The government’s plan to increase the number of physician associates (PAs) working in hospitals and primary care can, at first sight, seem both plausible and practical.1 It has been argued that offloading some of doctors’ work to faster trained PAs could free-up doctors to better concentrate on more skilled work, resulting in a quicker service for patients. But in general practice these plans will be undone by several oversights and mistaken assumptions that risk fragmenting and alienating our already ailing GP workforce.
The current trend and plan are that patients presenting to their general practice will be increasingly triaged by a PA so that doctors can engage with patients who are deemed to have more complex or “serious” health issues. The underlying fiction here is that patients and their illnesses present in ways that are almost always straightforward. Yet experienced doctors know that serious conditions can initially present in a way that seems commonplace and trivial. And symptoms that appear to be serious can, paradoxically, be due to something transient and fairly benign.
One of the central skills of medical practice in primary care is to make rapid judgments that are largely accurate on the basis of, for example, ambiguous or incomplete information, unclear communication, and variations in presentation. For instance, abdominal pain, chest pain, backache, loss of appetite, headaches, and tiredness are common presentations in general practice, all of which may signify serious illness, and yet most do not.
GPs are well placed to navigate such vagaries and uncertainties, especially when they are able to provide personal continuity of care to patients who are known to them. By contrast, delegating these tasks to staff with less depth and breadth of medical knowledge makes the process more prone to error. To be “safe,” PAs are understandably more likely to react by having less tolerance of inevitable uncertainties. This can lead to higher rates of urgent or emergency referrals, risking overdiagnosis and overtreatment—all expensive, unsustainable, and sometimes adding iatrogenic consequences for the NHS.
Official documents promise that patient safety will be ensured by senior doctors supervising PAs overseeing patients. Yet setting up a system where doctors spend much more of their time supervising PAs in their less adroit consultations is a false efficiency. Employing healthcare workers at the “diagnostic front door” of general practice who are less able to exercise the kind of clinical editing that allows them to judge what does and does not need to be pursued will not save money, resources, or professional time—quite the opposite.
Also, it is doubtful whether many doctors would find this kind of managerial practice attractive: if anything, it is likely to add to the demoralised depopulation of the profession. For some years the idea that doctors’ skills should be saved for patients with more complex symptomatology has justified the development of various roles, such as care navigators, healthcare assistants, and PAs. But it is doubtful that many doctors will find the idea of an endless carousel of “complex” patients an appealing prospect.
“Saving” doctors’ skills
In previous decades, when general practice was at a higher ebb of recruitment, morale, satisfaction, and thus stability, GPs mostly enjoyed the range and variety of problems brought to them, particularly when this occurred in a setting that encouraged personal and social understanding through continuity of care. I remember greatly enjoying the almost random, unpredictable assortment of minor and major illnesses that I might encounter. “Transient and trivial” conditions usually could be quickly identified and patients given advice, clarification, reassurance, and, sometimes, prescriptions. Usually, this process was achieved with a growth of familiarity, understanding, and trust. These “lesser consultations” were, importantly, good investments for future, sometimes more serious, encounters. Wholesome bonds had been established.
This is why 30 years ago GPs mostly wanted to be committed partners, not locums. And the loss of this varying work profile is a large part of why many doctors do not now want to commit beyond locum or portfolio posts.
Even fewer GPs will want to do what is now planned for them: to be confined to dealing with “complex problems” (as often decided by other staff) in patients whose lives, stories, families, and neighbourhoods are unknown to them. Such doctoring becomes devitalised and stripped of any human or social context, leaving a zombie force of remote, understaffed, and unhappily dissociated doctors.
Also, it is unclear whether it will improve patients’ experience of healthcare. Several decades of NHS reforms and initiatives have largely destroyed patients’ comforting and anchoring sense of the role and identity of the person caring for them. The introduction of PAs may only add to the confusion. Already there are reports of patients not comprehending that the PA they saw is not some kind of special doctor.
PAs should not do primary diagnostic work for the reasons I have described, but they could be helpful in performing procedures prescribed by the diagnosing doctors, such as vaccinations, venesections, biometric measurement and monitoring, application of dressings, maintaining and advising on devices, lifestyle advice, and support.
But if nurses can be successfully trained to do all this, why, and at great expense, train and employ yet another cadre of health practitioners? Why not instead understand and protect more fully the humanly complex work that doctors and nurses can do, and then invest in them more realistically? This seems a much better way to create a more efficient workforce of healthcare workers who get great personal satisfaction from jobs they want to stay in.