How low-funded practices are more likely to rely on physician associates

 In the fourth part of our series on the rise of physician associates, Madeline Sherratt and Jaimie Kaffash dig deep into the data to look at the characteristics of GP practices and PCNs that are more likely to employ PAs. And the results are illuminating…

We have already reviewed the effect of physician associates on GP recruitment, the clinical responsibilities of PAs and how effective they are. Today, we are taking a look at what kind of GP organisations are more likely to take them on.

We have dug deep into the data to take a look at practice income, deprivation levels, geography, rurality and contract type. There are roughly 1,950 PAs in general practice in England – what kind of practices are most likely to employ them?

The first thing to say is they some physician associates are employed directly by practices, and others – the majority – are employed by primary care networks (PCNs), usually through the additional roles reimbursement scheme.

For the purposes of this data piece, we have combined the two sets, using the assumption that PAs will be split proportionally between PCN member practices. This is not usually the case in practice, but it is the most accurate way of analysing the data.

We have also looked at two measures – the proportion of a practice/PCN’s medical workforce that are physician associates, and how many patients there are per medical staff member. Looking at both these measures allows us to differentiate between:

• practices/PCNs/areas that appoint many PAs as extra staff, but they are supplementary to the wider healthcare team (ie, where the patients per staff members are low);
• and those who are reliant on PAs provide more care (ie, where there are lots of patients per staff member).

To put it simply, the higher the bar and the point on the line graph, the worse it is for patient care.

Practice income

The most striking point about our analysis is how clear the link is between practice income and the likelihood of the practice and wider PCN relying more on physician associates.

We placed each practice in a decile for payments per registered patient based on NHS Digital data. Those who received the least income were in decile 1, while those who received the most were in decile 10.

The proportion of staff who were PAs in the least funded practices were more than double those in the highest funded. Not only that, but they had far more patients per staff member too.

Dr Steve Taylor, the GP representative for the Doctors Association UK, says: ‘If you have less money to go around, then some practices with simply be pragmatic about how much money they have to spend – especially when PAs are cheaper than a salaried doctor.”

Dr Farzana Hussein, GP and former clinical director for Newham Central 1 PCN, says she made the decision to the contract back for her poorly-funded practice because she refused to take the alternative option of hiring PAs. She says:  ‘I ran a 5,000-patient practice Newham (a deprived area in East London) for 22 years. I left in January this year because I wanted to run a model which was still primarily salaried GPs – which I thought was safer – but I could not make the numbers work.

‘I chose personally not to have a practice-employed PA and one of the reasons for that was because I did not feel I would have enough money left over for the GP to supervise. Despite this, I feel the demonisation of PAs is wrong, and I don’t enter into that argument because doctors and PAs are brilliant in their own right.

‘The issue is that we are trying to pay for doctors and put PAs in to replace them – we’re trying to put cats into a kennel – and that is just the wrong system.’

Deprivation

There is also a link between the deprivation levels of a patient population and the use of PAs – but this wasn’t as strong as the practice income, with PAs making up roughly 3.5% of the medical staff in the more deprived areas, going down to just over 2% is the more affluent areas. There were slightly more patients per staff in the more deprived areas, but maybe not as many as might be expected.

It was noticeable that the more affluent areas were more likely to have a higher percentage of GPs than the more deprived areas. But, again, this is not much of a surprise.

Rurality

Our analysis also found that PAs are far more likely to make up a higher percentage of the medical workforce in GP practices in urban areas. 

Dr Taylor says it is more likely PAs currently live in more urban areas as ‘we currently at a point in the cycle of PAs where they tend to be younger, therefore, with housing and everything else – they’re not going to be able to afford a house in the countryside.’

Traditionally, it is generally harder to recruit in rural areas, he says, but also staff turnover is more frequent in urban areas. ‘Some of it will be pay, some of it will be based on age demographics, and it may be that rural practices are more stable in terms of staff turnover because staff are more likely to remain there for a long time.’

Conclusion

It should be emphasised that, at the moment, the numbers of physician associates remain fairly low. It is unlikely that more than one in 20 medical staff are PAs even among the lowest funded practices and PCNs. But NHS England and the current Government have made it clear that this is the direction of travel, and they are looking to increase the numbers of physician associates. At the same time, there is no indication that they are going to increase funding for practices to recruit GPs – or even include GPs in the additional roles reimbursement scheme.

So what Pulse’s analysis may well show is that, as finances continue to bite, it is conceivable that more practices and PCNs will be turning to PAs to fill a gap they can’t afford to fill with GPs.

Unless the Government increases funding, it is more likely that the PA, and not the doctor, will see you now.  

Tomorrow, we will be featuring a map showing how much your region relies on physician associates

Methodology

Workforce numbers

To get full workforce numbers at a PCN level, we combined NHS England’s Primary Care Network Workforce data and the General Practice Workforce practice-level data.

Practice level data

For the practice level data, we extracted the data on the total number of fulltime equivalent GPs (excluding trainees), the total number of FTE nurses and the total number of FTE direct patient care (DPC) staff, which together covers all the clinical staff. We also separately extracted data on FTE physician associates, which are incorporated within DPC staff.  

We used the EPCN data to match practices to PCN as this is much more reliable than the workforce data.