PAs aren’t the enemy – this is a systemic issue

Editor Jaimie Kaffash argues that the toxicity of the debate around physician associates is detracting from the structural problems

I’ve always believed that ‘punching down’ is reprehensible. And the whole debate around physician associates does make me feel uncomfortable.

I say this having run a seven-part analysis and investigation into the role of physician associates in general practice – the vast majority of which is critical of the move to increase their number.

I stand by all our conclusions: that PAs are being used as cheaper alternatives to GPs; that their lesser training poses clinical risks, both in terms of missing red flags and practising more defensive medicine; and that they aren’t actually particularly efficient in reducing GP workloads or providing patient care.

But I also agree with shadow health secretary Wes Streeting – this debate has become toxic. This is, as he says, due to a ‘failure of leadership and not listening to doctors and allowing this toxic culture to erupt’.

This toxic culture has led to a focus on individuals – on vocal PAs and vocal doctors. Yet this is not about individuals, it is about systemic issues around safe practice and the systemic underfunding of the NHS. And although I am writing this about PAs, these arguments can apply to any member of a multidisciplinary team.

On safe practice, the truth is, I don’t feel qualified (ironically) to say what, if any, specific tasks PAs can undertake in an MDT. But what I do know is that the PA role – like any other clinical role – should be defined by what tasks its least competent, fully-qualified practitioner can do. And when looked at in these terms, the role is very limited.

A number of the GPs we spoke to had the attitude that the role is problematic, but their own PA was very good. But with the lack of regulation, and any worthwhile scope of practice, GP practices are deciding themselves what roles their PAs can take on.

I am not normally in the habit of saying GP practices should have restrictions on the way they operate. But in this case, I really think it will benefit everyone – including practices, PAs and patients – to have strict regulations in place on their scope of practice. 

Then we get to the systemic underfunding of the NHS. Because the reason that practices are utilising PAs beyond their competence is because they have little option. Many can’t afford GPs. Our exclusive analysis revealed that the lowest paid practices rely most heavily on PAs. In other words, PAs are taking on tasks because there is no one else to do them.

One solution, as I have argued before, is to include GPs in the additional roles reimbursement scheme. (We could even go back to the days when all practice staff are paid for centrally – but that is an argument for another day).

But whatever payment mechanism is in place, it doesn’t make up for more funding – which practices desperately need.

It is almost certain that Mr Streeting will be the next health secretary, and I hope he follows through on the comments he made at the MJA event earlier this week.

He said that PAs do have a role to play in an MDT, and I will have to take his word for it, and that he will increase general practice funding. We will remove the toxicity from this whole debate if he is able to follow through with both these promises. The ball is (likely) in his court.

Jaimie Kaffash is editor of Pulse. Follow him on X (formerly Twitter) @jkaffash or email him at editor@pulsetoday.co.uk