As 2024 draws to a close, Pulse looks at the big issues in general practice this year, such as the implementation and regulation of physician associates
With physician associate (PA) regulation starting this month, its quite the task to remember how we ever got to this point at all. 2024 began with the legislation which would allow the GMC to begin the process of regulating PAs getting the rubberstamp approval in the House of Commons. The House of Lords subsequently passed it a month later, in a move labelled as ‘extremely disappointing’ by the BMA.
The trade union then set out a ‘first of its kind’ guidance on ‘scope of practice’ for PAs. To ensure safe working, it stated that PAs should never see ‘undifferentiated’ patients in a general practice setting – a GP should be the first port of call for triage of all patients, and then decide which ones PAs can see.
The RCGP, which had previously come under fire for its position on PAs, had a vote which essentially changed its stance. The college’s council voted against the GMC regulating physician associates, saying that ‘another regulatory body would be more appropriate.’
Two weeks later, the GMC launched a consultation, seeking views on how it should regulate PAs. Regarding ‘scope of practice,’ the regulator said it would exclude any proposals given that there is nothing similar for doctors. The RCGP followed suit, launching its own consultation on PAs in general practice, which eventually led to it advising practices to ‘halt’ PA recruitment, until the profession was fully regulated.
A Pulse investigation into the rise of PAs highlighted how low-funded practices are more likely to rely on physician associates and what the implementation of the role means for GP recruitment.
PA discourse quietened down during the summer months. The general election brought in a new government and health secretary. The latter had previously stressed the importance of addressing GPs’ concerns on PAs, but further discussion on the subject was sparse following his appointment.
The CQC set out how it planned to inspect PAs in general practice. The watchdog said that GP practices should be able to show ‘how they assure themselves’ of PAs’ ‘competence’ and ensure that the PA supervisor is ‘easily accessible.’ This echoed an earlier recommendation from the BMA for PAs to have named supervisors. The union later reinforced this position in updated guidance, saying that GP supervision of PAs must take place immediately after each patient and before they leave the surgery.
The Royal College of Physicians admitted that it had ‘failed’ doctors on the issue of PAs. This followed an extreme backlash from members about the handling of a debate on PAs, which led to over 80 fellows declaring no confidence in the college, and the president being forced to step down.
If the summer was scant with physician associate updates, the autumn was anything but. The RCGP voted to completely oppose the use of PAs in general practice, as well as agreeing on a new set of guidance to limit the scope of practice for physician associates already working within general practice. The GPC similarly voted to completely ‘phase out’ PAs in general practice, with GPCE chair Dr Katie Bramall-Stainer arguing that while general practice ‘desperately’ needs more staff, the bottom line is that we need more GPs – not additional roles generating ‘more work for already-stretched GPs.’
The trade union threatened NHS England with industrial action over PA safe guidance action; the RCGP also set out its own guidance which ‘severely limits’ the PA scope of practice. Speaking at the Pulse LIVE conference last month, GMC chair Dame Carrie MacEwan said that PAs will need to have individual scopes of practice as they will be working in a variety of different roles; the the regulator will refer to any ‘relevant guidance produced by royal colleges and other expert bodies’ in any fitness-to-practise processes that arise.
As the year closes out, it is still difficult to know how 2025 will play out for the role of PAs in general practice. The GMC made only ‘minor tweaks’ to PA regulation following the consultation launched in March – despite 3,000 responses. The health secretary announced an independent review into the safety of PAs, but given that regulation has already begun, it is difficult to envision how any recommendations from the review that might suggest limiting the role could be implemented.
So the year of a Physician Associate from a doctors viewpoint. Here’s what it feels like for a PA:
I have been working daily (even through doctors strikes) to help patients under intolerable pressure as any mistake I might make is amplified on social media and sent to the Daily Hate. I love my job yet feel despair about the future and have lost trust with doctor colleagues, even though I try to help them and other staff care for our patients. Why do they hate me? The GMC now regulate me after years of delay. I live in hope that I can be the person and professional I have worked five years for and carry on learning to be a better at my job. Happy new year to all our PAs – keep smiling if you can.
So I take it you are actually a GP, given that only GPs can comment?
I don’t hate PA’s I just don’t feel that you can do the same job as someone with significantly more training. I also don’t want a whole generation of young doctors to turn away from general practice because all their prospective jobs are being done by people with less training for less money. I don’t believe this is an unreasonable view to hold.
The damage and despair felt by Physician Associates, is directly caused by those GPs who have in my opinion recklessly for personal financial gain employed less costly staff replacing GPs without the necessary consideration. In some cases (not all), they have been employed inappropriately or for the purpose of personal offloading of the GPs own work without reasoned due diligence or analysis in defining the scope of this new role from its inception. They have chosen to benefit themselves at the cost of the Physician Associates role being rationally and properly appraised from the initiation of this position and thereby prevented PAs having a valuable clearly delineated role as colleagues within the NHS or otherwise in whatever role the PA scope was finally to have been formed.
Those GPs currently employing PAs, particularly those jumping on this bandwagon from the outset without proper evaluation of this role need to look at themselves first and the lead role they have played not only in destroying the roles of their GP colleagues but also the potentially irreparable detriment they have caused to Physician Associates and their profession in my opinion for clear and reprehensible personal gain.
Two points to respond. Firstly Christine nurse practitioners have been doing what you say -seeing appropriately triaged patients – for years as well, perhaps you want them to be sacked too?( They don’t take any examinations nationally to demonstrate their skills either). Secondly centrground I agree if PAs or nurse practitioners are used without triage and clinical supervision then that employer should be exposed as negligent- PAs are excellent clinicians who grow in teams that support them and believe in them. The NHS needs them, nurse practitioners and others along with the increasing number of doctors qualifying ahead to cope with our growing elderly demographic.
its just a depressing death spiral of funding and quality since i qualified in 2003. I’m going back to Canada intermittently but ideally would like to take a regular job in the UK instead of locumming but the terms just never seem favourable. I don’t like other healthcare professionals asking me advice about patients that i haven’t seen because i worry if something goes wrong ill be blamed. Its a shame