Nada Khan is an Exeter-based GP and clinical academic, and an Associate Editor at the BJGP.
Anyone keeping track of plans to include physician associates in the UK’s NHS multi-disciplinary team (MDT) knows that it’s not been a smooth journey so far. The President of the Royal College of Physicians (RCP) resigned in June 2024 following rifts within the RCP leadership and members expressing a lack of confidence in her leadership and ‘failure to take action’ on limiting the rollout of PAs in practice.1 Plans to include PAs in general practice have been further upended with a recent Royal College of General Practitioners’ (RCGP) call to halt all additional recruitment and deployment of physician associates in practice.2 The RCGP acknowledges that this is a ‘difficult step’ but that the recommendation was made to protect patients, PAs themselves, and the GPs who are clinically responsible for supervising PAs.
The RCGP Physician Associate survey and recommendations
The RCGP position is based on results from a recent survey of its membership, with over 5000 responses representing 10% of RCGP members.2 The College points out that the sample demographics mirror the RCGP membership, but the results do need to be taken within the context of not knowing the perspectives of the 90% who didn’t respond to the survey.
The survey focussed on what PAs are currently doing in practice, how members felt they should be working, and perceived benefits and risks of having PAs in practice. A third of respondents report currently working with PAs, with most respondents stating that PAs were recruited to try and tackle workload pressures and offer support roles in their practice. Of those GPs working with PAs, 20% reported that they first decided to start employing PAs because they were unable to afford to pay GPs, which feeds into concerns about an employment crisis and role substitution for GPs funding within the Additional Roles Reimbursement Scheme, which covers the salary of PAs.
The survey focussed on what PAs are currently doing in practice, how members felt they should be working, and perceived benefits and risks of having PAs in practice.
Another serious point of contention about the role of PAs is the debate over whether they should be seeing undifferentiated or untriaged patients. Of those respondents to the RCGP survey already working with PAs, 36% reported that PAs were seeing untriaged patients in their practice, and were often used as the first point of contact for minor conditions and for more serious conditions like abdominal pain or headache that didn’t have clear clinical pathways or escalation processes. When all respondents were asked, however, who PAs should be seeing in general practice, 62% felt that patients should be triaged by a GP or another member of the clinical team before being seen by a PA. Only 3% of respondents agreed with the statement that PAs should be able to see un-triaged patients. Most felt that PAs should not be the first point of contact for potentially serious conditions, and should be instead be seeing suspected minor or common conditions with clear clinical pathways, or doing follow-ups after patients were seen firstly by a GP. Alongside minor and common conditions, GPs responding to the RCGP survey felt that PA could be taking on tasks such as completing health checks, chronic disease management, contraception advice and immunisations. It’s worth an aside to note that this aligns with a strategy of handing more ‘simple’ tasks to the practice MDT and leaving GPs to see the more ‘complex’ patients. David Zigmond wrote here in the BJGP about the drawbacks of saving GPs just for more complex problems and taking away the ‘random and unpredictable assortment’ of minor pathologies that are sometimes seen as ‘easy wins’.3,4 A problem-stratification approach to care leads not only to GP cognitive fatigue, but a fragmentation of care that moves away from thinking holistically about a patient.4 It may be wise to think carefully about better integrating roles like PAs into the MDT and taking a team-based approach, rather than a framework that encourages the taskification of general practice.
The final section of the RCGP survey focussed on perceived ‘benefits and risks’ of PAs in general practice. A third of respondents said they couldn’t identify any benefits to including PAs in general practice teams. The respondents also endorsed several statements relating to challenges in practice, including a lack of clarity on the scope of the role, lack of public understanding of the role, supervision and regulation issues, concerns about patient safety and role substation of GPs. 61% of respondents were aware of specific examples of negative effects on patient safety, and provided some context around this through free-text responses, citing patient safety concerns around misdiagnosis and diagnostic errors, inappropriate prescribing due to perceived gaps in knowledge, and concerns around how PAs were introduced to patients in practice or how their roles were explained to patients.
Curran and Parle wrote a summary of PA training pathways here for the BJGP, but many GPs lack a firm understanding of that, or how PAs gain their clinical knowledge and skills.5 Many of the free-text comments in the RCGP survey relating to concerns about use of PAs impacting on patient safety and quality of care revolved around the lack of training and knowledge to manage complex presentations in general practice. Some respondents felt that use of PAs ‘devalued’ the training and expertise of GPs and undermines a sense of professional identify as a general practitioner. Research from 2017 highlighted similar concerns from GPs about whether PAs could safely deal with patient complexity, with this cited as a strong barrier to successful integration of PAs into the general practice workforce.6
On the back of this survey, the RCGP is asking practices to stop recruitment of PAs into general practice until PAs are regulated and the RCGP publishes guidance on the scope of practice and supervision requirements for PAs in practice.2 For those PAs already in practice, the RCGP is recommending practices ensure that PAs are being appropriately supervised and do not see patients that have not been triaged by a GP, and that patients re-presenting with a problem first seen by a PA should be seen by a GP.
What are the wider perspectives on PAs?
Other stakeholders, including the RCP membership, the BMA, and the Faculty of Physician Associates (currently hosted within the RCP) have been vocal around setting out their own views and priorities over how PAs should be rolled out in general practice.
The BMA has been acting to defend its own membership from confusion over different roles and patient understanding of ‘who is a doctor’, and a perceived devaluation of the medical profession.7 BMA guidance has lumped physician associates into a category called ‘medical associate professionals’ or MAPs, which includes PAs and two roles based in secondary care: anaesthesia associates and surgical care practitioners. The BMA has published its take on the scope of practice for these roles, defining them as an ‘assistant role to doctors’, working to support doctors. Mirroring the views of the RCGP, the BMA position is that PAs should not be seeing any untriaged or undifferentiated patients for an initial assessment or diagnosis, or making any independent management decisions.8 In general practice, the BMA suggests that this means that PAs should only see selected patients after triage, and any changes to management needs to be reviewed and approved by a GP before those changes are enacted. The BMA’s ‘red lines’ further suggest that PAs should not see any children, make any referrals or advice and guidance without it being reviewed by a GP. The suggested tasks appropriate for PAs include seeing these triaged, and selected patients in cases where there is an appropriate protocol to follow. These competencies and scope of practice are at odds with those on the Faculty of Physician Associates websites, which suggests that PAs should see patients with undifferentiated diagnoses, and formulate, develop and deliver differential diagnoses and management plans.9 How are these fundamental differences from two divided stakeholders on the roles of PAs going to be resolved?
Most respondents to the RCGP survey felt that PAs should have scheduled time to debrief with a named GP supervisor, with practice or PCN based funding to ensure protected supervision time. The BMA has published its own guide on how PAs should be supervised in practice.10 Supervision is not to be taken lightly. It costs time, and money, and when GPs are doing the supervising, it’s taking them away from their own patient-facing work. In practice, much of this supervision has been sporadic especially when staff don’t have immediate access to a named supervisor.11 The BMA suggests that each patient should be fully discussed with the named supervisor, and that time to achieve this level of supervision needs to be allocated within the working day, but this is a current challenge given supervision time is not factored into ARRS funding and is seen as one of the limitations of how the funding is provided.
The regulatory battle
PA regulation, or the lack thereof in the UK, has been problematic, and the row over which body should regulate PAs is still being fought. Regulation is important – at the moment, individual practices are responsible for ensuring that PAs have the right credentials, have passed the UK PA exam and are on a voluntary register of PAs declared fit to practice in the UK. Regulation will standardise and centralise this process, and will help set standards for PAs in practice. The question is, who should be the regulator, and should it be the General Medical Council or not?
Most respondents to the RCGP survey felt that PAs should have scheduled time to debrief with a named GP supervisor, with practice or PCN based funding to ensure protected supervision time.
The RCGP’s preference is that a body other than the GMC should regulate PAs, but it looks increasingly likely that the GMC will take on this role given new legislation and a framework to open a register for PAs before the end of 2024. 62% of the respondents to the RCGP survey felt that a PA’s GMC number should be preceded by the letters ‘PA’, but members were not asked if the GMC should be the preferred regulatory body.
The BMA, however, is strongly against PAs and other MAPs being regulated through the GMC over fears of ‘blurred lines’ between doctors and these other roles, and had instead pushed for PAs to be regulated by the Health and Care Professions Council, which regulates roles such as physiotherapists and paramedics. The BMA has announced legal action against the GMC’s plans to regulate PAs, so this is an issue that is yet to be fully resolved. With the RCGP recommending a halt to PA recruitment and deployment until they are fully regulated, clarity around regulation is a pressing matter for PAs and the practices employing them.
Final thoughts
This RCGP survey on PAs has given the College some steer from the member community on what PA roles could look like in the future. Questions remain over who PAs can, and should be seeing, and how the regulatory battles will be resolved. The RCGP planned guidance on the scope of practice and supervision requirements for PAs in general practice will hopefully provide some further direction for PAs and practices. With several opposing stakeholders firmly entrenched in their views on how PAs should be deployed, developing and successfully implementing any guidance in this area will be a tricky undertaking.
References
1. Limb M. RCP president steps down “with immediate effect” after physician associates row. BMJ. 2024;385:q1383.
2. Physician Associates Royal College of General Practitioners; 2024 [Available from: https://www.rcgp.org.uk/representing-you/policy-areas/physician-associates.
3. Zigmond D. Physician associates: dissociated doctors. Br J Gen Pract. 2024;74(740):120-1.
4. Khan N. The complex consultation – are we seeing more complex patients and why? : BJGP Life; 2024 [Available from: https://bjgplife.com/the-complex-consultation-are-we-seeing-more-complex-patients-and-why/.
5. Curran A, Parle J. Physician associates in general practice: what is their role? Br J Gen Pract. 2018;68(672):310-1.
6. Johnson M, Jackson R, Guillaume L, Meier P, Goyder E. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health (Oxf). 2011;33(3):412-21.
7. BMA position statement on physician associates and anaesthesia associates: British Medical Association; 2023 [Available from: https://www.bma.org.uk/news-and-opinion/bma-position-statement-on-physician-associates-and-anaesthesia-associates.
8. Safe scope of practice for Medical Associate Professionals (MAPs). London: British Medical Association; 2024.
9. Who are physician associates? : Faculty of Physician Associates; 2024 [Available from: https://www.fparcp.co.uk/about-fpa/who-are-physician-associates.
10. Guidance for the supervision of Medical Associate Professions (MAPs): British Medical Association; 2024 [Available from: https://www.bma.org.uk/supervisionofmaps.
11. Jones B, Anchors Z, Voss S, Walsh N. A qualitative investigation of the Additional Roles Reimbursement Scheme in primary care. Br J Gen Pract. 2024.
Featured image by Markus Spiske on Unsplash.
