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At the heart of general practice since 1960

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)

  • John Glasspool

    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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