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How physician associates can help general practice

The GP Forward View promised 1,000 physician associates to support general practice by 2020. Dr Peter Dixon explains how these health professionals are trained and the role they can undertake within practices.

The first physician associate or PA was introduced in the UK in 2003. PAs are defined by the Royal College of Physicians, Faculty of Physician Associates as ‘healthcare professionals with a generalist medical education, who work alongside doctors providing medical care as an integral part of the multidisciplinary team’.1

They are set to form an increasingly essential element of the NHS workforce in England. The GP Forward View revealed that Health Education England would invest in training 1,000 PS to support general practice by 2020. But what exactly will these PAs do?

What is a PA?

A PA is a dependent practitioner and whilst able to work autonomously with support, is always under the supervision of an experienced physician.

The idea of PAs was originally developed in the US by Dr Eugene Stead at Dukes University North Carolina in 1965 and based on his experience of fast track training doctors in the second world war. In the US, there are at present around 104,000 practising PAs.2

PAs are now a global profession and can be found in Australia, Canada, New Zealand, Netherlands, Germany, India and Israel with equivalent healthcare professionals such as the Feldsher of the Russian Federation and old Soviet bloc countries and the clinical officers of sub-Saharan Africa practising similarly though under alternative names.3

A PA’s role includes taking a history and performing an examination, ordering and interpreting of appropriate investigations, performing diagnostic procedures such as venepuncture, the formulation of a differential diagnosis and of a management plan as well as delivering treatment such as giving injections.

PAs can care for patients with acute or chronic conditions and provide health promotion and disease prevention advice for patients.

Whilst at present they cannot prescribe, courses are offering integrated training in prescribing safety in anticipation of prescribing rights and if the UK follows the US model, as seems logical. Currently PAs cannot order X-rays though they can discuss a case and make suggestions to their supervising doctor.

How are PAs trained?

Individuals undertaking PA training are usually the holder of a science-related degree. To become a PA they have to undertake a two-year postgraduate training course in Physician Associate studies to diploma or masters level. At present, there are 28 such courses offered in the UK.

Training is split between teaching in the medical sciences, pharmacology, communication skills and clinical reasoning followed by a series of GP and hospital placements.

Of vital importance is that PA training emphasises a medical pattern of problem solving rather than a nursing one, and it is this that provides the key difference from a practice nurse. Thus, for example, a PA will not just request investigations but just as a doctor would, go on to interpret and act on the results.

Health Education England has committed to providing PA students with £15,655 of annual financial support and there are different local arrangements for funding this as tuition bursaries, placements and salary costs. University fees are around £9,000.

In the UK, there is no current regulatory body for PAs, however there is a voluntary Physician Associate Managed Voluntary Register (PAMVR). Run by the Faculty of Physician Associates at the Royal College of Physicians it enables a potential employer to check the qualifications of a PA.

To gain entry to the register a PA must complete a PA programme and pass a national examination as well as recertify every six years and maintain up-to-date practice through CPD, accumulating 50 hours annually.

PAs can currently expect a salary on Band 7 Agenda for Change, which starts around £31,000, and with experience reach band 8a. Indemnity is available from all the defence organisations.

How does the role work in general practice?

In general practice the PAs role is collaborative and supportive of the GP and other members of the primary health care team. It enables the GP to see more complex patients and frees up time for other jobs such as visiting or teaching.

The PA can see both acute and chronic patients and is able to undertake numerous tasks both clinical and managerial where appropriate.4

Clinical

  • Seeing a mixture of acute and chronic patients, taking histories and examination.
  • Mental health assessment and review
  • 6-week baby check
  • Review of chronically ill at home
  • Undertaking chronic disease clinics
  • Telephone triage
  • Visiting

Investigative

  • Taking and interpreting ECGs
  • Taking and interpreting pulmonary function tests
  • Taking blood and interpreting blood results.

Practical clinical tasks after additional training and/or certification.

  • Performing minor surgery e.g. Sebaceous cyst or lipoma removal.  
  • Injecting or aspirating joints
  • Performing cervical smears
  • Performing contraceptive implant placement or removal
  • Fitting and removal of IUDs

Managerial

  • Being available for patients, staff and colleagues at the surgery
  • Reviewing and helping act on letters arriving at the practice
  • Reviewing, interpreting and acting on abnormal test results arriving at the practice.
  • Undertaking audit, research and significant event analysis.

PAs provide an additional resource

General practice is changing and is facing both a recruitment crisis and increasing workload. PAs provides an additional resource to help practices meet these challenges.

They can be trained and moved out into the workforce quickly and, whilst some of their duties might be performed by a nurse, their training in the medical role and medical way of thinking provides a potentially precious presence in our practices that should not be ignored.

  • Dr Dixon is a GP from Bury, Greater Manchester and teaches on the Physician Associate Studies course at the University of Central Lancashire’s School of Medicine.

Useful resources

For more information about PAs visit the Faculty of Physician Associates website. The Faculty is part of the Royal College of Physicians.

References

  1. Faculty of Physician Associates. Frequently Asked Questions for employers interested in physician associates
  2. US Department of Labor, 2016. Occupational employment statistics.
  3. European Observatory on Health Systems and Policy Policy brief - Health care in central Asia.
  4. Royal College of Physicians. Who are physician associates?.

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