Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Physician associates in general practice—time to pause and reflect

BMJ 2024; 385 doi: (Published 25 June 2024) Cite this as: BMJ 2024;385:q1393
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on X @HelenRSalisbury

Last week the Royal College of General Practitioners (RCGP) advised its members to halt the recruitment of physician associates (PAs).1 This came after a review of survey results showing its members’ experiences of, and views on, the PA role. The responses were analysed by an independent research company and published in full—in welcome contrast to events that followed a similar study in another royal college.2

More than 5000 GPs and GP trainees responded to the RCGP questionnaire, around 10% of the membership. The headline findings are that four in five respondents are concerned about patient safety, and 50% are aware of specific examples of safety being compromised by misdiagnosis, inappropriate treatment plans, or poor communication. The survey also uncovered a lack of triage, so that PAs were seeing potentially seriously ill patients, and a lack of clinical supervision, with no time set aside for this in many surgeries. More than a third of respondents (36%) said that they believed there was no safe role for PAs in general practice.

In March the RCGP published “red lines” on PAs, asserting that they shouldn’t be used as replacements for doctors and should always be supervised by people both willing and properly trained to undertake that supervision.3 Its latest bulletin, building on the survey, advises that all recruitment of PAs into UK general practices should be halted until the role is regulated and until practices can implement the guidelines on scope, triage, and supervision that the college is currently developing (due in September).

There’s a wide gap between what’s advised by the RCGP (or the BMA before it) and the expectations of NHS England, as expressed in the primary care network contract.4 NHS England still insists that PAs should be “first contact,” seeing undifferentiated, undiagnosed patients, although it does now acknowledge that supervision is required.5 I suspect that most GPs will choose caution and adhere to BMA and RCGP guidance.

While most GPs will welcome the tide turning against the replacement of experts at medicine’s front line with much less highly trained staff, we should also be asking how we got here. Replacing doctors of 10 years’ training and experience with PAs (and nobody should be in any doubt that replacement was always the intention) was, from the start, a blatantly dangerous plan.6 How is it that so many people in positions of power and influence in the medical establishment agreed to this in the first place? And why has it taken them so long to acknowledge that this emperor has no clothes?

I feel huge sympathy for the many individual PAs in practice who work carefully, within their capabilities, supervised by equally diligent GPs. Students currently enrolled on courses have been sold a lie about what sort of career their training would fit them for. They’ve been let down by the structures of governance and by individuals within those structures who led them to believe that they could be “medical professionals” after a two year training course.7

In the pause while we sort out possible future roles for these people, a period of reflection is due from those who have brought us to this point—alongside an apology to all patients and staff harmed during this misguided experiment.