Helen Salisbury: Physician associates in general practice

Last week, the tragic and avoidable death of a young woman was discussed in parliament.1 The patient had presented to her general practice with, reportedly, obvious symptoms of a deep vein thrombosis and a pulmonary embolus. This diagnosis was not made then, nor after her condition worsened and she returned a week later. She died a few hours after this second visit.

The patient was under the impression she had been seen by a doctor, but in fact, at both appointments, she had seen a physician associate (PA). This qualification is given after a degree and a two year clinical skills course, and there are a growing number of PAs practising in the UK, in hospitals and in general practice. They have been brought in with the idea that they will support doctors, taking medical histories and examining patients under a doctor’s supervision. They cannot prescribe drugs.

This case highlights potential problems, including the fact that patients remain confused about who they have consulted. The role is not regulated and there is no statutory register of accredited PAs—according to the report in Hansard, the PA in this case is still practising as a locum. It has been proposed that the General Medical Council regulate this profession—a suggestion opposed by the BMA as an unwelcome blurring of boundaries.2 PAs are paid just over £40 000 after their first year and usually work a 37.5 hour week, so it is not surprising that some hospital doctors tasked with supervising them—who have had many more years of training and take on more responsibility but work longer hours for less pay—feel aggrieved.34

The overriding concern, however, should be about safety. The role description states that PAs should be supervised by doctors, but nowhere is that level of supervision defined. Most doctors are unfamiliar with PAs training and what competencies we should expect of them. In our practice we discuss every patient our PA sees, as we do with our medical trainees, but this clearly is not the case in all surgeries. There may well be safe roles for PAs working more at arm’s length with a defined set of problems (for example, routine hypertension clinics), but the undifferentiated nature of presentations to general practice mean that very close supervision is needed if a PA is seeing new patients.

Why are we employing them at all if they require such onerous supervision before they can be regarded as a safe choice? Clearly, most practices would prefer to employ a doctor if one was available, but they are in short supply. There is also a major economic factor at play. Unlike doctors, PAs effectively cost the practice nothing, as their salaries are covered by the additional roles reimbursement scheme, which was intended to lighten the load of GPs and solve the workforce crisis. It has brought welcome additional skills to our surgeries, with the arrival of pharmacists, physiotherapists, and visiting paramedics—unfortunately, it has also led to a dangerous dilution of standards when underqualified and inadequately supervised staff are left standing in for GPs.5

The blame for this sorry situation does not lie with PAs themselves. Some of it belongs to overstretched practices that fail to supervise the PAs working with them, but the largest share lies with NHS England and its determination to solve our workforce crisis on the cheap.