There have been many calls for better access to GPs, but no clamour at all from patients to be able to get an appointment with a Physician Associate: yet that may be all that is on offer to 2.4 million patients in nine North West London boroughs if plans to reshape primary care services are carried through.
Arguments over the proper role in primary care of Physician Associates (PAs) – who have passed a limited 2-year postgraduate course rather than the much more lengthy process for training doctors – have continued and widened since the angry rejection of plans by NW London Integrated Care Board (ICB) to put PAs or other non-doctors, and not GPs, into the front line of response to urgent ‘same day’ calls in primary care.
The partial, temporary retreat and half-hearted apology by the ICB, which followed quickly after leaked details of the scheme first came to public view last month, has not brought an end to the stand-off in NW London.
Campaigners, patient groups, local politicians and GPs still want the controversial plan (for fewer, new centralised “hubs” rather than GP practices to handle all calls seeking “same day” response throughout the ICB) to be scrapped.
Some NW London GPs argue that their practices already offer excellent and timely access; they are angry that a top-down imposition of a ‘one size fits all’ scheme could undo their hard work and make things much worse for their patients.
Others are furious that the ICB has attempted to push through major changes without publishing the results of pilot studies last year, and without any attempt at consultation with GPs or patients.
However ICB bosses appear to have their eyes fixed on the offer of additional funding – which can only be used to hire “additional roles” primary care staff who are neither doctors not nurses.
So although the immediate threat to impose the new scheme by April 1 has been held back, it has not been dropped, and there are hints it may be brought back again before the end of 2024.
So what do we know about the training of PAs?
NHS England guidance specifies that PAs must have completed a 2-year post graduate physician associate course, achieving either an MSc or the lesser qualification of a Post Graduate Diploma. Having then passed another exam they should work as clinical staff “under supervision of a doctor as part of the medical team.”
But where PAs are recruited to work in primary care with funding from the Additional Roles Reimbursement Scheme (ARRS), NHS England insists each PA has to “provide first point of contact care for patients presenting with undifferentiated, undiagnosed problems.” (page 91)
It was this proposal, to use less qualified PAs rather than doctors to triage patients seeking urgent treatment, that triggered the explosion of anger in North West London. The ICB’s example given to show how hubs might work revealed 93% of first contacts in each hub would be given by call handlers to PAs, with a ‘supervising GP’ handling only 7% of patients.
The NHS England guidance goes on to require PAs “participate in duty rotas,” – a proposal that has this month been dropped in the case of hospital staff, after hostile coverage from the Daily Telegraph, which then reported:
“NHS England has ordered hospitals to stop using physician associates (PAs) on doctors’ rotas. Officials wrote to trusts this week to say that such staff are “not substitutes” for medically trained professionals – and should never be used as “replacements” to cover doctors’ shifts.”
The BMA is demanding an inquiry into the extent to which including PAs on rotas is leading to them replacing doctors.
But there are other worrying proposals. For example NHS England insists PAs must “undertake face to face, telephone and online consultations for emergency or routine problems” – as determined NOT by the GPs in the practice, but “by the PCN [Primary Care Network]” – with no mention of GP supervision. Identifying a suitable named GP supervisor for each PA would also be down to the PCN.
Oxfordshire GP Dr Helen Salisbury has been among the many angry GPs pointing out that handling the first contacts is a far from simple task for those lacking experience:
“As a GP, I often don’t know what a consultation will be about until I’m halfway through—never mind what the patient told the receptionist or wrote on the online form. A patient may present with a request for sleeping pills, trouble with piles, or problems with hormone replacement therapy, and we may then have a complex consultation about traumatic bereavement, bowel cancer, or depression.”
The NHS England guidelines are explicitly rejected by the BMA’s recently published ‘Scope of Practice’ guidelines which seek to set out the proper roles for PAs and Associate Anaesthetists.
Mixed messages in place of guidelines
But while the BMA is seeking to establish a clear approachs, the bodies that should already have done this have been in chaos. Two Royal Colleges have been embroiled in bitter arguments, and the GP and Supervisor and Physician Associate Guide, previously offered as a “useful resource” by the RCP’s Faculty of Physician Associates, is currently “under review to consider feedback and ensure it reflects the current policy environment.” The FPA apologises “for any inconvenience this may cause.”
Meanwhile the focus of NHS England and of the growing list of Universities that train PAs (whose courses cost upwards of £12,000 per year) seems to be on encouraging PAs to believe they will cover increasing areas of work that patients expect to get from doctors, while giving no details on exactly how adequate supervision should be carried out, what its knock-on effects may be on each practice, or who carries the can if anything goes wrong.
Manchester University’s recruitment literature for PA courses even promises to give students “a detailed knowledge of pharmacology and prescribing safety (in anticipation of changes to legislation to allow physician associates to prescribe).”
Another medical school website even went so far as to describe one of the Senior Lecturers leading the PA course as a doctor, despite their lack of appropriate medical or academic qualifications – and only hastily deleted the offending section after being challenged by The Lowdown.
Graduating PAs who pass the Physician Associate National Certifying Examination are classed alongside nursing and other professional staff, rather than doctors, and are not included in the doctors pay scales. They jump straight in at Agenda for Change Band 7 £43,742 per year / £22.37 per hour (plus additional London Weighting for NHS staff working in London). This band is for senior qualified nurses and professionals.
Newly qualified PAs in hospitals therefore begin with higher pay than many of the junior doctors who have more years of appropriate training, and who have the added responsibility of supervising the PAs’ work. To rub salt into the wound this is taking place as junior doctors have been waging a bitter and protracted fight to restore their pay to 2010 levels.
PAs also come in at a higher pay band than many of the fully-trained nurses and other professionals they will work with.
In general practice PAs are cheaper than qualified GPs, and this is leading to growing concern that they and other “alternative roles” could begin to outnumber GPs.
The FPA does state formally that “Physician Associates (PAs) are a relatively new member of the clinical team, seen as complementary to GPs rather than a substitute. […] The Physician Associate role is in no way a replacement for any other member of the general practice team. […] By employing a PA, it does not mitigate the need to address the shortage of GPs or reduce the need for other practice staff.”
However despite this, the FPA website also makes clear that Primary Care Networks (PCNs) can access ‘Additional Roles Reimbursement Scheme’ (ARRS) funds to cover the full cost of hiring PAs (at total costs of up to £53k per PA per year).
ARRS funding (which according to NHS England was in excess of £1billion in 2023/24) also covers eleven other new roles: Clinical Pharmacists, Pharmacy Technicians, Health and Well-being Coaches, Dieticians, podiatrists, Paramedics, Health Practitioners, Nursing Associates, Occupational Therapists, First-contact Physiotherapists, and Care Co-ordinators.
However none of this funding can be used to hire qualified GPs or nurses that so many patients are eager to see.
As a result we have the spectacle of locum GPs unable to find work as Primary Care Networks are encouraged (and funded) instead to recruit a range of staff who are not doctors.
All this comes at a time when GPs have been increasingly demoralised by burn-out, chronic levels of under-funding (primary care spending reduced from 8.9% of NHS budget in 2015 to 8.1% in 2021-22), worsened by the government’s insulting 1.9% uplift to GP budgets for 2024/25, repeated failures to deliver promised increases in numbers of GPs, with 1,700 fewer fully qualified permanent Full Time Equivalent GPs in post than 2015, and the long term plan to further reduce the proportion of GPs in the primary care workforce (p65).
There have been stark warnings in the medical press that things are set to get worse, as primary care moves ever further from the traditional model:
“We currently have a situation where NHS England and the government have given up – and now seem in cahoots to dismantle traditional partner-led GP surgeries, in favour of super practices using hubs and online triage. This is hated by many GPs and patients alike. (Perhaps only popular with those who get to sit behind a screen clicking the buttons – but not actually seeing the patients in the interminably complex clinics).”
In this situation there is a real danger that the well-meaning students who sign up and pay up for 2-year PA and equivalent courses to train for what they believe to be useful work in the NHS will find themselves caught in the middle of angry exchanges and disputes between doctors and NHS management.
They deserve better: clear, agreed guidelines on how the NHS can best use the skills and knowledge they gain from the academic and practical elements of their courses to strengthen the workforce and better serve patients.
What is the evidence on the impact of PAs?
NHS managers and Royal College chiefs arguing for increased use of PAs brush aside the mounting anecdotal evidence of patient harm arising from PAs being allowed or encouraged to act beyond their remit (such as missed or mistaken diagnosis, ordering x-rays or writing prescriptions). They claim to have evidence of positive results so far.
However, data published by the National Institute for Health and Care Research in November 2022 definitely points in the opposite direction. It turns out that while adding doctors and nurses improves results and patient satisfaction, trying to make do with the various alternative staff has quite the opposite effect.
It is less efficient, less satisfying for GPs, less popular with patients, more likely to wind up increasing use of A&E – and far from saving money, it winds up costing more.
“Employing clinicians who are not GPs did not reduce GPs’ workload or improve their job satisfaction, research found. In the short-term at least, new roles in general practice for other clinicians, such as paramedics and physician associates, increased the time GPs spent delegating tasks and supervising.”
The same study notes that some additional roles – notably pharmacists – can deliver benefits, but:
“The highest quality of care (as measured by the Quality and Outcomes Framework) was seen with more GPs. Higher quality prescribing and lower prescribing costs were seen with more pharmacists. Higher overall NHS costs were seen with overall higher numbers of healthcare professionals, but employing more non-GPs was only slightly cheaper than employing GPs.”
Perhaps even more worrying was the warning that: “Higher numbers of other clinicians (apart from nurses and GPs) were associated with more accident and emergency attendances.”
American experience
In the USA, where there is a much longer and wider experience of seeking to use less qualified physicians associates with much greater autonomy to make up for gaps in the medical workforce, the evidence is even more stark. One study explains:
“An examination of cost data for the South Mississippi system’s accountable care organization (ACO) revealed that care provided by nonphysician providers working on their own patient panels was more expensive than care delivered by doctors.
“[…] per-member, per-month spending was $43 higher for patients whose primary health professional was a nonphysician instead of a doctor. This could translate to $10.3 million more in spending annually if all patients were followed by APPs [advanced practice providers], says the analysis. When risk-adjusted for patient complexity, the difference was $119 per member, per month, or $28.5 million annually.”
The study grew out of efforts to identify the highest-cost physicians and work with them to cut spending. However the results were unexpected:
“We were a little bit surprised at how stark the differences were, at the most-costly end of the spectrum between physicians and advance practice providers.… It appears that the additional costs had to do with a combination of several factors that included more ordering of tests, more referrals to specialists, and more emergency department utilization.”
The AMA (US equivalent to the BMA) is waging an ongoing campaign against “scope creep,” and claims hard evidence supports their defence of the leading role of doctors, arguing that “Expanding nonphysicians’ scope of practice also increases costs. For example:
- X-ray ordering rose 441% among nonphysicians.
- Nonphysicians needed twice the number of biopsies to screen for skin cancer.
- Patients were 15% likelier to get an antibiotic from a nonphysician.”
And it claims patients prefer physician-led care:
- 95% saying it’s important for a physician to be involved in their diagnosis and treatment.
- 91% agreeing that a physician’s education and training are vital for optimal care.
- 75% saying they would wait longer and pay more to be treated by a physician.
Future role for PAs
While the AMA, rooted as they are in the commercial US health system, appears to take a negative view of any staff who are not doctors, the BMA Scope of Practice does make clear that Physicians Associates here can and should play a useful supportive role, working to assist GPs and under proper supervision.
It’s important that campaigning in defence of the GP practice-led model of primary care does not fall into the trap of under-estimating the skills and commitment of staff who have invested years of their life and large sums of money in seeking qualifications that will enable them to play a role in patient care. These staff also need to have access to trade union representation to ensure they are not forced against their will into covering tasks which are beyond their scope and training.
Until there is an end to continued government under-funding and under-staffing, the shortage of GPs will continue to be a limiting factor in the development of primary care, and so the opportunity for GPs to delegate some appropriate tasks to PAs may well help to lift some of the burden and enable local services to improve.
It may also be the case that in some rural areas, with scattered population and limited access to GP services, establishing centralised hubs to handle urgent calls may improve access and care for patients, provided there is sufficient GP involvement and control.
But with ARRS funding now distorting the priorities of local health bosses and financial interests skewing the Royal Colleges it seems the fight to secure the future of general practice is in the hands of campaigners, GPs and the BMA.
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