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Guilty by associate

Guilty by associate

Columnist Dr Copperfield says tragedies are bound to happen more often when general practice is fronted by ‘non-doctors’, such as physician associates, rather than GPs

Let’s be 100% clear. I am absolutely not, for all sorts of obvious reasons, commenting specifically on the tragic case of a patient allegedly misdiagnosed by a physician associate (PA).

And to be even clearer, say 110%, I would add that there must be some absolutely excellent PAs out there, just like there must be some absolutely rank GPs – so that, in an ‘Is this a PE?’ diagnosis-off, there will be the odd occasion where the PA gets the PE, while the GP gets the GMC.

But. And it’s a ‘but’ visible from space. Sooner or later, something like this was bound to happen. Put non-doctors – whether PAs, advanced nurse practitioners (ANPs), first contact pharmacists or extended role tea ladies – at front of house, then, at some point, they will be working beyond their skill/knowledge set and/or without adequate supervision, and disaster will ensue. For the simple reason that it’s not easy spotting the needle of catastrophe in the haystack of dross but, all things considered, actual GPs are the best at doing this.

Just like they’re also good at the diametric opposite: tolerating uncertainty. Again, this is something noctors are less comfy with, resulting in over-investigation and over-referral – less headline grabby than missing a life-threatening problem, but in the great scheme of things, arguably the greater issue.

Add to this the lack of clarity – whether by accident or design – over whether the patient is actually seeing a ‘proper’ doctor or not, and you have the toxic mix of an inflated level of trust from the patient and a deflated level of clinical acumen from the ‘physician’.

Which doesn’t mean, of course, that PAs and the like don’t have a role – though such was the shock in this particular case that the practice seems to have disassociated itself from physician associates entirely. But it does mean that tragedies will happen, more often than they would if general practice was fronted by GPs. That 10 years of training is there for a reason.

And, to be 120% clear on this, the responsibility here lies squarely with the Government. General practice has been boxed into a corner where health policy has, on the one hand, dismally failed to address the GP workforce issue, and on the other, virtually mandated the use of quasi doctors, and with that you get quasi medicine.

I’d tell my MP face to face, but I assume I’d just get to see the politician associate.

Dr Copperfield is a GP in Essex. Read more of his blogs here



Please note, only GPs are permitted to add comments to articles

Dr Brendan O'Brien 11 July, 2023 11:47 pm

“… seems to have disassociated itself from associate physicians”. I assume this is a typo and meant to read “physician associates”?

Jonathan Heatley 12 July, 2023 10:59 am

The public are naturally focussed on the tragic ommissions but what no one remarks on is the HUGE amount of work GPs do when they triage and save onward referrals to secondary care. Having confident experienced GPs doing this keeps the good ship NHS afloat. I feel that younger generations are less confident and refer onwards a lot more than my generation now retiring. As for Noctors it may be even higher as they are guideline driven.
My practice used to have a pick up rate of 10 cancers per 100 referrals or one in ten. We were castigated for not applying the gold standard cancer referral rate to pick up 3 cancers per 100 referrals or one in 30. This ‘gold standard’ triples the referral rate for a trivial extra return, and triples the hospital work load and guess what? we have a 7 year waiting list.
Beware talk of ‘world class service’ or ‘gold standard care’ as there is not the funding for it. We need to concentrate on getting the basics sorted.

Shaun Meehan 12 July, 2023 11:36 am

PAs are university biomedical graduates with a further 2 year intensive masters clinical training. As a GP PA trainer I know they fully earn their status as clinicians who work under clinical supervision. They do this brilliantly in hospital and in primary care. They are not the problem here but scapegoats for a primary care running on empty for years. We know they are a key part of a future where GPs manage a team of all skills. We should embrace their role in primary care and support them as we do all our staff. To do that successfully means we need a change of government-let’s put our criticism where it belongs in the intentional defunding of our NHS under 13 years of conservative chaos.

Merlin Wyltt 13 July, 2023 9:12 am

The Government have defunded primary care. There aren’t enough GPs. The way round it is to get someone else to see the patients. Paramedics, nurses PAs. They don’t have anything like the training of a GP–but they can process the patients at a cheaper rate.

Sujoy Biswas 14 July, 2023 11:23 am

The PAs and indeed many ARRS roles are being rolled out as canon fodder.
They may well have a biomedical degree and 2 years clinical but this at best puts them at a level of a recently qualified practice nurse or paramedic. It’s not fair on them or patients to expect them to perform at the level of a GP or Advanced Nurse practitioner in a busy primary care environment without intensive supervision.
Either way GP workload will be increased. Any help welcome but we need to be clear this will not save GP time.

Anonymous 14 July, 2023 6:48 pm

Noctors are pretty much the same. Except they really are risk averse and either admit, over investigate or bounce back to GP.
I worry that some PAs are under the impression they can fly solo and nobody will notice.

Anthony Gould 15 July, 2023 2:54 pm

Sadly I suspect rigorous root cause analysis would likely suggest system failure due to lack of resources and clinicians
The government, previous governments and nhs workforce planners have tried to reduce the real term costs of the NHS without understanding and forecasting the workforce needs effectively
They (probably) simply have not worked out thatGPs can no longer see 10 patients an hour as medicine is more complex especially with an aging population
Simple arithmetic indicates you need a doubling of the GP numbers as a minimum. Adding less trained clinicians and allied medical staff mainly enhances the service quality such as chronic disease management and seeing usually straightforward clinical presentations although clearly advanced nurse practitioners can and so deal with many clinical consultations as well as many GPs do
By triggering early retirement due to stress and pension charges the government has reversed GO numbers which is simply unfair to patients and clinicians
Shame on you

Truth Finder 17 July, 2023 4:34 pm

Clearing up after Noctors with unnecessary blood results (there’s a lot of that!) , scans and referral letters.

Decorum Est 17 July, 2023 5:30 pm

As Anthony Gould mentions above, there have been massive demographic changes in the last 50yrs i.e. ‘Population aged 75+ years of United Kingdom increased from 2,659.58 thousand persons in 1971 to 5,892.76 thousand persons in 2020…..’ i.e. close to 10% of population are over 75yrs of age, living with multiple morbidities, having much higher expectations from medical care and that medical care has become more complex and expensive. On top of all this, there are multiple agencies calling for better medical provision and the medico-legal complex has became so burdensome that every medical service provider in living in a constant state of treat.
It’s unsustainable.