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GPs shouldn't dismiss physician associates - my practice couldn't do without them

Dr Patricia Wildbore argues that the new role is vital

When my partners and I were searching for a locum a few years ago, we heard about physician associates, who work sessions seeing patients and do home visits, and who are cheaper than GPs. Initially we employed Chris (our first PA) for a session a week. We audited his notes, we questioned his patients, we quizzed our staff. His note recording was better than any GP in the practice, and patients and staff were delighted with him in equal measure. We found that there was minimal extra work involved in signing prescriptions for him (PAs cannot sign prescriptions, X-ray requests, sick-notes, or death certificates because they don’t yet have their own statutory professional body). In 2012/13, Chris joined our practice full-time as the first PA profit-sharing partner in the UK. He sees patients at the same rate as the GPs and we consider him an asset to our team. This year we also took on a salaried PA.

We all know we are in crisis - we feel increased pressures and workload daily, we hear patient complaints about access to care, we see the increasing ageing population and the increasing multiple morbidities. We are also living with the year on year decrease in income and we know we can’t recruit into general practice.

After my experience with Chris, I believe the answer to these problems could be physicians associates (PAs). Health Education England, the Royal College of Physicians, Royal College of Surgeons and the RCGP think so too.

In fact, Health Education England recently commissioned 205 PA training posts, a 754% increase on the previous year.

PAs are trained using a medical model on a two-year intensive post-graduate programme; they have already done a science degree. They work under the direct supervision of a doctor and support doctors by taking medical histories, performing examinations, diagnosing illnesses, analysing test results, and developing management plans. Currently there is no national post qualification training programme so every PA’s experience is different, although there is a national qualifying exam.

On average PA take longer to consult than GPs but they are more cost effective.¹ With appropriate post graduate training and experience it has been shown patient management and satisfaction were similar when comparing GPs and PAs.² PAs have their own professional indemnity; they have to be re-certified every six years with a two-hour general medical MCQ and so will always be up to date.

Following seeing how helpful Chris is, we have encouraged one of our healthcare assistants to train as a PA at Birmingham medical school. Since 2013, after Chris was employed full-time, our patient access and satisfaction have improved, we are a more relaxed team and this year our income has gone up. We decided to ‘invest’ in the person and have no regrets in the slightest.

References

1 Drennan V, et al. 2015. Physician associates and GP’s in Primary Care: a comparison. British Journal of General Practice. Published online 1st May. DOI: 10.3399/bjgp15X684877.

2 Parle J, et al. 2012. The case for the physician assistant. Clinical Medicine: 12 (3); 200-06.

 

 

 

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Readers' comments (24)

  • Every little helps. The fundamental question is, sometimes a PA does not know what they do not know. And that bridge can be greater than a well trained doctor. If the NHSE remove indemnity/litigation this can work.

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  • Some details about what sorts of patients he sees (are they selected?) would be helpful to understand the role - and in what way the role differs from say a salaried GP (prescribing, x Ray requests, sick notes, death certs aside) and from an advanced Nurse practitioner.
    If the role is very similar to a salaried GP then is he happy with the much lower wage (am assuming it is much lower from what you said)? And if the answer is that ultimately responsibility lies elsewhere are other GPs happy to take on the responsibility for someone else's assessment and management plan without seeing the patient?
    Am still not convinced re physicians associates - but I do understand primary care is being under funded to make this sort of move necessary

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  • Exactly, if funding was adequate, if the job wasn't as shite as it is now, if you had no problems recruiting, you would prefer a GP partner wouldn't you?
    PAs are not the solution, they are a stopgap, to give yourself the faint illusion that you're managing the shite that we're in at the moment. We need to get rid of the shite, not spray perfume on it to help it to smell better.
    Does it even pass the FFT test? Would you want your family to see a PA or a GP when unwell? Would you yourself want to see a PA or a GP?

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  • Dear Dr Wildbore,
    Thank you for sharing your experience in employing PAs. The voices of those who work with PAs provide evidence, rather than conjecture.
    I would just like to clarify that the UK Physician Associate Recertification Examination is a four hour examination, comprising 200 Single Best Answer questions.
    People interested in learning the facts about PAs should visit www.ukapa.co.uk.
    Kind regards,
    Karen Roberts, MSc, PA-C/R
    Chair, UK Physician Associate National Examination

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  • Thanks for the link Karen. I did have a look at the website - Am still a bit confused as to ultiamately how PAs differ from GPs in many respects - it says they can take a history, examine, order tests, interpret results, formulate management plans and may ultiamately prescribe as well. It says that although they are initially supervised they become increasingly independent, have their own indemnity etc.
    Begs the quesstion - why is so much money spent on training doctors through medical school, foundation years and 3 years of GP training (a minimum time of 10 years) if it can be done by PAs with significantly less training.
    Is it worth some of the PAs in training going through medical school so that there are more independent practitioners?
    Not trying to be facetious, am genuinely interested and as I said earlier I do recognise this is likely to be the future and in terms of funding - clearly the powers that be would much prefer a cheaper workforce.
    It is interesting to note that in the states PAs were created because there were not enough GPs.
    Another consideration is where will PAs come from - it says on the website the most common previous occupations are nurses, paramedics and HCAs - possibly creating/exacerbating staffing problems in those areas?
    I think ultimately a lot of people will be suspicious about why a new health professional category is required

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  • duh, its required because politicians won't tackle the tougher problem of making the job better for existing and attracting prospective GPs and just want to throw money at hiring PAs. They think the general public will be ok with seeing the GP-lite, lesser trained PA, whilst having having their own GP accessed through private healthcare. In future, if I want a member of my family to see a GP and not a PA, I probably will have to pay for one. Makes me wonder why I pay so much taxes and that a big chunk of it goes to healthcare eh.

    I also wonder why on earth and nurse/paramedic/HCA would want to be a PA, or anyone with half a brain cell for that matter. Poorly/similarly remunerated, (20k/year) to take on almost as much risk as a GP? To see all the mundane shite?

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  • Please excuse me if any of this does not make much sense but as I only have "half a brain cell" it may just be nonsense for you all, although I will try my best.

    I am Chris, the PA mentioned in the above article and I thought that I would try and answer a few of the appropriate questions.

    People (many with two or even three brain cells) seem to want to be PAs as they have decided they want a career working in medicine after already completing their first degree. Some are those who feel their current roles (nurses, paramedics etc) do not satisfy their needs or goals. Others may be those who have not managed to get into medical school, but they seem to be in the minority. I think a lot of people are attracted to it as it does not entail another several years study after they have already completed their BSc.

    There are a few questions about wages as well. Looking at the jobs advertised, starting salary seems to be easily achievable at £35k and increases from there tithe mid £50's for some I believe. I do not want to discuss my salary other than to say that I am very happy with it.

    My surgeries run the same as every GP in our practice. My patients are not screened at all and I have 10min apts and also undertake telephone triage, home visits and teach medical students. The only things that I do not really do are the items mentioned in the article. The way I work may be influenced by the fact that I have been qualified for 8yrs and have worked in general practice for all of that time.

    Many of the points raised by people stating that we are a cheaper alternative obviously have some merit, we would be fools not to see that but it does not mean the role is useless and should be discarded. Rather than moan about us it would be better to see how a practice can use us effectively to ease the workloads on GPs and ensure that they then have the time they need to spend with those seriously ill. I really believe that you do not need the years of in depth training and studying that GPs have in order to be able to deal with 75% of general practice consultations. GPs are a hugely skilled and intelligent workforce, we do not need to be wasting their time dealing with minor illnesses and many of the things that a PA can see. The crucial part of PA training is knowing when to get help and to not be afraid to ask for it. Yes nurses can do a similar job in some aspects but take years to train up after they have done their nursing qualifications and still often think along the nursing model rather than the medical one which takes time and does not always work in the time constraints of general practice. I am not saying ANPs are rubbish, I have met many excellent ones that well deserve their role and they do have their place but PAs work differently.

    Asking if a GP would be happy for me to see and treat their families is an interesting question. For me the answer is yes, I have several patients that are GPs and see me happily themselves and I also look after their families.mperhoas they too have half a brain cell?

    It is always going to be an interesting debate, look back in time and all of this has already been covered when nurses wanted to stop many historical nursing tasks and become ANPs and nurse consultants etc etc and now they are an entrenched part of the NHS.

    Discussion about a subject is good. Inflammatory comments about how many brain cells people have are puerile and do not add anything constructive to the debate! Let's at least keep it civil shall we?

    I am always happy to discuss things and if anyone would like to speak to me about the role then feel free. I will go out on a limb and say you can email me at cdeane@nhs.net if you want to.

    Thanks,

    Chris

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  • Sorry, should say 'perhaps' above rather than whatever autocorrect thinks mperhoas is!

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  • PAs are trained using a medical model on a two-year intensive post-graduate programme; they have already done a science degree. They work under the direct supervision of a doctor and support doctors by taking medical histories, performing examinations, diagnosing illnesses, analysing test results, and developing management plans. Currently there is no national post qualification training programme so every PA’s experience is different, although there is a national qualifying exam.

    I am a Level 6 practice nurse and was not trained in the medical model but I have a science degree and 15 years battling my professional development.
    GPs have not allowed my training to sign prescriptions, though I am registered with a professional body. However, I already take medical histories, diagnose many illnesses, analyse my own initiated test results, and develop management plans.
    Why on Earth, are the Government and SOME GPs not seeing what is often already beneath their noses.

    I may not have done 2 years intensive training but nurses like myself have often done 20 years of university modules and could easily sign sick notes and X-ray forms if the powers that be could see what is already under their noses too.

    It isn't professional protectionism, it is just so frustrating to spend years chafing at the bit feeling capable of doing more and not being able to because of politics.

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  • Chris makes some excellent points and handles the criticism levelled at PAs well. However, I am an ANP and I have to say @11.10 is correct, for those of us who have fought the system to develop our roles with yrs of university learning at graduate and post graduate level education, the most frustrating aspect of this discussion is the failure of NHSE to see that the NP and ANP role is already out there and can be harnessed effectively to add another dimension to patient care and aid inthe staffing crisis in general practice. May be it's is because NP and ANP are more expensive than the 20k alluded to in this forum. May it's because nurses are hopeless at projecting themselves as a Professional group.
    Nurses are regulated by a professional body, we have yrs of experience to pull on, and a minimum of masters level education for the ANPs. We can order tests, we can prescribe. Chris alludes to the nursing and medical models being different, I am sorry Chris but they are not. We use a strategy for information gathering, assessment, planning and evaluation. Both models are essentially the same and the emphasis is on the patient is to improve their well being. Nursing models or medical model is weak argument to say that PAs are better. I have been educated to use both approaches and they do not differ greatly. All Qualified ANPs will be fully versent with the medical model.
    ANPS, NPs or PAs these roles will help general practice, but they are NOT a replacement for a fully qualified and experienced GP. As I have said In other discussions, I add value to my practice because the GPs I work for are supportive of my role, my continued professional development and I am managed and supervised extremely effectively. You cannot just drop a nurse or PA into general practice without a good job description and a mutually agreed role. That is a recipe for failure.

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