A GP practice in North London has made the decision to stop employing physician associates after an incident of ‘poor quality’ care contributed to the death of a patient.
The role of physician associates in general practice was discussed yesterday in Parliament, as Labour MP for Worsley and Eccles South Barbara Keeley raised the issue following the death of Emily Chesterton – the daughter of her constituents Marion and Brendan, who died in November 2022 after suffering a pulmonary embolism.
She had made an appointment at the Vale Practice in Crouch End after feeling unwell for a few weeks and reported calf pain and feeling breathless, and saw a physician associate at the practice.
PAs are part of ARRS and can perform diagnostic and therapeutic procedures and develop treatment management plans, under the supervision of doctors.
Speaking in the House of Commons, Ms Keeley said: ‘Emily believed that this appointment was to see a GP, but the person she was booked to see at the practice was a physician associate.
‘After a short appointment, the physician associate diagnosed Emily with a sprain and possible long Covid. She was told to rest and take paracetamol.
‘At no point during the appointment at the GP surgery was Emily made aware that the person who had diagnosed her was not a doctor.’
Ms Keeley told the House of Commons that Ms Chesterton made another appointment at the practice a week later, as her leg was swollen and hot and she struggled to walk a few steps without becoming out of breath, and saw the same PA.
She said: ‘It appears that this was a short appointment and that Emily’s legs were not examined. The physician associate suggested that Emily’s breathlessness was due to anxiety and long Covid and prescribed propranolol for the anxiety.
‘In messages Emily sent on this day, she described seeing “the doctor” and it appears that she was never told that the person she was consulting for medical assistance was not a fully qualified GP.
‘In its serious incident report, the Vale Practice states that patients should not see a physician associate twice for the same condition, and guidelines make it clear that physician associates cannot currently prescribe, with any prescriptions needing to be signed off by a supervising GP.
‘It appears that the oversight of prescribing medication was missing and that this system failed in Emily’s case.’
Ms Chesterton’s health deteriorated on the same evening and she took a propranolol tablet as advised by the PA.
Later her family called an ambulance but she suffered a cardiac arrest on the way to the hospital.
Ms Keeley said: ‘The coroner concluded that the poor quality of care given to Emily Chesterton by the physician associate at Vale Practice contributed to her death. That concerns me deeply, and it should concern the Minister, too.
‘The Government must now move quickly to regulate physician associates and learn from the events that led to the sad and tragic death of Emily Chesterton.’
The coroner concluded that Ms Chesterton ‘should have been immediately referred to a hospital emergency unit’ and that ‘if she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived’.
Ms Keeley also added that the practice made ‘a collective decision to terminate the contract of the particular physician associate’ and that ‘a decision was made not to employ physician associates going forward’.
Health minister Will Quince said: ‘Improved patient safety and care lay at the heart of the NHS long-term workforce plan, which, backed by significant Government investment, shows our determination to support and grow the healthcare work- force.
‘As set out in the plan, roles such as physician associate play an important role in NHS provision, but critically, healthcare teams remain supervised and led by clinical experts.
‘We would strongly recommend that employers only consider recruiting PAs who are on the voluntary register.
‘It enables supervisors and employers to check whether a physician associate is qualified and safe to work in the United Kingdom.’
A spokesperson for the practice told Pulse: ‘First of all, the practice would like to extend their heartfelt condolences to Emily’s family, for the tragic loss of their loved one.
‘The practice team have spent considerable time reflecting on this case and implementing changes to try to ensure that nothing of this nature happens again.
‘Since this tragic incident happened, the practice ended the employment of a physician associate. We cannot comment further due to our duty of patient confidentiality.’
The DHSC has now closed the long-awaited consultation on new legislation to bring and PAs into regulation and expanding their role.
READERS' COMMENTS [27]
Please note, only GPs are permitted to add comments to articles
Reducing quality generally is in my opinion unfortunately government policy using cheaper and less qualified staff via PCNs. PCNs which are a quality lowering proposition often scramble for anyone who can fill a PCN role amongst the many PCN ARR roles now available simply to use (or more accurately waste!) NHS funding via this ARR funding. However, we should not forget that senior roles within GP practices such as practice managers are usually without any qualifications and rarely have a degree They are often put into senior roles where they direct far more qualified professionals . Admin staff with the title practice manager is also no longer a fit for purpose method in a failing NHS and high quality degree level management is required for the future.
Physician Associates are dedicated professionals who give their best in often very difficult situations( due to the pressure on all the NHS- primary and secondary care). Their role is to support doctors in treating their patients and we should remember as GPs that our job is to provide clinical supervision to them in the same way we provide clinical supervision to nurse practitioners, care co-coordinators and other staff. Perhaps we should be looking at our clinical care systems( using data on computer) to create a flow and pick up potential problems that could be escalated in future. I would add your headline suggests removing PAs is necessary but would we remove all GPs in the same circumstances?
agree fully Shaun
This is what healthcare on the cheap gets you, I’m afraid. A GP in similar position would have a fair chance of facing a negligence manslaughter charge. PAs should only be used under close supervision and while I can see roles for example, in heart failure clinics, I personally am unconvinced of their ability to safely handle the general unfiltered morass that we see in general practice.
This is a very sad and distressing outcome for the patient and family, and also for the GP Practice as a whole, and also the PA.
In terms of regulation, the PA appears to have been ‘practising medicine’ in terms of consulting with the patient and making a diagnosis and treatment plan at the level of a Specialist Doctor in General Practice. It also sounds from the details given as if the PA did not clearly identify that they were not a fully qualified GP, but that is actually very hard to tell, due to the working environment and relationships, and the fact that GMC and everyone else is happy for them to use the term ‘Physician Associate’ which implies that they are a kind if ‘Physician’. Most patients would equate a physician at a skill level equivalent at least to a fully-qualified GP, and probably higher than this and closer to a ‘Hospital Physician’.
The semantics of the terms are confused by the fact that ‘Associate’ just means anything from colleague to contractor or Partner; whereas ‘Physician’ means Doctor. It is a dangerously wrong choice of term for the role these people would be performing, and likely to lead to legal problems.
I do not know if a PA would be expected to put calf pain and SOB together = ADMIT STAT in the same way a GP would, and the problem is one of maybe not knowing what they do not know. However, they are left in a position where they are ‘practising medicine’, and therefore come under the auspices of the GMC, and according to the Medical Acts, they fall within GMC regulation – and clearly patients expect them too as well.
GMC, RCGP, BMA, and NHS, all need to take immediate action to choose a more appropriate name for this role, and ensure they are regulated as ‘Medical Practitioners’ when they do that role for patients. It is the only way they can be properly supported.
Calf pain and breathlessness. I think for a gp it would be straight forward. You can’t replace gp with any body.
I am sure there are very good physician associate and they may have consulted doctor in this situation.
Symptoms to tie all in to one pathology is an art all gps acquire after many years of training.
After the event it’s always all straightforward and obvious. Has no one who commented in this way never made a mistake? Never missed a serious problem?
What was the presentation and circumstances, level of supervision, post surgery debrief with senior?
It may be convenient to scapegoat an outsider PA, but really the practice needs to look at itself and their internal works such as supervision and training.
My PA comes to see me for advice as many times a day as needed, often asking questions well above the level of the many GP trainees I’ve trained.
Some Bloke
More to this than meets the eye———–reporting very suspect
It was always going to be when not if. Doctors are trained for 5 years at medical school and 5 or more years on the job to deal with this. Less than a year learning and minimal supervised practice will only lead to tragedy. There is a place for non doctors in practice and most do a great job. But front line undifferentiated patient care is not that. Newly qualified GP struggle with the uncertainty and often stop working or cut down their hours. Those that don’t know what they don’t know are the most dangerous.
The NHS. The best health service in the world. No one had said it yet so I thought I’d be the one this time. This sadly is only one of the many deaths due to the “system” on a daily basis.
One can ask questions about the person selection, the quality of the education, the quality of the examination. The quality of the supervision and the supervisor. I know nothing about this particular case and am not commenting on this individual case. Someone has decided that it’s a system error from reading between the lines. How many people were commenting on forums like this about the huge increase in risk with part trained people being let loose on the general public when this ridiculous plan was first suggested? Sadly it’s the patients who end up with the poor deal.
Any GP that didn’t join up the 2 dots of calf pain and breathless and come up with free trip to ED would deserve a spanking from the GMC in my view. If someone actually died as a result they would likely have to kiss their ass goodbye. The idea that a GP could make this mistake and it would not raise more than an eyebrow in the comments above seems ridiculous to me.
I agree totally with Alexis Manning and Jamal Hussain . I don’t understand how anyone can be allowed on the patient diagnostic interface without any regulation being in place from a professional body .
can i turn it on it’s head ?
how many patients has this PA seen with similar symptoms, who DID actually have anxiety/covid etc, and who were given the same treatment, and got better afterwards. this PA might have seen dozens of patients – the huge majority of whom have got better.
who shall cast the first stone ?
Cause of Death 1a Jeremy Hunt
Seriously? Your argument is that they hadn’t been involved in any other patient deaths so can’t be that bad?
No Alexis, this isn’t what David said. Oversimplifying isn’t going to help to improve things in the future.
Sad case like this is always going to polarize opinions and this is what’s happening here.
But I genuinely want to hear from others your views on different but real case too.
A frail nonagenarian walks in for their flu jab, which HCA administers under PSD, which GP signs. Few days later patient has a fall and lies on the tiled floor of their kitchen for 16 hours waiting for emergency ambulance – nothing unusual for modern day UK. By the time they make it to hospital they have CAP, but also PE, and are dehydrated and exhausted with pain. Patient dies in hospital. It is thought that age, frailty, but also polypharmacy contributed to the fall. Reaction to Vaccination could have been one last straw that destabilised the frail patient.
Since we are all so happy to point fingers of blame here, who should be blamed for unnecessary death in this case?
A genuine question.
No thanks, I’m not playing your strawman game. 10 years of GP training is not, and can never be, the same as 2 years of PA training. These sort of events will be more frequent as time goes on, but pretending that a non-GP can do the work of a GP safely is not the way forward.
Alexis, I am guessing you are salaried or locum.
Why should any non GP be placed in a position where they are expected to do GP level work? Who’s fault is this- employed PA or the practice?
It could have happened to anyone. Many of us have missed have missed one or the other genuine pathology.
Esmat, all of us have. But not everyone is capable of admitting it and changing their practice to really improve safety. Look at the comments like “calf pain+ breathless=dead in two minutes”, it’s as if like no one seen a COPD patient who tripped and strained an ankle while reaching out for lighter before this case.
GMC are big factor why that is so. Perversely their patient safety first agenda creates nearly oppositely directed outcomes. Add criminal manslaughter legislation.
So less confident clinicians are just digging in and defending, claiming they never make any mistakes. No real learning or improvement possible in these circumstances. Good luck!
I agrée with Jamal Hussein. Swollen hot leg and breathlessness = A+E. C’mon it’s pretty straight forward, even in hindsight, even though we’ve all made mistakes, blah blah.
Physician Associates seem to work well in the US, but like many ideas from the US, it is something I feel we have copied badly. Speaking from many years on the coalface in many practices up and down the UK, the only PA I’ve worked with who I thought was safe and competent had been trained in the US.
So many patients go to hospital clinics and think they have seen a doctor, and when the letter arrives it was soem nurse run clinic.
I am looking at a Physician Associate degree accepted CV at this very moment and prior to the degree courses it shows three grade ‘E’s at A’ Level. Of course someone will argue that A’ Levels are not everything with which I agree and it would be right that some who perform poorly at A’ Level make excellent NHS staff . However, when you are flooding the NHS with thousands of lower qualified individuals who are doing some of the work formerly done by doctors without full knowledge and consent of patient groups, then expect some overall dramatic increase in risk, harm and poor outcomes as time passes.
One of the weaknessess of the ARR scheme is that a diminishing number of GPs are expected to supervise, educate and “sign-off” the work of increasing number of roles including FCP, PA – as well as do their own day job.
This spreads GP resource too thin – and isn’t going to be safe.
Patient safety and quality of care should ALWAYS come FIRST. Human life is priceless. Based on knowledge, training, experience and intellect who is MOST LIKELY to make the correct diagnosis and ultimately save lives?
It would be unwise to make generalisations on PAs based on a single anecdotal incident.
And always be wary of the retrospectoscope……what appears blindingly obvious with hindsight is often far more obtuse in real time.
I distinctly remember a similar case of DVT/PE missed over 3 consultations by 3 experienced GPs, so I will cast no stones.
If we must generalise, then PAs are usually far more likely to stick to their algorithms and over investigate/refer than GPs, making them far less efficient but probably less likely to miss serious pathology.
Very sad situation indeed.
I don’t know if constant supervision of someone is possible properly when you have your own 10 minute treadmill to run. Also I have seen many PAs working on 5 minute appointments. This is unbelievable. If at all, they need more time than GPs.
If you are told about calf pain and SOB symptoms, yes it is a spot diagnosis. But gleaning the right symptoms from a general presentation is an art and a science and needs experience.
The Govt plan involves hiring thousands more of PAs. This can be useful if the system allows for time and space to work accurately. Otherwise it will be a bundle of confusion and hasty mistakes leading to poor outcomes for patients and clinicians alike.
Firing the PA does not sound right. Most of us could be fired in various circumstances.