Physician associates (PAs), previously known as physician assistants, were first employed in the UK in 2003; the role is based on the US role of the same name, which has been established for over 40 years. PAs have now been introduced to many healthcare systems worldwide, including Australia, the Netherlands, Germany, India, and Canada.
PAs are mid-level dependent medical professionals who are trained as generalists in the medical model to perform tasks such as obtaining patient medical histories, performing clinical procedures and clinical examinations, diagnosing diseases, and formulating medical management plans.
The training courses available within the UK vary in terms of preferred learning approaches: some utilise problem-based learning and others adopt a traditional lecture-based method. However, they are all directed by the outcomes described in the Competence and Curriculum Framework and the list of key conditions that are outlined in the Matrix Specification of Core Clinical Conditions for the Physician Assistant, both of which were initially developed by the Department of Health (DH) in 2006 and revised in 2012.1,2 The Royal College of General Practitioners (RCGP) and the Royal College of Physicians (RCP) jointly led the development of these documents, with input from representatives from universities, employers, patients, junior doctors, and PAs. Following an intensive 24-month postgraduate diploma, all prospective PAs have to undertake a national examination that broadly assesses clinical knowledge and skills. Due to this generalist training PAs are able to offer a flexible skillset that can be utilised in various clinical specialties and can change, as required, over time. To ensure that PAs who move between clinical disciplines maintain up-to-date clinical acumen, all PAs are required to undertake a recertification examination, basically taking their ‘finals’ again, every 6 years. To stay on the managed voluntary register, which is maintained by the Faculty of Physician Associates (FPA) at the RCP, PAs are also required to achieve 50 hours of continuous professional development (CPD) per year.
There are currently 29 universities offering training courses and it is estimated that there are over 1200 PAs in training.3 Unfortunately, an exact number of PAs working within the UK is unobtainable as registration is voluntary; however, it is believed that there are approximately 550 PAs currently working within primary and secondary care. It is thought that there are 58 PAs working within general practice (48 full-time equivalent):4 some PAs hold additional responsibilities such as management or academic roles and work within general practice part-time.
WHAT IS THE ROLE OF THE PA WITHIN GENERAL PRACTICE?
On qualification, a PA is able to see patients in their own appointment slots, formulate a differential diagnosis, and develop a patient-centred management plan. The responsibilities held by a PA working within general practice vary depending on their experience, and their scope of practice will develop over time at the discretion of their named supervising GP, with many experienced PAs working at a semi-autonomous level. This means that supervision may be remote, such as when PAs are providing home visits or care home reviews. Although PAs are currently unable to prescribe, they are trained in clinical therapeutics and are therefore able to prepare prescriptions for their supervising GP to sign, having devised an appropriate management plan. Other responsibilities of PAs include reviewing diagnostic test results such as blood tests and imaging reports, reviewing correspondence from secondary care, and referring patients on an urgent or non-urgent basis to the emergency department, assessment unit, or secondary care specialties. PAs have also been utilised in helping practices reach Quality and Outcomes Framework targets, and in educating patients in specialist review clinics. More experienced PAs are also trained in minor surgery, joint injections, cryotherapy, and cervical smear collection. These are additional skills gained after initial qualification and training, which are often acquired due to the needs of the practice as well as individual PA specialist interests.
Despite the generalist training of PAs, most PAs exiting training schemes go on to work in secondary care, with only a small number taking up general practice posts. There is only anecdotal evidence as to why this is the case. A factor that needs to be considered is the criticism of PAs within the medical profession, often from practices, or from clinicians, who have never worked with a PA.
Although there is limited research on the use of PAs in general practice, Drennan and colleagues in 2015 reported positive responses regarding PA safety and effectiveness when aspects of their consultations were compared with those of GPs.5 However, it should be noted that many GPs reported that they utilised PAs to see the less complex patients, allowing GPs to focus on the more complex clinical presentations. In their most recent study,6 Drennan and colleagues discussed the common concerns that have been raised on a macro- and micro-level regarding the use of PAs in general practice. They highlighted that a significant issue for those making resource decisions was in regards to the lack of ‘jurisdictional authority’, most notably the inability to prescribe and order X-rays. This lack of authority is described as having an impact on cost-effectiveness despite an appropriate knowledge base.
GPs remain the experts in generalist medicine and their skillset of managing multiple conditions and atypical presentations cannot be substituted by other health professionals. Nonetheless, general practice is at crisis point, with many GP posts unfilled and experienced nurses leaving the NHS. PAs can be part of the solution to ease current primary care pressures if they are permitted to utilise their skillset.
WHAT ARE THE CURRENT DEVELOPMENTS?
Support for the PA profession gained momentum in 2014 with the DH stating that PAs were one of several workforce solutions for the shortages in general practice. Jeremy Hunt, Secretary of State for Health, stated that 1000 PAs were to be trained and made available to work within general practice by 2020; this was included in the General Practice Forward View.7
In October 2017, the RCGP published a position paper on PAs working in general practice.8 The RCGP describes the PA role as ‘complementary’ rather than a substitution for that of GPs. The role can directly help extend the capacity of the GP in response to evolving healthcare needs in an ever-expanding and ageing population. The RCGP has highlighted the steps required to utilise the PA role fully and to integrate PAs into general practice, echoing many of the issues raised by Drennan and colleagues. The most prominent theme is the urgent need for professional regulation and, following this, the consideration of how PAs can attain the right to prescribe. It has also been highlighted that further research regarding their role within general practice is required, specifically on cost and impact. Some of the concerns raised in the RCGP position paper8 are based on anecdotal feedback from GPs who are working alongside PAs. Although on the whole positive, the feedback echoed the recurring theme of lack of professional regulation as a cause for concern.
WHAT ARE THE NEXT STEPS?
The DH initiated a public consultation on the professional regulation of PAs and some other currently unregulated groups, which closed on 22 December 2017. The reasons for this public consultation are cited as ‘rising demands for medical treatment and advances in clinical care’ creating a need for a ‘co-ordinated approach and greater skill mix within NHS healthcare teams’.3 The consultation has been strongly backed by many royal colleges, Health Education England, the General Medical Council, and the Health and Care Professions Council. If approval for regulation follows, then PAs could be statutorily regulated within 2 years or so; this would remove the ‘glass ceiling’ preventing their wider and more cost-effective use.
PAs are certainly not the answer to the mismatch between workload and demand, but we believe that they are at least a part of the answer.
Notes
Provenance
Commissioned; not externally peer reviewed.
Competing interests
Alexandra Curran is a lecturer on the University of Birmingham PA course and a UK-trained physician associate. Jim Parle is the Chair of the UK and Ireland Board for PA Education and Director of the PA course at the University of Birmingham.
- © British Journal of General Practice 2018
