Part and parcel of the politically calculated undermining of the NHS in England is the introduction of cheaper staff. As has become the pattern of late, it is a process conducted by stealth. In this bog I look at what is happening in the primary care sector. It serves as a rider to my recent publication on accessing GPs (‘Combining experiential knowledge with scholarship in charting the decline of the National Health Service in England’ https://doi.org/10.3389/fsoc.2023.1185487).
The dilution of what is on offer in general practice is continuing apace. Currently the debate is focusing on the introduction of Physician Assistants or Associates (PAs), although as we shall see the issue is a good deal broader than this. Originating in the US in response to a shortage of qualified medical practitioners during WW2, PAs comprise ‘a type of healthcare professional’, although there remains significant variation in training and scope from country to country. PAs, in a nutshell, practice semi-autonomously under the supervision of a physician, or autonomously perform a subset of medical services provided by physicians.
The brief of the PA is to support doctors in the diagnosis and management of patients. They work in hospitals as well as with GPs. Most currently work in general practice, acute (internal) medicine and emergency medicine.
As described in the NHS literature, a PA is typically a graduate with a bioscience-related first degree who has undertaken postgraduate training and works under the supervision of a doctor. Additionally, undergraduate integrated Master of Physician Associate Studies programmes are now available, requiring A-levels or equivalent for entry. And a registered health professional such as a nurse, allied health professional or midwife can apply to become a PA. Plus there is a level 7 apprenticeship for PAs (allowing for the opportunity to earn a living while qualifying).
The training, it is claimed, equips PAs to undertake a number of everyday tasks, including: taking medical histories from patients; performing physical examinations; diagnosing illnesses; seeing patients with long-term chronic conditions; performing diagnostic and therapeutic procedures; analysing test results; developing management plans; providing health promotion and disease prevention advice for patients. A comprehensive list indeed.
The salaries of PAs are usually covered by the Agenda for Change (AFC) pay rates, consisting of nine bands. Preceptorship posts that support newly qualified PAs with the transition to the workplace typically start at £32,306 (band 6). Following a preceptorship year, PAs are normally employed on band 7, starting at £40,057 and rising to £45,839 based on skills and experience.
The ’profession’ of PA does not (yet) have statutory regulation, so PA is not a protected job title. PAs are currently advised to join the Physician Associate Managed Voluntary Register (PAMVR) on becoming qualified.
The introduction of PAs into primary and secondary care has caused deep concern within the medical profession. This is partly because of fears for patient safety arising from a dilution of medical services due to the appointment and integration of increasing numbers of lesser trained staff. There is a need here to factor in the jealously guarded autonomy of the medical profession here. For all that they have been on the back foot since the imposition of the new managerialism and the post-2010 – and continuing – political assault on the NHS, doctors’ representative bodies have always been quick to defend their professional interests. And the rapid insinuation of PAs into the NHS is seen as thin end of yet another thick wedge. But notwithstanding matters of professional self-interest, there are several areas of deep public concern.
The British Medical Association (BMS) has given voice to some of these. In September of 2023 the BMA stated that PA roles ‘unhelpfully blur the distinction between doctors and non-medically qualified professionals’. Too often patients and their families are unaware they have not been assessed by a doctor. To cite Goffman, PAs are ‘passing’ as doctors, GPs and consultants; but ‘they are not doctors’. The General Medical Council (GMC) should not, the BMA insists, be made responsible for regulating PA roles. This should be done by another body. Why in any case would the GMC sign up to the institutional dilution of the role of the doctor? Even allowing for a natural articulation of professional self-interest, it is difficult to disagree with the BMA’s judgement that the medical profession is being devalued. They add that it is wrong that ‘a newly qualified doctor entering postgraduate training is paid over £11,000 less per year than a newly qualified PA, while the doctor’s role, remit and professional responsibility is far greater.’
The NHS Long Term Workforce Plan makes it clear that roles like that of the PA are to expand significantly. Patient confusion is manifest. I will retain the focus here on general practice. Surgeries are being transformed. For example, in the surgery with which I am currently registered, a poster in the (deserted) patient waiting room lists the following staff: four GP partners; eight members of the ‘GP team’; an unspecified number of GP trainees; two PAs; one paramedic practitioner; one social prescriber; two first contact physios; two clinical pharmacists; six practice nurses; one operations manager; one finance manager; one assistant operations manager; one reception manager; and one operations coordinator. Well, if diversity is the aim … Unfortunately, this plethora of therapists and administrators doesn’t mean you can actually see your GP. At my last appointment with a nurse I asked her to check up on an ear infection. She asked me if I’d like the duty doctor to have a look. I said that would be good. She couldn’t find a duty doctor (although I’d just recognised two GP partners walking through the waiting room). I asked to make a face-to-face appointment with ‘my’ GP (the one I’m registered with, whom I’d a few moments earlier witnessed walking through the waiting room, and who told me the last time I saw him that he would always see me if and when required). The first available appointment to see him was in a month’s time.
I diverge. What is the problem here? I have explored in my article the nature of and reasons for the rapid undermining of the NHS in general and of primary care in particular (see link above). Doctors are not driving this thoroughly destructive tsunami of change as much as trying to survive it. It is a politically calculated assault, fully engaging Starmer and Streeting as well as the Tories. But specifically referring to the expanding role of the PA, what more needs to be added?
The ‘how’ is of interest as well as the ‘why’. As far as the ‘why’ goes, it is unambiguously clear that both major political parties are set on a regressive replacing of the NHS with a more market-oriented health care system. Underfunding the NHS is part and parcel of this truly frightening project. As to the ‘how’, we now find ourselves in a situation where trainees and newly qualified GPs are finding it increasingly difficult to find jobs, notwithstanding the undoubted fact that seeing a GP has become absurdly challenging (not just for me, but throughout England). A recent poll by the Royal College of General Practitioners (RCGP) found that 61% of GPs had experienced difficulty finding a vacancy. The fact is that NHS England has cut funding (per patient) by 20% in real terms via the GP contract. Funding is being directed elsewhere in general practice, including other roles such as PAs and clinical pharmacists. This is being done through the ‘additional roles reimbursement scheme’ (ARRS), which allows surgeries to claim funding for the salaries of some clinical staff. Cash-strapped GP practices are being pushed to take on more roles like that of the PA when it is more GPs that are required. The Chair of the RCGP wrote: ‘it is staggering to see our members say they are struggling to find jobs when general practice is over-worked, overwhelmed and in desperate need of more GPs. Patients are crying out for appointments because we don’t have enough GPs to care for them, so it’s a scandal that newly qualified GPs are unable to find work.’ A fully qualified GP now look after 2,294 patients on average, 198 more than five years ago.
All this is to contextualise what is happening in primary care and throughout the NHS. It is to paint a broader canvass than we are commonly treated to. But I must still close this short and overly condensed blog with a familiar mantra of mine. I say to GPs. Square with your patients! Don’t pretend to yourselves or to us that the limited and often frankly inadequate service you are offering is ‘good treatment and care’. The best you can genuinely offer in increasingly troubled times may not equate with good quality treatment and care, and in fact it rarely does. Put posters up in your surgeries accepting the truncated service on offer and explaining that you are doing the best you can in circumstances that are beyond your control.
I can’t resist appending a recollection of my own experience of GP care throughout my childhood and well into adulthood. I could see my GP any day by turning up to the surgery and queuing, and/or (he) would if indicated come on a home visit that same day. And despite all the population, scientific and medical changes that have occurred over the last half century, which I don’t in any way minimise, there are no excuses for the calculated and wanton political destruction of our once-exemplary NHS.