How effective are PAs and do they reduce GP workload?

In the third part of our series on physician associates in general practice, Eliza Parr asks whether the increase in numbers is worth the money, and whether they are easing pressures on GPs

For those cynics among you, it may seem unlikely that the Government will listen to doctors’ concerns about the clinical safety of the physician associate role, or how its expansion might be contributing to GP unemployment. Indeed, former Conservative health minister Lord Bethell likened doctors trying to slow the rollout of PAs to ‘Luddites’ who seek to prevent progress.

But if there was a strong argument on the cost effectiveness of PAs, and whether they do in fact relieve pressures on the NHS, the Government might be forced to take note.

At the moment, it seems ministers and NHS England are convinced – at least publicly – that PAs are helping. The Government has previously said that growth of the PA role will ‘reduce pressure on frontline services and improve access for patients’, and that these professionals ‘free up time for other clinicians’. It repeatedly points to one 2019 study which found that PAs can improve continuity for patients and release doctors’ time for more complex patients. (This study was focused only on hospital settings, and many of its findings were based on just six case studies.)

Specifically on the additional roles reimbursement scheme (ARRS), NHS England has said PAs and the 17 other ‘new’ primary care roles ‘improve access to general practice’ and ‘solve the workforce shortage in general practice’. And since the scheme’s introduction in 2019, the Government has achieved its goal of recruiting over 26,000 additional roles into primary care (while dropping its target for 6,000 more GPs).

But many doctors, including 55% of those answering a BMA survey earlier this year, have found that PAs are in fact increasing their workloads. And recent research suggested that the ARRS has failed to substantially reduce workload pressures for existing GP practice staff.

So, how effective are physician associates in general practice?

How GPs use PAs

NHS Digital does not hold specific figures for PA consultations, but ‘other direct patient care’ consultations – which incorporate PAs, alongside pharmacists, physiotherapists, paramedics and mental health professionals among others – now provide 25% of all consultations, up from 18% in September 2021.

It could be argued that the increased proportion of consultations delivered by non-GPs has helped the Government massage the figures. Doctors’ Association UK (DAUK) GP spokesperson Dr Steve Taylor says this has given the Government the ‘very misleading’ chance to applaud its achievement of 50 million more ‘GP appointments’ a year. ‘If I’m a patient, I assume that means with a GP,’ he says.

Regardless, these extra appointments do exist and PAs – while only making up around 5% of all non-GP, non-nurse staff working across PCNs – are the profession whose work most closely mirrors GPs (which, as our piece on their clinical responsibilities showed, is controversial in itself).  Some of this would involve seeing undifferentiated patients, but there are other – less controversial – tasks they are taking on.

Professor Azeem Majeed, professor of primary care and public health at Imperial College London, says: ‘They could do routine QOF follow-ups, follow-ups with people with long-term conditions, follow-up post-discharge from hospital, to make sure patients are compliant with the medication and discharge plan. They can work on things like screening and public health interventions like vaccination.’

One GP partner in the North West says a lot of chronic disease management can be ‘delegated’ to PAs because it is ‘nice and easy, and protocolised. It’s all quite simple to do. So it does take that burden off you.’ However, he adds, ‘an advanced clinical practitioner (ACP) or practice nurse could do this just as well’.

PAs may bring other benefits to practices. Dr Kevin Anderson, GP partner and director of workforce at the Haxby Group, suggests PAs increase patient satisfaction in part due to their longer appointments.  ‘They have more time than the GP to speak to the patient. Speaking to the patient can be part of the treatment as well as the assessment – so PAs have a role in that.’

However, even these benefits – taking on some GP consultations – could have negative effects. Dr Dean Eggitt, a GP partner and Doncaster LMC CEO, warns that increased use of PAs in the name of ‘freeing up’ GP time to concentrate on complex cases could in fact lead to faster burnout. ‘If you’re going to push me to 100% efficiency, where I’m seeing only the most complex patients and supervising other people, without any sick notes or simple tasks, I am working at the top of my game all day, everyday – you will burn me out. It’s unsustainable, in the long term.’

Supervision

The potential increase in the complexity of cases is not the only drawback of PAs taking on more GP consultations. Arguably the much bigger downside is the supervision required – which may even render redundant the intended reduction in GP workload.

NHS England has been clear that GP practices must ensure that the ‘overall responsibility for supervision of PAs is by a named senior doctor’. It has also said that all work undertaken by PAs ‘must be supervised and debriefed with their supervising GP’.

However, there are no detailed requirements for the exact level of supervision GPs must provide. The Faculty of Physician Associates (FPA), which is part of the Royal College of Physicians, previously published a GP supervisor guide, but has taken this down from its website to ‘reflect feedback’. An old version of the guidance stated that newly qualified PAs ‘may need more supervision and support’ but that this ‘should lessen’ as they grow in ‘confidence, knowledge and skills’. It also said that, since PAs ‘practise medicine’, they are required to have a clinical supervisor, and this is ‘usually a GP because PAs assess and treat patients in the same way’.

An example of PA’s job plan provided by this now-removed guide suggested that PAs could complete 96 appointments a week with half-hour reflection periods after each session and a one-hour weekly tutorial with a GP.

This level of supervision is of course time-consuming for GPs, alongside their own clinical commitments and supervision of GP trainees and foundation doctors.

Dr Eggitt, who employs a PA at his practice, believes this ‘heavy’ supervision is ‘the biggest downside’ of the role. He says he does not ‘redo’ what his PA has done, and trusts how she has sought information and performed examinations. But he has ‘oversight of every single patient’ she has seen. ‘Every patient, every clinic, every day. So it’s almost like an MDT on every single patient.’ This takes him around 30 to 45 minutes throughout the day – but he highlights that he is a ‘fast worker’. ‘I wouldn’t expect that of my GP colleagues, they would probably take significantly longer’.

A GP partner in the North West who uses a PA says he and his GP colleagues dedicate around half an hour after each session to debrief. ‘One of the doctors is on call so we go over everything that way. We do that, and we also have monthly meetings, and we have random case analysis. So there’s all sorts of stuff that goes on,’ he adds.

‘There comes a point where you’re supervising so much and overseeing it so much that it becomes not worthwhile to do so. And if the PA isn’t up to it, that can be the case.’

And unlike GP trainees who will qualify and work autonomously, PA supervision is indefinite. Hampshire GP partner and Wessex LMC member Dr Shamit Shah says this is necessary, because PAs are not on the same level as GP trainees. ‘Yes, the level of supervision may reduce in time, but it’s never going to go away.’

With PAs, GP trainees, foundation doctors, medical students and many new ARRS roles, GP supervisors have a lot on their plates. ‘If I have to spread myself thinner and thinner with different types of trainees, I have less time to dedicate to somebody and they have less time to learn from me – it’s quite simple,’ Dr Eggitt says.

GPs may also run out of rooms, which could lead to practices reducing their GP training opportunities if they have already taken on ARRS roles. Dr Shah, who calls for more estates funding, says most practices are in a situation where ‘they could possibly have the capacity for trainees, but they don’t have the room for it’.

But Dr Selvaseelan Selvarajah, GP partner and Tower Hamlets LMC member, said it ‘shouldn’t be an either or’ situation. ‘It should be “yes you can take PAs if you want to, but we should also prioritise GP training first” – given we’ve lost 2,200 GPs from the workforce since 2015.’

Beyond the increased supervision burden, there is also a question around whether all GPs are sufficiently confident and qualified to take on a supervisory role. DAUK’s Dr Taylor worries that PAs in some practices will have to be supervised by GPs who have ‘never actually been taught to supervise themselves’.

Financial impact

The upfront cost of hiring a PA is undeniably cheaper than hiring a GP. The average starting salary for a PA on a 37-42 hour week is around £44,000, rising to £50,000 for experienced professionals, according to the National Careers Service. For salaried GPs, NHS England figures show that the average income in 2021/22 was £68,000 for a full-time role. And with the majority of PAs employed by PCNs, where it’s likely most come under ARRS, many practices using them won’t be out of pocket.

But Dr Anderson warns that PAs should not be taken on for financial reasons, because there aren’t clear cost benefits. ‘You don’t ultimately save money in the first year or so of having a PA or anyone like that, because you’re going to have to invest your doctor time in supervising and training them, supporting them.’

Dr Anderson says a time and motion study he carried out around 10 years ago found that it would be more expensive to have an advanced clinical (ACP) for a year than it would be to employ a GP because of the time needed for tutorials, supervision and debriefs.

Another more recent study, published earlier this year, looked at the economic consequences of expanding the hospital-based anaesthesia associate (AA) role, which is coming under GMC regulation alongside PAs at the end of this year. The study concluded that for the AA operating model to be economically viable, AAs should be paid less than 50% of the supervisor’s salary – which is not currently the case, with AA salaries ‘greatly exceeding’ 50% of a specialty and associate specialist (SAS) doctor. They suggested that in order to make economic sense, the NHS should pay AAs less, give them more autonomy to boost their productivity, or ‘terminate’ the role altogether.

Dr Shah points out that having the funding for a PA under the ARRS means that there are 10 patients each session that get seen that ‘no one would have seen otherwise’. But, if given the freedom to choose how to spend the funding, he would ultimately choose another doctor instead. ‘I have to put time and effort to supervise the PA to do part of my work. Whereas I could get someone who would do the full job, and get through more patients.’

The expansion of PAs may also be causing waste in other parts of the system. A US study from 2022 found that increased reliance on physician assistants ‘is expected to increase the prevalence of medical diagnostic error and defensive medicine’. So, the ‘cost/access advantage’ of shifting towards PAs is likely to be diminished by the ‘aggregate defensive diagnostic practices’ of those same PAs.

In Nottingham, consultants have said that the ‘quality of their referrals’ is now different because they are more often coming from ‘non-doctors’, according to GP partner Dr Irfan Malik. He says this is just anecdotal evidence, but his hospital colleagues ‘have noticed a change in quality’. ‘It’s a whole load of professionals referring to them, and it’s often something that the GP may have managed in-house before but may be triggering referrals now,’ he adds.

Indeed, Dr Asif Qasim, an interventional cardiologist in London, recently said the number of advice and guidance (A&G) requests his department received has ‘more than doubled’. In a post on X in March, he said: ‘More than 50 every day due entirely to non-doctor requests – PAs, nurses, pharmacists with no discussion with the GP. Frequently incomplete and often unnecessary. Expensive and high risk.’

Medico-legal risk

Supervising PAs isn’t just time-consuming – it can also be legally risky. PAs are covered by the same state-backed indemnity scheme as all general practice colleagues. But GPs, who must assure themselves of a PA’s competency, may be held accountable if their supervision falls short.

A 2017 GMC case, recently spotlighted by Pulse, saw a secondary care doctor suspended due to ‘inadequate supervision’ of a PA, as well as his below-standard care of two other patients. The tribunal found that although the PA had taken a history from the patient, a collateral history should have been taken by the doctor – and by not doing so, he had failed in his duty.

In response to Pulse’s coverage of this case, the GMC recently emphasised that ‘doctors are not accountable for the decisions and actions of PAs and AAs, provided they have delegated responsibility to them in line with’ the GMC guidance. The regulator argued that the case ‘has been misrepresented as setting a precedent or policy position’, clarifying that one tribunal decision ‘sets no legally binding precedent on future tribunals’.

But it seems GPs continue to be concerned about what level of supervision they should provide in order to ensure safe practice. In Doncaster, an out-of-hours provider recently brought in a policy requiring GPs to review every assessment made by a PA before the patient is discharged. This was in part a response to GP concerns about their medico-legal risk as supervisors.

A GP in Merseyside says: ‘If you’re going to be held responsible for what they do, then essentially you have to check everything they do – by which point you may as well have done it yourself.’

Given the high level of supervision they require, and their inability to perform all the functions of a GP, the cost effectiveness of PAs is uncertain at best. Professor Majeed argues they cannot be cost effective ‘unless they deal with all the problems that GPs would do, which means working independently without much in the way of supervision’.

 But this kind of operating model, given the serious concerns about patient safety, is unlikely.