Intended for healthcare professionals


Why the fuss about physician associates?

BMJ 2024; 385 doi: (Published 16 April 2024) Cite this as: BMJ 2024;385:q862
  1. Margaret McCartney, senior lecturer, GP12
  1. 1University of St Andrews, UK
  2. 2Glasgow, UK

Features of the debate around physician associates (PAs) have crystallised a range of underlying problems in the NHS into a lightning rod. This now has serious implications for the future of general practice and the medical profession itself. Unless we look back and understand why we have medical royal colleges and regulation we risk further alienating doctors—current and future.

To be clear: my argument is not with the many individual PAs who have, with good faith, engaged in their training and work, with high aspirations for patient care. The current crisis is not their fault. The same cannot be said for the medical and political leaders who have led us here. Nor can we blame every current leader: this crisis has been drip fed for years, with those expressing concerns or asking questions urged to “be kind or be quiet.” But we should really be looking further back to understand what is at risk in general practice and the wider medical profession.

Team working is well established in healthcare, but it is possible to increase activity while adding little value for patients. Skilled practitioners can do much, but doctors who ultimately retain responsibility for patient care need the power to discharge their leadership effectively. This requires enough staff working in systems that enable clinical safety. Doctors being given more responsibility to supervise less skilled staff, all while having little control, is a recipe for burnout and disaster.

In 1950 the Lancet published the investigation of a doctor called Joe Collings into general practice in England and Scotland.1 Practices were overwhelmed, premises were unfit, and there was no coherent training or standards in practice. “The overall state of general practice is bad and still deteriorating,” he wrote. This “will continue until such time as the province and function of the general practitioner is clearly defined, objective standards of practice are established, and steps are taken to see that these standards are attained and maintained.”1 The Royal College of General Practitioners was subsequently formed in 1952 by a collective of GPs who defined their work and organised training, research, and postgraduate education. It was recognised that the management of undifferentiated symptoms was risky and needed particular skill. This is of critical importance and yet seems to have been lost in the decades since.

When Collings wrote his report, general practitioners were overwhelmed with work. We still are, and supervising less skilled people who will not end up autonomous practitioners—in the way that trainee GPs will—is a false economy. Rather than concentrating resources on supporting doctors to do their jobs—for example, with doctors’ assistants, by putting serious effort into retaining doctors, or enabling them to work more clinical hours—the training of PAs is focused on producing staff more quickly, but with a shallower skill set. Newly qualified doctors are rebelling, quite rightly, because they have been sold an expensive degree and left in massive debt only to be starkly underpaid, while also being expected to take responsibility for lesser trained but better paid PAs.23 Neither is this just about money. It is about the lack of respect and autonomy doctors experience, the sources of stress at work, and what might actually alleviate it.

The question of what training is needed to do what work is critical. Either all staff in general practice seeing undifferentiated patients adhere to the set standards of medical school, vocational training, traineeship, and exams or none of us do. Holding doctors to a different set of standards is illogical. General practice made itself an evidence based specialty because it was prepared to set standards and call out bad practice by setting up training, examinations, certification, and long term educational commitment. The establishment of an independent Royal College of General Practitioners faced much opposition “by ridicule and by pressure,” including from the other medical colleges.4 We now risk undermining the efforts that developed general practice into what it is today.

Usually we keep our most trained and skilled people for the most difficult and important jobs that require higher expertise. But we have got it bizarrely inverted. Highly skilled GPs can end up doing purely administrative or non-medical work—which should either be delisted or given to an assistant—while the tasks that require most training get done by someone with less training, such as a PA. Direct patient care is the raison d’être of GPs, and the system should be designed to support it. If doctors aren’t willing to do the hours—as clinical NHS work is so stressful that it becomes intolerable—then that is the problem that needs to be tackled. Adding more, less well qualified staff to do the most difficult jobs may make doctors’ stress worse, as they take responsibility for others’ decisions.

This debate has revealed an existential crisis in medicine. It will not take long before school leavers look at medicine and then look elsewhere. There have been examples of strong leadership from some colleges, and we need more. The value of general practice cannot be understated. If continuity of care was a drug it would be a blockbuster.5 Yet care has been deliberately fragmented, allowing the NHS to spiral downhill. By adding more PAs to help, I predict that costs and activity will increase, efficiency will decrease, and a government minister will eventually invite a review, which will likely report, like Collings did, that the overall state of general practice is bad and still deteriorating.