Physician Associate Article

Written by Dr Krishan Patel, LLR Training Hub Clinical Fellow

In a world where the landscape of healthcare is ever changing and fraught with new challenges, a workforce which is adaptable is an invaluable resource. In Primary Care especially, the value of the allied health professions cannot be underestimated. Nurses, Pharmacists, Physiotherapists, Paramedics, Healthcare Assistants, Mental Health Facilitators and Social Prescribers amongst others are extending the breadth of care available in General Practice. Oftentimes, they are able to add a layer of experience and perspective beyond the traditional GP. We need to continue to recognise the exponential value that interprofessional working in primary care creates. 

The role of Physician Associate (PA) has long been an important component of the American healthcare system. Yet, here in the UK, we are still at the early stages of integrating this profession into our NHS. We have not yet realised the benefits of this dynamic new workforce on our doorstep. PAs are healthcare professionals who have a generalist medical training. They are autonomous in that they are responsible for their own actions and decisions, but work alongside a supervising clinician, such as a GP or Hospital Consultant. 

“Physician Associates are a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision” – Health Education England.

Much in the way we have seen the rise of allied health professions such as Healthcare Assistants, Advanced Nurse Practitioners and Advanced Paramedic Practitioners over the years, we can look to Physician Associates as the next blossoming healthcare profession in the UK. PAs have the potential to bolster our workforce and aid in our endeavours to manage the demands and health needs of our population. 

Despite training as generalists in Medicine, PAs are predominantly based in secondary care at present. According to the most recent census by the Faculty of Physician Associates in 2019, only 25.3% of PAs were based in General Practice. Furthermore, here in the East Midlands we have a relatively small number of PAs compared to other areas in the country.

The role of PAs in Primary Care is not well defined, and for good reason. The deliberately non-prescriptive role allows local providers to adapt the use case for Physician Associates to the needs of the healthcare system in a particular region. The level of clinical responsibility and complexity taken on by a PA generally advances with their career experience. 

Physician Associates will often work at the level of a trainee doctor. However, unlike a trainee who will rotate placements regularly, PAs can provide valuable continuity of care and develop experience in a role that temporarily rotating doctors in training may lack.

“Supervision of a qualified PA is similar to that of a doctor in training or trust grade doctor, in that the PA is responsible for their actions and decisions. Physician associates are defined as dependent practitioners. Whilst they are supervised they are able to work independently and make autonomous decisions” - Royal College of Physicians.

The role of PA in General Practice can take on many different forms to suit the needs of a surgery or Primary Care Network (PCN). To explore some of the potentials of a PA in General practice, below are the profiles of two PAs working in a Leicester based GP practice followed by an abridged interview on their views about working in Primary Care. 

Chibangu – Primary Care Physician Associate, Glenfield Surgery

Chibangu works as a full time PA in General Practice. She initially came to the surgery as a student PA and was offered a permanent post after graduation. The majority of her work involves triaging and management of acute cases presenting to the surgery. She also takes on the responsibility of learning disability reviews and regularly co-ordinates with the practice’s registered learning disability care homes. 

Why did you choose to pick General Practice?

You get the variety of everything in GP. In GP you get the opportunity to build relationships with your patients because you see them multiple times; they come back to you. Whereas in secondary care it is a bit of a revolving door. I like having that constant relationship with patients. That would be my main reason for picking general practice.

What are the benefits to a practice from having a workforce of PAs?

I think GPs were taking a lot of responsibility that actually doesn’t necessarily need to be conducted by a GP. Having a PA frees that GP to do more specialist or complex things which is a win-win for everyone really; both patients and clinicians.

How can patients benefit from a workforce of PAs?

Patients appreciate having a physician associate. GP appointments these days are more of a commodity. By having a PA you can differentiate between what is more complex and what is less complex, what needs managing sooner and what can wait.

What are your views on the different ways PAs can be applied across Primary Care?

The good thing about a PA is there is no limitation in the sense that you can be trained to do a lot of different things. If a practice had an area that they thought could be improved, they could get a PA trained to have them take over that role.

What would be your advice to a practice that might be considering having a PA as part of their team?

I think definitely be open to one. As a PA, we definitely value support from our colleagues and seniors. As much as we work independently, just knowing that you’ve got someone that you can go to and query any concerns is really important. For me, that would be my top tip.

Sara - Primary Care Physician Associate, Glenfield Surgery

Sara works as a full time PA in General Practice. She initially worked in secondary care for a number of years before choosing to move to a post in General Practice. She primarily manages acute cases presenting to the surgery via telephone, covering a wide variety of presentations and selectively inviting patients for physical examinations. 

Why did you choose to pick General Practice?

I like the history taking, examination and formulating a diagnosis. That’s something I never got in hospital because they’ve already been clerked. If there was a new issue, that was the aspect that excited me in hospital. I had GP friends that did minor surgery and that really interested me. I thought maybe I could have a specialist interest in that in the future. You just don’t know where opportunities might arise until they come.

What are the benefits to a practice from having a workforce of PAs?

I think they can take a lot of what comes through the door. We can be moulded and trained to doing varying types of clinics. I think we’re quite versatile like that. Ultimately, a PA can do whatever their senior trains them up to do. So if you have good senior support and training opportunities, they could be a real asset to any GP setting.

How can patients benefit from a workforce of PAs?

More appointments ultimately. Being able to see a clinician in a quicker time.

What are some of the barriers that Primary Care need to overcome to attract more PAs?

I think when you graduate it’s overwhelming knowledge-wise with what you’ve learnt. I think sliding from being a student to hospital setting in my mind was easier because of the support and learning opportunities. Learning never stops. There are already training programmes for the GP trainees in hospital, the F1/F2 teaching and even registrar teaching. There isn’t anything formal for PAs, but we kind of just tagged along. Wherever you have an interest our seniors were supportive they were like “Yeah, go train! Go to see that webinar or go to that conference.” I have colleagues that are doing endoscopies and cystoscopies. It depends on what speciality you’re in and whether your registrar or consultant is willing to train you, then that’s great. I don’t think GP has that at the moment. I don’t think there’s any specific training opportunities for PAs and I that would be something which would be good perhaps.

What would be your advice to a practice that might be considering having a PA as part of their team?

Start getting students to do placements. I think what Chibs had is the ideal transition because you can teach them how to work and see how good they are and what they need. By the time they graduate to potentially get a job it is a lot smoother. It may be useful to invite one of the PAs from the local area and having an informal chat. I think most of us are quite willing and friendly.

PAs undergo a post-graduate 2 year training programme after a biomedical or life sciences undergraduate degree typically. They are required to complete 50 hours of CPD per year post-qualification and sit a recertification exam every 6 years. Currently there is a voluntary register of PAs but in the future there will be a requirement to register with the GMC. 

The scope of a PA’s practice is determined by the scope of practice of the supervising physician. They will act within their own limitations and to set guidelines. They can see patients of all age groups and can order investigations (excluding ionising radiation), interpret results and formulate management plans. PAs can be involved in practical procedures, home visits, teaching and service design/audits with training and supervision. Whilst a newly qualified PA would require more supervision, with more time and experience in a role, a PA will become more independent and autonomous. 

For those organisations looking to consider recruiting a PA to their workforce, as well as the resources below, speaking to a PA in post would give an insight into their daily duties. Health Education England recognise the need to attract more PAs into Primary Care and offer £5000 to surgeries taking on a new PA as part of a preceptorship that can be applied for via the LLR Training Hub. 

In the years to come, we will need to continue to diversify our workforce. We are beginning to appreciate that not all medical problems require a doctor’s appointment and in fact this can be an inefficient use of resources. While we have a role in educating our patient population about the different healthcare professionals they may encounter at the “front line”, we must plough ahead with creating capacity and adaptability in our workforce. Ready and waiting to be moulded to our patients’ needs are the growing profession of Physician Associates.

The LLR Training Hub would like to thank Chibangu, Sara and the Glenfield Surgery Practice Team for their support and sharing their experiences.