PI Brief Update

Why The Physician Associate PA Role may mean the end for GPs - Dr Mark Burgin

14/08/24. Dr Mark Burgin discusses the existential risk to primary care posed by the increasing use of allied professions to work as in front line roles.

Primary care is about 100 times more efficient than secondary care, they see 10 times as many patients for one tenth of the budget. As primary care staffing and funding falls the workload has dramatically increased in A and E and secondary care. The specialists are closing waiting lists and are becoming overwhelmed with the workload.

Secondary care has largely had flat performance despite substantial increases in workforce and funding. Unlike their more nimble counterparts in primary care the numbers of episodes of care had remained flat. Strikes and other disruptions has led to extraordinary increases in waiting list numbers and failure to meet targets.

Medical and political leaders have been reluctant to link the decisions to reduce primary care funding by about 30% with the worsening performance of secondary care. They have denied that such a link occurs and even argued that a person who cannot get an appointment with their GP will not turn up in A and E a couple of hours later.

Solution one - allied health professionals

Practice nurses have become an essential part of the primary care team but some have extended their roles beyond routine work to the management of chronic disease and minor illness. Some have become ‘independent practitioners’ and are able to prescribe drugs without having to get a GP to sign the prescription.

Paramedics, pharmacists and physios have joined the ranks of those seeing patients front line in primary care aided by limited funding held by practice care networks. GPs in turn have spent more time supervising these allied health professionals, speaking on the telephone and doing paperwork and less time in face-to-face assessments.

Some GPs have voiced concerns that the number of allied health professionals means that to supervise them properly they will not have any time left. This has led to increasing complaints about unsupervised allied staff seeing unselected patients. GPs are highly trained to work in a high-risk way and encourage the allied staff not to work more safely.

The failure of allied staff to not use a defensive medicine approach which would increase the number of investigations is important in clinical negligence. The argument that because GPs do not need to perform these investigations it is safe for allied staff to do the same is mistaken. It is alleged that excess death rates and falls in life expectancy is evidence for chronically misdiagnosed patients having poorer performance.

Solution two – more GPs

Attempts to increase GP numbers has been largely ineffective because of structural problems in training and the high attrition rates of younger GPs. Older GPs are less likely to leave and do something less stressful but younger GPs have options and stay an average 6 years after qualifying. This means that the UK will have to train about 5 times as many GPs as it needs to ensure that enough are available.

The ongoing fall in overall GP numbers for 20 years has left a huge gap in the number of doctors needed to deliver modern care. Other countries have list sizes of patients per GP of about 800, in the UK it is still rising and is currently 2300. To compete the UK would need three times as many GPs! Any hope that the numbers of GPs will rise as more GPs undergo training has been dashed by news of fully trained GPs who cannot get jobs because of problems with funding.

The widely reported increase in numbers of GP appointments is not reflected in improved access to GPs. The appointments are often with allied health professionals and can also be double counted. A patient will have a chat to one professional, then come in to see a second professional and have a further chat with a third professional all for the same problem. An issue that would have been dealt with in a single appointment can generate many contacts.

Solution three – The Physician’s Associate

The unique role of the Physician’s associate is best illustrated by the GMC being responsible for their regulation. Whereas other allied staff have their own regulatory authorities the decision to include PAs with doctors was deliberate. The PA is special and to understand the reasons we need to go back to medical training.

Doctors undergo 5 years of medical school training in science and clinical skills to equip them for any roles that they may face in their professional careers. This is clearly wasteful as much that they learn will never be used and costs of training each doctor is about quarter of a million pounds. After medical school they are given two year foundation training before a lengthy specialist training.

Even in primary care which has a relatively short training program the GP will have undergone 10 years post school training before they start work. The PA can start work in half that time, they undertake 2 years formal training following a three-year degree. PAs are younger, have not wasted time on subjects they will not use and are given specific on the job training for their current role.

There has been extraordinary resistance from GPs to these talented new professionals. Other allied professionals are not seen as much of a threat because their roles are more limited. PAs may at present require substantial support and not perform very differently from other allied professionals, but this will not last forever. PAs cannot go back to other roles because they are not nurses, pharmacists or physiotherapists.

The future

Unless GP numbers rise soon and by 10s of thousands there will be a demographic implosion in primary care as older GPs retire. Even if younger GPs can find jobs and be retained in the workforce, they will be largely restricted to supervising other staff. PAs are already taking the bulk of learning opportunities in some areas and this will continue to increase. The financial implications of returning to a GP first model means that no government will agree and once GPs are gone they will not return.

The PAs must therefore become apprentice doctors, they must receive the training and support to ensure that they reach the same level of skills as doctors. They must have the opportunity to sit the same examinations and to join the medical register as fully qualified doctors with the same status as conventionally trained doctors. This will ensure that PAs are sustainable and will not simply collapse when GPs are no longer available to support them.

There are many conventionally trained doctors who will resist this despite having complained that the system is not fit for purpose. The training is too long and leaves doctors with excessive debts, they are overtrained for their daily tasks but lack practical skills. Medical students are selected for their ability to study rather than communication skills or practical abilities.

There will be expenses involved in ensuring that PAs progress professionally, that they are capable of the tasks that they are given. They will need to become self-regulating and engaged in sharing knowledge and testing performance. There will need to be difficult decisions as to how to manage PAs who cannot achieve the highest standards. The funding for primary care will need to return to the previous 11% from the current 8% of the total health budget.

Conclusions

Physician’s associates can be seen as yet another allied health professional who will depend on doctors to supervise them. Another more progressive view is replacing the current ‘dinosaur’ medical training with an apprenticeship will invigorate the profession. Doctors of the future will come from a wider range of backgrounds and they will have better communication and practical skills.

Doctors probably have little use for their current extensive book knowledge when they can access the internet. As AI solutions become embedded in health systems, the need for old fashioned training will be replaced with the ability to collaborate with the AI. In the next few years for instance we will see radiologists using AI to help them read complex 3 scans and produce better reports than a human (or AI) could do individually.

Physician’s associates are part of that change, they will learn whilst on the job ensuring that their experience is relevant for their role. They must be allowed to become qualified doctors so that they can cooperate rather than compete with the medical profession. Their knowledge and skills must be monitored to ensure that they are able to provide safe care.

Lawyers are already aware of the issues such as staffing shortages, professionals acting outside of their competence and lack of supervision are having on their clients. The GMC work on regulation of PAs is opening new opportunities for legal challenges. As differences emerge between doctors who have been trained by conventional and apprenticeship routes further ethical questions will arise.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

Image cc flickr.com/photos/didbygraham/219375981/