Physician Associates: why the controversy?

Primary care workloads are a perennial concern in the NHS.  With problems recruiting and retaining GPs, policies to expand the skill mix are a usual mainstay of calls for improvement.  Plans to expand the Physician Associates (PA) workforce are one policy to relieve the pressure.  However, a current British Medical Association (BMA) campaign is focusing on the risks of this role, not the benefits.  Why the controversy?

Many patients currently struggle to see a GP. I recently registered with a new practice, and I am still trying to figure out how to get a GP appointment.  I have, though, been ordered to see a practice nurse and a phlebotomist for blood tests and to consult with a clinical pharmacist by phone.  Failing to do so already, the practice warned by text, resulted in my medication being ‘reduced by half’; failure to remedy this within a few weeks would result in this ‘being halved again’.  Setting aside the rather punishing attitude to health management, this experience underlined two things. First, primary care in the UK is already delivered by a mix of non-medical professionals. The traditional ‘comprehensive, continuing’ care from a named GP has largely disappeared. Indeed, care of any sort has perhaps disappeared; replaced by a routinised, task-oriented approach to management.

Second, it illustrates a key driver of primary care workloads.  Rather than being ‘patient-led’, much demand is ‘provider-led’.  It is generated not by patients who are sick, but by incentives for practices to routinely monitor long-term conditions and screen for new ones.  We are no longer simply ill or healthy, but constantly ‘at risk’, in states such as pre-diabetes, or ‘at risk’ of heart disease.  This medicalisation – what Natalie Armstrong suggests as system-generated over-diagnosis and overtreatment – has increased primary care workloads. 

The non-medical workforce in primary care has expanded to help meet this increasing burden of screening, monitoring and treatment.  As part of this workforce, Physician Associates are a relatively new role in the UK. Pilot schemes based on US models were started in 2003, and the Faculty of Physician Associates was established as part of the Royal College of Physicians in 2013. Physician Associates work alongside a named senior doctor, (as part of a multidisciplinary team) providing care to patients in primary, secondary and community care environments. They are required to complete two years of post-graduate training after a biomedical degree (comparable to the five-year medical degree). The BMA assert that “to patients, PAs/AAs and doctors may look the same and appear to be doing a similar job. But the fact is, PAs do not have the same qualifications or expertise as doctors. Too many patients believe they have been seen by a doctor when they haven’t, and this can lead to tragic consequences”. There are estimated to be only around 3000 PAs currently practising in the UK, over half of whom are in general practice.  This number is likely to increase, with ongoing recruitment crises for GPs, and many universities now offering accredited postgraduate PA training. The UK government asked the General Medical Council to bring in a process of formal registration for PAs to replace the current voluntary register.

So why the BMA concern?

PAs barely registered in the public consciousness until the widely reported death of 30-year-old Emily Chesterton from a pulmonary embolism, after two consultations with a PA. The PA, who Emily believed to be a doctor, had diagnosed a sprain.  Her death prompted questions asked in the Commons on the role and title of PAs, after the coroner reported that, had she been referred appropriately, this death would likely have been prevented.  The recent BMA campaign, widely covered in the press, echoed these concerns. They quoted a survey with what they called ‘shocking’ findings: that the majority of doctors felt PAs were a risk to public safety, and half believed that PAs increased, rather than decreased costs. The BMA GPs’ committee stated: that PAs are “not a substitute for a doctor who undergoes years of medical training” that enables them to provide complex, highly skilled care to their patients.  PAs should, argued the BMA, be renamed as Physician Assistants, and that their registration should be with the Health and Care Professions Council, not the General Medical Council.

At one level, this is perhaps inevitable ‘boundary maintenance’ on the part of a professional body keen to preserve its prestige and authority, and ensure the continued subordination of other professions.  Certainly, research on initial PA pilot schemes identified a range of concerns from existing professional groups, despite policy support: these included nursing leaders worrying that PA schemes would erode investment in nurse practitioners. However, research on patients’ perspectives found them in general positive about seeing a PA.

But are the BMA right to caution that PAs might not address the challenge of primary care workload?

Workload concerns are nothing new. Horobin and McIntosh’s study of GPs’ work is a sobering read. In urban areas, time-poor doctors worried about missing serious illness and being unable to provide a high standard of care to large patient lists; in rural areas, GPs could not take time off, as their work spread across seven days a week.  This study is over 50 years old; with interviews from the mid-1970s.  By then, Horobin and McIntosh note, ‘workload and time’ were already perennial preoccupations of the profession.

Assessing the impact of changing workforce composition on this long-standing challenge is difficult.  Changes in skill mix happen at the same time as other changes, such as incentives for GPs to do more ‘task-oriented’ work such as asthma management; the impacts of COVID; or the effects on recruitment from immigration policy. There are complex interactions between health care demand, supply, workforce and costs.   However, the evidence to date does suggest at best uneven results for health care costs, clinical outcomes, and patient and provider satisfaction from shifting work from GPs to nurses, PAs, or other professionals.

And what of the BMA concerns around patient safety?  Again, Horobin and McIntosh’s paper is interesting. They open with a consultation extract from an earlier study.  Here, at the end of a busy clinic where the GP has seen many colds already that morning, a patient comes in coughing.  The GP diagnoses yet another cold, sending the patient on their way to the pharmacy for medication. Much of the GPs’ work back then, it seems, was routine trivia; minor symptoms we are constantly told modern patients ‘can no longer manage themselves’.  Unfortunately for the patient in the reported extract, their symptoms were of pleurisy, not a cold. Doctors, too, can fail to diagnose accurately.

Of course, much has changed in UK primary care since the mid-1970s.  For GPs, the hybridisation of work within larger practices has generated pressures to reframe what it means to be a doctor in primary care, and focus on specialism, and biomedical skills, not patient-centred, continuing care.  In this contemporary setting, the PA is perhaps more an identity threat than other professionals, given their training in the ‘biomedical’ model, and their generalist skills. Unlike phlebotomy, with carefully prescribed remit, or nursing, with its claims to a unique perspective, PAs, as a professional group, threaten the legitimacy of the very role of general practitioner.  Having them registered on the same register, and not clearly labelled as ‘assistants’, might undermine many of the claims for the special status of medical professionals, particularly in settings where patients can no longer access a GP.

Addressing workforce challenges in primary care is not straightforward.  Controversy over the potential contribution of Physician Associates has, though, suggested that some assumptions that drive policy change may not be well evidenced. First, workload problems do not appear to be anything new. Second, they may not be driven by patient demand. And third, new, cheaper, professionals may not reduce costs in the short term. However, the introduction of the Physician Associate does perhaps raise uncomfortable questions about what the unique contribution of the general practitioner is to the modern NHS, if it is no longer to provide continuing and accessible primary care.