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Intelligent solution or poor substitute?

Health secretary Jeremy Hunt wants to see 1,000 new physician associates in primary care by 2020 to address the GP recruitment crisis. But critics are sceptical of the role’s implications for existing professions, including nursing.

While a Twitter storm is perhaps not the best indication of a real problem, there are serious questions in this debate about the primary care workforce.

Physician associates (PAs) are graduates, often in science, with two years’ postgraduate training and a nationally recognised qualification to work as assistants to doctors. While most UK-trained PAs are in acute hospitals, a few work in general practice.

Health secretary Jeremy Hunt announced ambitions to employ 1,000 more PAs in general practice by 2020. This was part of the ‘new deal’ for primary care that aims to address the national GP recruitment crisis and support seven-day working.

Health Education England created 200 new PA training places for 2015 and courses have already begun. There are currently only around 200 PA posts across the NHS.

The first PAs to work in general practice in the UK were US-trained and joined practices struggling to recruit GPs in 2003. They set up a professional body, the UK Association of Physician Associates, now the Faculty of PAs within the Royal College of Physicians. The Department of Health developed a competency and curriculum framework and by 2008 a number of universities had established PA training programmes.

Last year saw the publication of research funded by the National Institute for Health Research (tinyurl.com/oq5o899). This looked at the published papers on PAs in primary care and undertook an observational case study of 12 practices, half of which employed PAs. This case study showed that PAs tended to see patients with same-day appointments and worked at the younger end of the demographic than GPs.

Researchers looked in detail at more than 2,000 same-day consultations, searching for differences between GPs and PAs. Patients seen by the PA were no more likely to come back within a fortnight for the same or a linked condition. PAs tended to spend longer with patients than the GP, but the cost per consultation was £6.22 lower. In some practices the PAs were focused on maximising practice income, for example by maintaining patient registers.

The researchers concluded that PAs offer a potentially acceptable and efficient addition to the general practice workforce. However, there were some caveats. One of these was that GPs and nurses without experience of working with PAs often held negative views. This was amply illustrated by the response when Nursing Standard asked practice nurses whether PAs were a threat or an opportunity. They came down firmly on the threat side. As one respondent noted, she wanted to be a ‘mega nurse, not a mini medic’.

Jeannie Watkins is senior lecturer and clinical placement lead in PA studies at St George’s, University of London. She qualified as a nurse in 1996 and as a PA in 2007, and worked in general practice from 2007 to 2014. She is well aware of the criticisms of PAs, especially from those who have not worked with them. ‘I am not sure most nurses know what PAs can do,’ she says. ‘As with any sort of change, some people are anxious and want to know if it means their job is on the line.’

Complementary

The precise role undertaken by PAs in general practice depends on the practice and its population, as well as the experience of the PA, says Ms Watkins. ‘They will be seeing patients, triaging, taking histories, doing physical examinations and requesting investigations, as well as running long-term conditions clinics.’

As a PA, Ms Watkins says her role complemented that of the nurse practitioner with whom she worked. ‘Everyone at the practice was willing to have an extra pair of hands,’ she says. ‘I started by working alongside the nurses, getting to know them and discussing patients.’

One difference between the two roles, she says, is the amount of biomedical knowledge underpinning clinical practice. Another is that nurses are professionally regulated and allowed to prescribe, while PAs are not registered and cannot prescribe. Ms Watkins says this is a major obstacle to employing more PAs in primary care.

Picture credit: David Mitchell

Heather Henry, co-vice chair of the NHS Alliance and a Queen’s Nurse, thinks most nurses’ objections go deeper than a fear of the unknown. Primary care nurses do not want to see the team pushed down the medical model road, she says. They are also sceptical about the true value of a graduate with two years’ training who is unregulated to work effectively in a complex primary care environment, where there is multiple comorbidity and polypharmacy.

‘The experienced GP and nurse practitioner in primary care are looking at undifferentiated problems, says Ms Henry. ‘There is scepticism about whether the physician associate can deal with that level of complexity.’

Physician associates in the UK

The first physician associates (PAs) to work in general practice in the UK joined Black Country practices struggling to recruit GPs.

PAs have two years’ postgraduate training and a nationally recognised qualification to work as assistants to doctors.

They are represented by the Faculty of Physician Associates within the Royal College of Physicians.

PAs are unregulated and cannot prescribe.

The attitude of primary care nurses also reflects the relative lack of research and investment in their own specialty, she says. ‘Where is the cost-benefit analysis of employing an advanced nurse practitioner? We need that kind of analysis too.’

As is so often the way, she says, politicians are tempted by the shiny new solution, when a tried and trusted method is at hand. ‘Why are we investing in the new when we are completely ignoring the old?’.

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