a GP, not an ANP or PA, however experienced. You have to agree that PAs are a stopgap measure that fools nobody. There would be no need for PAs if the job wasn't so shite for GPs that they're all leaving.

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  • I'm all for any help that we can get, we need more clinicians if we are going to deal with the increasing workload. Physicians associates are well-educated science graduates who then go on to do 94 week diploma or masters over a two-year period. Studying in the medical model covering all the main specialties as well as general practice. They are then often placed in a hospital setting where they are carefully supervised by senior medical colleagues/registrars and consultants. Very similar to junior doctors being supervised with their hands held the first year or two. Physicians associates work as part of a team and can provide high levels of care.
    I'm sure many of these physicians associates would have preferred to be doctors, but with the ridiculous medical entrance exams (UKCAT etc) some very good would be doctors have been lost to biomedical science and other allied health fields.
    Let them join us and be grateful for their enthusiasm and help that they are offering!

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  • We should be fighting the negative changes to our job, rather than troubleshooting the shite being foisted onto us. This is us saying, we'll take the shite and deal with it in ever so innovative ways, when our leadership should be saying, stuff this shite

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  • We have an ANP -total cost 50k with study leave+ expected sick leave and defence fees cost around 65 to. 70k Even at the 50k is a complete waste of money with most patients coming back and filling her apps with patients basically coming back for a chit chat !

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  • Finally! Well said!! Don't forget the other professions working in advanced roles though which could readily support the GP caseload! 25% of GP contacts are MSK (acc to RCGP website) - advanced Physio roles can assist in this area - Independent prescribers and autonomous. Good evidence of reduced onward referrals, reduced imaging and prescribing costs. Physician associates are non-regulated, non-autonomous, with no prescribing rights....

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  • 1. There are studies/research showing PAs are cost effective and clinically effective in general practice
    http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0016/118501/FullReport-hsdr02160.pdf
    http://hsr.sagepub.com/content/16/2/75
    2. PA's in general practice pay their own indemnity unless they negotiate for the practice to pay on their behalf
    3. Have you ever met or worked with a PA?

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  • Another step down the road of increasingly compartmentalised medical thinking-fits well with computerised models of control but lacks the flexibility and empathy of the experienced pre QOF GP. .It wil deliver something measurable and even useful but the patients experience of being cared for by another compassionate person may be reduced.

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  • Reply to GP Partner 29May 12.47, yes I agree.
    PA role could include what we do and see low risk pts healths checks, chasing BP's, ACR's watching out for AKI, looking at trends, a slowly declining Hb and alert the dr. If QOF is not going to go, and in a way Funding from QOF is preserved, all the patients not assessed in the QOF, could be chased up. If QOF could be extended to cover 18mths 'deadline', many more pts might be assessed because capacity with PA, rather than in the immediate QOF year the same regular pts are seen, and the irregular pts continue to be missed.
    We already rely on receptionists to take responsibility-they do even if people disagree, and pharmacists give out meds/creams without specific training in dermatology/dental/psychiatry. No different from an FY2, (second year dr). PA can do visits where FY2's cannot.
    GP Principal

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  • As a GP who works both in the US and the UK, I found the views expressed appallingly uninformed. The care I provide to patients whether I'm working in a low income immigrant clinic or well-heeled metropolitan community in the US versus how I practice on the NHS is absolutely no different. Please, Dr Drage, don't comment on things you don't know anything about...that piece of writing just showed complete ignorance and bigotry.
    Re whether PAs are a good thing for the NHS, personally I think it'll be a struggle to culturally adapt US-trained PAs to function on the NHS plus hard to imagine how one could entice top candidates away from better US incomes and cheaper cost of living. But as providers as a whole, I hold my PA colleagues in very high esteem. In the US they have a well- defined role that is extremely useful and provides excellent support for doctors..

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