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From ‘good enough’ to ‘this’ll do’

From ‘good enough’ to ‘this’ll do’

Editor Jaimie Kaffash argues that the true problem with increased use of PAs is being misunderstood

It always amused me that surgeons refused to use the title ‘Dr’ due to barber-surgeons sulking at the  actions of the snooty Royal College of Physicians. It also demonstrates that beef between various groups of healthcare professionals has been going on for centuries.

That said, I feel like the disputes between primary/secondary care doctors and physician associates aren’t fully understood by the wider public and the media.

This isn’t about doctors’ snooty protectionism, like the aforementioned RCP. It isn’t about the headline-grabbing never-events that have involved PAs – although that is of course an issue. And, it isn’t even that GPs are moaning because they are out of work while the number of PAs increase (even though this is a situation bordering on criminal).

At the heart of the profession’s concern with the increase in PAs is because this represents the slow deterioration in standards of care.

I’ve always believed in the adage ‘perfection is the enemy of good’. But while GPs aren’t able to achieve many of the laughable standards that NICE says they should, they reach the standard of ‘good enough’. In recent years, GPs have only been able to meet the lowest threshold of ‘good enough’ due to a variety of reasons – shortened appointment times, burnout and lack of referral options among many others. But GPs’ training and experience will at least ensure that red flags are not missed and patients will be put on the most appropriate pathway.

However, I feel that with the more widespread use of PAs, the NHS and Government have basically settled on using a cheaper alternative – PAs are not just supporting GPs, they are often taking on the work that should be done by GPs.

What does this mean in practice? In the vast majority of cases, being seen by a PA instead of a GP won’t make a difference. PAs aren’t stupid – their degrees are still hard work, and they are still getting trained. As a result, they will spot the majority of obvious red flag cases. Meanwhile, most cases they will see will be self-limiting.

The problems will come on those odd occasions where there are subtle signs of something sinister – subtle signs that would be spotted more often than not by GPs. Conversely, PAs will also be practising more defensive medicine, leading to unnecessary patient anxiety and more pressure on the health system. (This also leads to a discussion about whether these HCPs do actually save time and money – but that is a whole separate blog).

Again, this isn’t a slight on PAs individually. GPs go through a minimum of ten years’ education and training for a reason – so that they do spot an urgent case, and are able to reassure a patient when something is not sinister. PAs simply don’t have the education and training to do this at the same standard. The standard of service will lead to more patients suffering – maybe not many, but certainly some.

The Government could rectify this – plough more money into general practice so PAs are a genuine support to GPs, and are not replacing them. But it has made an active decision not to do this. It has settled on lowering the standard from ‘good enough’ to ‘this’ll do’.

Jaimie Kaffash is editor of Pulse. Follow him on X (formerly Twitter) @jkaffash or email him at



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

David Church 21 February, 2024 7:17 pm

The RCPs ‘Physician Associate’ training programme apparently is 2 years of study.
Medical Students have spent 5-6 years at Medical School already.
Graduating Medical Students should be able to undertake a 2-week training conversion programme to qualify them to work in General Practice on the same basis as ‘PAs’ immediately.
Then the medical school course should be reduced to just 3 years, to bring student loans for Medical Students into equity with PA’s expenses.

So the bird flew away 21 February, 2024 10:14 pm

And extending the “this’ll do” principle to orthopaedics, the govt’s next training up carpenters to take on some routine hip and knee replacements (under supervision, of course).

Decorum Est 21 February, 2024 11:08 pm

Jaime Kaffash, Pulse is RUBBISH. I don’t disagree with your commentary or knowledge besides saying ‘big girls blouse’ and ‘waffle, waffle’. If you have something to say, ‘say it’. Not some nonsense about, ‘I’ve always believed…….’.
Just STAND-UP and just make a CLEAR STATEMENT!

John Graham Munro 22 February, 2024 7:30 am

@ Decorum Est——-careful—–I was once suspended for deriding PULSE

So the bird flew away 22 February, 2024 10:13 am

Seriously though, I would say we GPs are definitely more than “good enough”, and not just “good” but “bloody good” even despite the funding cuts over the last decade or so.

My clear statement is that GPs are the Alpha and the Omega of the NHS.
And that the NHS, as a Prime National Asset, should be beyond party politics. Every patient contact starts and ends with us GPs (our hospital colleagues help out with their special skills). We provide not only health/illness care but social, psychological and mental health security for everyone. We are an umbrella of protection and a broad safety net; an ever-present advocate especially for the poor, the invisible and the disenfranchised in society.

GPC and GPs should go over the head of the Govt and take these kinds of arguments directly to the public. Industrial action would at least throw a bright light on the dire situation in primary care.

Prometheus Unbound 22 February, 2024 1:15 pm

PAs definitely impact on secondary care workloads, with increased referrals and increased requests for advice and guidance.
At some stage in the future, hospitals will up the price for their increased workload and primary care costs will increase to either have GPs triage PA referrals or reduce PA usage.

There is no OA supervision structure being applied in primary care setting, just an xray and prescription signing process.

A B 25 February, 2024 2:36 pm

Why isn’t this being discussed in normal media?