With the publication of the government's health White Paper,1 and the impending handover of commissioning to GPs, the future of family medicine, and indeed the NHS, is at a crossroads.
According to the White Paper, every GP will have to join a commissioning consortium by 2011/12; and primary care trusts (PCTs) will be abolished in 2013.1
Commissioning will take up a lot of GP time and doctors, who are already involved in patient care and management of their organisations and business, will have even less time to devote to patient care.
The leader of the British Medical Association and the General Practitioners Committee warned GPs earlier in the week of the extent of the task ahead; as the time required for commissioning will be substantial. The warning was accompanied by a gentle nudge towards hiring NHS managers instead of private sector consultants.2
Considering the diverse nature of the work currently undertaken by PCTs — all 152 of them — radical change to the way GPs currently work is essential for the new model to be successful.
Paul Charlson, a member of the Doctors for Reform steering committee and himself a GP, has warned of the need for a culture change in general practice in preparation of GP consortia.3
Dr Charlson warned that the burden will fall to a few GPs who are interested in commissioning, while other GPs will have to focus on more complex tasks.
This leaves a gap for the management of repetitive and so-called ‘low challenge’ tasks which GPs have to deal with.
Although repetitive and seemingly unchallenging, these cases still need to be dealt with for the improvement of the health of the general population. Also, this could potentially widen health inequality gaps with doctors working in areas of relatively higher deprivation whose practices are currently understaffed and could increase concerns about impending retirement of GPs from South Asia who are the ‘backbone of the medical labour force’ in inner city neighbourhoods.4
While it is still unclear what the final picture will be, it is worth considering ways to handle the gap in patient care which these proposed arrangements will almost certainly create. Physician assistants in primary care could offer a realistic solution to fill the gaps in care which will be created by the reorganisation of GP tasks.
In view of the responsibility that GPs will be taking for commissioning, the introduction of physician assistants into primary care would free up GP time to manage more complex cases, to mentor, supervise, to provide primary care leadership, to improve quality of care, and to focus on commissioning. An estimated 70–80% of tasks previously carried out only by physicians can be done by physician assistants at the same level of quality.5 Much of the burden of paperwork imposed on doctors may also be handed over to physician assistants. This fits the ethos of introducing physician assistant practice in the UK: the National Practitioner Programme, while active stated that the role was intended ‘to take over all the repetitive and protocol based work which doctors do’.6
The Physician Assistant
The shortage of doctors and expense of their training led to development of alternative health professionals to carry out routine and repetitive tasks under supervision of doctors. Physician assistants were licensed in the 1960s in the US mainly to expand capacity in primary care where doctors were often over-worked in rural and medically under-served areas.5,7,8
Graduates with a good science degree are offered training which comprises an intensive 2 year curriculum similar to a condensed traditional medical course.9
Conceptually within a ‘medical model’, the training for physician assistants aims for competency in history taking, examination, diagnosis, management, and referral. In the US physician assistants take a national certification exam to qualify, and have to be recertified by examinations every 6 years.5 Similarly, surgical care practitioners, who work as permanent members of the surgical team carrying out minor procedures and as surgeons’ assistants, were introduced in the UK in 1989.10 Physician assistants have been shown to provide patient care that is indistinguishable from the quality of care provided by physicians.8,11 As they have a smaller caseload, physician assistants are able to give more time to each individual,12,13 similar to the nurse practitioner, and high levels of patient satisfaction with physician assistants have been recorded in several studies.7,14
Physician assistants are regarded to be cost-effective as they reduce the workload of doctors at a lower cost.15 In one study in the US using physician assistants for regular visits (3–4 per week) to a nursing home (with supervision from physicians), the authors found reduced hospitalisation and medical costs compared with the routine policy of monthly physician visits.16 The physician assistant training programme attracts graduates previously under-utilised by the NHS, such as science graduates, those interested in working in health but not attracted to nurse training, and those who desire flexible working conditions.
In the US, applicants were initially predominantly men but women now comprise over 60% of working physician assistants. Physician assistants have been prepared to work in areas where GPs are difficult to recruit, and so could be directed to work in areas of deprivation as another step towards tackling health inequalities. Physician assistants could be commissioned by GPs to address inequalities in access to health care and ‘hard to reach’ groups that do not attend for chronic disease annual reviews and are not captured by the Quality and Outcomes Framework as they are reported as exceptions. The recruitment of physician assistants to more deprived areas, may inadvertently attract GPs to work there because of the reduced workload and better staff ratios, as they are able to devote more time to commissioning.
With radical reforms of the NHS, the introduction of these healthcare professionals has the potential to improve health outcomes and free up GP time to focus on commissioning.
- © British Journal of General Practice, 2010.
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