Margaret McCartney: Are physician associates just “doctors on the cheap”?BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5022 (Published 20 November 2017) Cite this as: BMJ 2017;359:j5022
All rapid responses
Whilst we recognise the increasing pressures which physicians face, the future of good medicine in the UK rests with treating patients rather than disease, as was emphasised 100 years ago by Sir William Osler. The introduction of guidelines has not helped and neither will the widespread introduction of “Physician Associates” (PA). Their main role appears to be to take medical histories and undertake physical examinations. These exercises can be of real value when conducted by an experienced physician who can ask targeted questions and search for relevant clinical signs. The risk is the development of a central European model clinic with acolytes reporting to a physician who never sees a patient.
The German proverb “A half doctor near is better than one away” comes to mind but putting more significantly less qualified shoes on the ground will not solve the problem. Compromise on quality may have been justifiable if there were a dearth of top rate applicants for medical school places but the reverse is true.
Dr Margaret McCartney eloquently outlined the reasons why the PA will have little value in primary care (BMJ 2017;359:j5022). Quality of care matters, the public deserves better and the introduction of physician associates will, as in primary care, fail dismally to “butter the parsnips” in hospital medicine.
J.A. Cotterill B.Sc. M.D. F.R.C.P.
Retired Consultant Physician
W.J. Cunliffe B.Sc. M.D. F.R.C.P.
Retired Professor of Dermatology, University of Leeds
R. Wilkinson. B.Sc. M.D. F.R.C.P.
Emeritus Professor of Renal Medicine, University of Newcastle upon Tyne
Competing interests: No competing interests
I am sorry that Radcliffe feels that I have been disrespectful towards physician assistants - there is none felt or intended. I am sorry. The focus of this column was about Jeremy Hunt's claim that PAs would reduce physician burnout, and I can find no evidence that this is the case.
I do agree with Radcliffe that GP days are long and stressful. However they contain many system problems clinical and non-clinical that (1) don't need to be done at all and (2) could be done by someone else. I don't think it's useful to train and employ more staff only to have them doing the same wasteful tick box QOF, for example - we need to get rid of this waste so that no one has to do it. Or the ongoing farce of ineffective and unfair benefits medicals - there is no point placing more staff in primary care to deal with the fallout when it is the companies providing these assessments who should be held to account and stopped from creating needless work in primary care.
These are the kinds of things that Hunt could take action on and which would be likely to help all in primary care. In terms of what could be done by others - an example is of scripts which are 'out of stock' and which can take hours to sort out - this would be far more efficiently done by pharmacy staff working to a health board agreed protocol. Primary care keeps being made to absorb the stress created by poor systems in places currently outwith our control. Rather than putting more staff in to deal with these, we should identify and remove those stresses, because otherwise the ask on primary care is infinite with no way to meet it. It is a great pity that there has been no move forward on the role of 'medical assistants' as proposed a few years ago and could have helped with much of the administrative burden on GPs and allow concentration on direct clinical care. The work on care navigators is awaited with interest. There is no 'protectionism' - in fact, I think it would be much better to use the talent and enthusiasm of people fully and admit vastly more people from a wider demographic to medical school - an extra three years training would create more doctors who can work autonomously, be regulated, and progress equitably in their careers.
Drennan and colleagues provide interesting reading in their references. However I can see no data in respect of safety caused by interruptions. It may be that practices who have employed PAs, as in this study, have done so because their workload was such that this is for them a safer system. But it cannot be optimal to build national policy on the expectation that interruptions are normal without reducing GP consulting time to ensure this is safely factored in.
Parle makes many assumptions. This is a pity. GPs are best placed to see patients - that's what we've trained for - rather than sort out Trampolining Consent Forms, commissioning, trying to communicate with Atos, or raising awareness of whatever has been in the news that week. General practice is nothing without the multidisciplinary team (as I've written often before and the reason why the fall in numbers and shortage of district nurses concerns me so much) and I think he has misinterpreted what I have written.
Competing interests: I wrote the article
I applaud Margaret's McCartney commentary in this weeks bmj. She is quite right to lay emphasis on the need for population level impact assessments and for the need for our NHS to learn from successes.
In another part of Somerset, we have indeed demonstrated population level savings in emergency admissions through our own project developing proactive patient centred care across a population of 30 000. The investment saved £6 of nonelective admissions costs for each £1 invested in the model and could save more if the model were fully funded. We are in process of rolling out this model across the rest of Mendip and our model of working has been shared with the Welsh assembly through compassionate communities with a roll out planned in the new year across the 65 federations in Wales.
Community development network enhancement and a focus in what matters to patients and their carers is what we aspire towards. This is becoming increasingly difficult to maintain in the current pressurised and fragmented environment of primary and community care. Investment in these priorities is cost effective The focus on individuals improves quality of patient care and at the same time improves the working lives of staff delivering our model.
We all need to hear about success in the NHS and to create an NHS environment where spread and development of success is supported through quality improvement methodology. We need investment In successes and for clear and enabling NHS pathways to effectively spread of learning.
Dr Helen Kingston Frome Medical Practice firstname.lastname@example.org
Competing interests: My practice has financially committed employment of staff and commitment of clinical resources to our project and its roll out across the Mendip area placing us under financial risk due to shortfalls in funding to support the full model and lack of ongoing NHS funding due to current financial challenges in Somerset
It is said," In primary care the evidence for PAs reducing workload is uncertain"; this is evidence based. if one looks at all issues dispassionately, there is a strong argument that PAs are indeed "doctors on the cheap".
Competing interests: No competing interests
I write this at the end of a fourteen-hour day in my GP surgery. This is the reality of everyday general practice. GP posts remain unfilled and funding is not flowing into general practice to help us meet soaring demand.
Physician associates may boost our workforce as members of our multidisciplinary teams. Evidence from the US and increasingly from the UK shows that PAs provide quality care, with high levels of patient satisfaction and are cost-effective. Margaret McCartney is unusually disrespectful in writing such a diatribe against physician associates. Opinions based on lack of experience, citing very little evidence, may be construed as prejudice and old fashioned professional protectionism. General practice is in crisis. PAs may not be the whole answer but they may represent part of the solution.
Competing interests: I am married to a member of the faculty of a PA programme
“Undergraduate medical education is dead, long live the physician associates” The governing bodies of clinical education cry!
With Jeremy Hunt and the Royal Colleges heralding the creation of Physician Associates (PA) courses at our universities as a positive step in ‘redistributing the workload’1 (or words to that effect) and the research being published that propose that physician associates can provide care to a certain patient population equivalent to that of a GP.2 I have to ask myself, if I was a that 16 years old again, would I even bother applying to and going through the gruelling medical school application process? Really, what is the point? Is the medical profession on life support?
Some may argue that “PAs can’t prescribe or they can request investigations which involve radiation, but a doctor can!” My response to that is “but, for how long?” with the crowds in Whitehall, Lincoln’s Inns Field, Red Lion Square and St Andrew’s Place joining the bandwagon of the PAs if will not before long that those limitations are removed and the PAs will be in full swing.3 Others might proclaim ‘What about performing operations, delivering a general anaesthetic, doctors will still be needed for that?” Alas, that is not the case either, as specialist nurse and advanced care practitioners are already performing many of those tasks (albeit minor cases) up and down the country, with some junior doctors not getting a chance to learn some critical skills, in the not too distant future PAs will also be joining the ranks, conducting those tasks.
So “really what is the point?” is the future doctor a ghostly being that no patients catch a glimpse of? or if they do is it in an out-of-hours setting in an understaffed, poorly performing hospital that the governing NHS authority is in dire needs to populate with staff to keep the wolf like CQC from knocking on the trust’s door? In all honesty no one, not even the powers that be can honestly paint that scene, with spending cuts and staff shortages and the old broken record that is Brexit looming.
Medical schools cannot rest on the laurels and let the ‘new child’ (the PAs) be the shining star. Medical schools now more than ever as well as practising clinicians (with a medical degree) must stand up and be accounted for and promote the fantastic career that is medicine. The second to none education that a medical degree gives you to understand and apply; physiology, pathology and pharmacology. The craftsmanship of being a clinician, a scientist a therapist and technician all in one sitting.
I welcome PAs into our workforce, but medics and medical schools need to wake up and smell the coffee, for our profession to survive we must rebrand, refocus and rejuvenate the role that makes us unique in the ever-expanding multidisciplinary team.
Thoughts from not a militant or moët medic but someone who loves his profession.
1. NHS, NPAEP. The National Physician Associate Expansion Programme. http://npaep. com.
2. Halter M, Drennan V, Chattopadhyay K, et al. The contribution of physician assistants in primary care: a systematic review. BMC Health Serv Res 2013;359:223. doi:10.1186/ 1472-6963-13-223. pmid:23773235.
3. Royal College of Physicians. An employer’s guide to physician associates. Nov2017. https://www.rcplondon.ac.uk/file/7623/download?token=4C7OyR_p.
Competing interests: No competing interests
Building an evidence base on primary care workforce Re: Margaret McCartney: Are physician associates just “doctors on the cheap”?
Building an evidence base as to the impact of different types of staff in general practice (or in any medical service) is challenging and takes time. Margaret McCartney is right to point out there isn’t any evidence of physician associates (PA) making a difference to levels of clinician stress and burnout. However there is more evidence available than she suggests on the contribution physician associates can make in general practice. This may be important to recognise at a time when general practices are struggling to fill general practitioner and general practice nurse vacancies.
Our National Institute of Health Research funded study [1 ] demonstrated that the physician associates were safely attending a younger, less complex group of patients than general practitioners. These were patients requesting same day /urgent appointments and the problems they attended with were classified mainly as minor self-limiting problems. Surveyed patients reported high levels of satisfaction with PA and GP consultations. When we interviewed patients their willingness to consult a physician associate was contingent on their own assessment of the severity or complexity of the problem and the desire for provider continuity .
Dr McCartney expressed concern regarding the current situation in which physician associates cannot sign prescriptions and alarm that the solution was to interrupt a GP. The practices in our study used checking and signing systems that avoided interrupting doctors. Practices in the study, with and without physician associates, used the same systems for their nurses and nurse practitioners who did not have prescribing qualifications.
Finally it was apparent through our interviews of GPs (some employing PAs and some not) that there were two viewpoints as how best to manage general practice clinical workload and deploy staff . One view was ‘doctor first’ was the most efficient i.e. the most senior clinician attends all patients and delegates activities to members of the team. The other view was that the patient population could be segmented so that the most senior clinician mainly attended the more complex patients and those with the most medically acute problems but also supervised other team members attending the younger patients with more minor problems. Our research offered evidence to suggest that PAs could contribute safely in a skill mixed general practice teams. As such PAs have the potential to be an asset to the primary care workforce in the face of shortages of doctors, increasing demands, and financial stringency.
1. Drennan V, Halter M, Brearley S, Carneiro W, Gabe J, Gage H, Grant R, Joly L, de Lusignan S.. (2014) Investigating the contribution of physician assistants to primary care in England: a mixed methods study. Health Serv Delivery Res 2(16). https://doi.org/10.3310/hsdr02160
2. Halter, M., Drennan, V.M., Joly, L.M., Gabe, J., Gage, H. and Lusignan, S., 2017. Patients’ experiences of consultations with physician associates in primary care in England: A qualitative study. Health Expectations. 20:1011–1019. https://doi.org/10.1111/hex.12542
3 Drennan VM, Gabe J, Halter M, de Lusignan S, Levenson R. Physician associates in primary health care in England: A challenge to professional boundaries?. Social Science & Medicine. 2017 May 31;181:9-16.
Competing interests: No competing interests
Let's face it: PAs are attractive to politicians mainly to fill up gaps from doctor shortages at lower (perceived) costs
The latest rapid response to Margaret McCartney's opinion piece is, in my opinion, so appallingly close to being patronising that I am driven to point out the essential facts about the role of Physician Associate (PA) in the UK:
1. Despite the existence of Physician Assistants (rather than Physician Associate as they were called in UK) in the US since the 1960s, the first official introduction of PAs into UK happened in 2003, from which "the UK Association of Physician Associates (UKAPA) was established, acting as a professional body for physician associates" in 2005 (ref 1). Despite the use of PAs for more than a decade in the NHS, they are still NOT under statutory regulation and thus any prospective "employers are strongly advised to be diligent in their recruitment process".
2. There is no doubt that the promotion of role of PAs in the NHS is incentivised by the perfect storm of insufficient numbers of doctors graduating from local medical schools and the need to keep health care costs down. Instead of increasing numbers of medical students for future planning of staffing NHS adequately with the right skill-mix, Professor Parle seemed to be more interested to employ biomedical scientists as PAs, thereby keeping reducing their unemployment rates. Although PAs costs half the salary of General Practitioners (GPs), they take at least 50% longer consultation time, and are only seeing a limited spectrum of conditions (tailored to PA's experience) compared to GPs.
3. While PAs are supposed to work "autonomously", they are not independent practitioners and ultimately have to be supervised under doctors in any role. This supervision costs in time and effort by doctors is rarely discussed and seldom properly monetised in any studies of cost-effectiveness of PAs. Similarly PAs has little if any prescribing rights in the NHS, and had to seek doctors to issue prescription for patients the doctors have not seen themselves. Thus PAs can hardly be used as a fair comparison to other allied health professionals including nurse practitioners who are supposed to be independent.
4. While PAs requiring indemnity, many employers are expected to pay for their indemnity if placed in GP practices (or covered by the trusts if employed directly by NHS trusts). The cost of indemnity is also rarely taken into account in cost effectiveness analysis.
5. With the GPs expected to cover more complicated cases while PAs have generally more limited scope of practice (and yet somehow "under supervision" of doctors who are cannot be at every consultation), wouldn't it be reasonable to conclude that these GPs will be undertaking higher medico-legal risks by the nature of their more complex patient load or the presumptive supervision they are responsible to provide for the PAs?
6. Similarly, claims of " no increase of investigations ordered" in some studies are flawed by the very fact the PAs and GPs are seeing patient caseload of different complexities and thus hardly a fair comparison in any case.
As much as some respondents may disagree with my view, it is clear that the key attraction of PAs to the NHS is to ease the staff shortage at lower costs instead of investing in the longer term solution to train more local doctors properly, which is no more than a few years longer than to train a competent PA fresh from university. This move is really a politician's patchup job, not a long term solution.
I, for one would not want to be the last remaining doctors in the NHS of the future somehow "supervising" all other health professionals who are performing the role of doctors yet cherry picking only the easy cases to see. Better double check your indemnity cover for "supervision".
Where has all the doctors gone, long time passing? Gone to overseas, every one.
When will WE ever learn?
2. Drennan VM, Halter M, Joly L, et al. Physician associates and GPs in primary care: a comparison. Br J Gen Pract2015;359:e344-50.
Competing interests: No competing interests
Dear oh dear, what a deeply disappointing personal view from Margaret McCartney. But I entirely understand where she is coming from as this was also my initial reaction when approached some 15 years ago and asked if I would run a PA course. My response? ‘It took me almost ten years to train and I am still learning’; ‘How can it be possible to treat patients with only 2 years training’; AKA 'Hmph’! But, unlike Margaret, I learned, by listening to those who know about PAs. And after all, the workload isn’t going away; and I speak as a GP with almost 40 years’ experience (14 full-time and, since entering academia, 25 years part-time). There is plenty of evidence of the effectiveness of PAs in other countries, and indeed of the effectiveness of non-Drs assisting with the medical tasks (and how are such tasks defined anyway?) We cannot simply carry on doing what we have always done and hope the workload problem will somehow be sorted. There are approximately 15,000 biomedical scientists graduating a year in the UK and the PA profession mostly recruits from them, thus bringing new people into medicine, avoiding impacting other professions, and indeed reducing unemployment.
There is no ‘magic stuff’ that only Drs can do: but there are plenty of things less qualified workers can do to the same standard but under supervision. And Margaret’s comment: ‘Forgive me for my old fashioned view that GPs are best placed to see patients’. Actually, no; I don’t forgive you. Old-fashioned can indeed sometimes mean ‘It was better then’; it can also mean ‘I have already made up my mind and am not listening’. Oh, and by the way Margaret: ever heard of nurse practitioners, extended scope physiotherapists, practice nurses, paramedics? Do you really mean that only Drs can see patients?
No, we need PAs, they will make a huge difference; and the evidence we have (and are gathering) shows they really will help us at the sharp end.
Competing interests: I am the Chair of the UK and Ireland Board for PA Education, the Director of the PA programme at University of Birmingham, have published on PAs and am one of the PIs on an NIHR funded study (14/19/26 - Investigating the contribution of physician associates (PAs) to secondary care in England: a mixed methods study).
I agree with Margaret McCartney that physician associates are not doctors on the cheap. Their role is different to that of doctors and the evidence, albeit of weak to moderate quality, suggests that cost effectiveness in primary care is equivalent to that of GPs.
Perhaps it might be useful to focus on patients rather than economics. The same article cited as evidence of financial equivalence also reports outcome equivalence in terms of re-consultation rates, referrals, prescriptions, tests and patient satisfaction - a finding that has been replicated elsewhere. In this study, the average age of patients seen by GPs was 8 years older than those seen by physician associates and the complexity of patients seen by GPs was higher. Most work suggests that experienced physician associates see patients in 10-15 minute consultations - presumably these less complex patients would otherwise have been seen by a GP. Taken together, this indicates that physician associates are not doing the same job as a GP but that the two roles are complementary in practice leading to increased appointment availability with no evidence for deterioration in quality of care or increased cost.
We found out this week that we have 1,193 fewer GPs than last year. There is no sign that the tide is turning. Physician associates are qualifying and ready to work in primary care. They are trained to be generalists and are therefore malleable to different roles at a time of an NHS workforce crisis. They are not a magical solution to the issues facing the NHS however, if, as a profession, we turn our back on physician associates, can we honestly say that we will be looking back in ten years’ time and be proud of our legacy?
Competing interests: No competing interests