What does the influx of physician associates mean for GP recruitment?

 In the first of our series looking at the role of physician associates in general practice, Eliza Parr looks at whether they really are replacing GPs

‘There are literally no salaried jobs in Birmingham at all. Where has all the work gone? You could explain it away for a few months, you could explain it away for part of the year. But this is getting ridiculous now. Can you really say that the work in general practice has disappeared? Of course it hasn’t – they’re just paying somebody else to do it.’

It is not just salaried roles. When the same GP looks for shifts on his locum platform, he says there are ‘literally zero’. The 15 practices in his local area that used to take on ‘regular locums’ have now ‘completely substituted’ them with additional roles. When he does sometimes pick up a shift at one of the practices, he finds that ‘literally all clinics are filled with ANPs, physician associates, and clinical pharmacists’.

The controversy surrounding physician associates has dominated general practice discourse in recent months. Debate has been fierce on social media, at times crossing a line on both sides. PA ‘scandals’ – splashed across newspapers – have reached far beyond online medical circles.

Amid the bad blood, there are some fundamentals at play for GPs revolving around medical standards, what it means to be a doctor and theories around NHS bosses wanting to replace GPs with cheaper – and less safe – alternatives.

Yet the number of PAs remains relatively low. As of April this year, there were around 1,950 full-time equivalent PAs working across primary care in England, according to NHS Digital. On average, that’s less than one PA every three GP practices. So, you might be left wondering – what’s all the fuss about?

Well, we are at the start of the journey, and it could be a rocky one. The ambitions are to increase this number substantially. NHS England’s long-awaited workforce plan, published last year, pledged to increase PA training places in a bid to establish a workforce of over 10,000 PAs by 2036. The plan does not specify what proportion will work in general practice, but it ‘emphasises the need to target more PA roles towards primary care and mental health services’. Around half of NHS PAs currently work in primary care (with the other half in secondary care) so it seems reasonable to assume that at least half of these 10,000 PAs will be working in general practice.

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GPs out of work

Yet even before this expansion begins, we are already seeing GPs out of work, in part due to PAs being employed in their stead. Over the last year, a long-standing ‘truth’ about general practice – that we don’t have enough GPs – has been destabilised. Reports of locum GPs struggling to find work have shocked the profession, and Dr Katie Bramall-Stainer, the BMA’s GP Committee England chair, declared that general practice has moved from a recruitment to an ‘employment crisis’.

Sessional GP Committee chair Dr Mark Steggles recently wrote to NHS England to say there are ‘extremely concerning reports’ of practices delivering care ‘predominantly with allied health professionals and physician associate appointments’. He cited a recent BMA survey which showed a ‘noticeable gap’ between the weekly sessions locums want to work and the amount of work they have been able to secure. And he called on NHSE or the Government to step in to stop ‘further losses of GPs’ from the NHS.

The stats on the NHS Jobs site reinforce Dr Steggles’ concerns, suggesting there aren’t many GP jobs available. As of this week (5 June 2024), there are just six salaried ‘standard’ GP roles advertised in practices, three of which are in Wales. The remaining 20 GP jobs are based out of prisons, special allocation services or out of hospitals for GPs with special interests.

This was echoed in the latest survey from Pulse in November 2023, when the signs of a GP employment crisis were beginning to show. The results revealed that there was a 44% reduction in the number of GP vacancies advertised over the previous year, with a 23% reduction in the six months between May and November.

The same survey also found that around half of the 426 locums surveyed said their shifts had decreased over the same period due to a lack of work available. Some said sessions had ‘suddenly dried up’ and they were ‘struggling to find daytime locum work’. Many claimed that practices are instead using ‘cheaper’ staff such as PAs, ANPs and pharmacists.

As a result of this shift, GPs – especially locums – have had to take drastic measures to get any work. Some say they have been forced to travel dozens of miles to find sessions, accepting shifts anywhere in the country – one GP was willing to travel from Cumbria to Cornwall for a week’s worth of work. Others are staying in hotels overnight in order to secure work far from where they live. At the recent LMCs conference, BMA Sessional GP Committee member Dr Amy Small said the Cameron Fund, a charity for GPs, is currently supporting locums who cannot find work. ‘GPs are having to go to charity to get money to survive – I just want to let that sit there for a minute,’ she told attendees.

Increased use of PAs

However, none of this in itself suggests that the expansion of PAs is the primary cause of this employment crisis. But there is some evidence that practices are in part recruiting PAs instead of GPs – with cost being the driving factor. A fifth of the 600 GP partners surveyed by Pulse in November said they had increased their use of physician associates since 2022, while over 60% said they had increased the use of pharmacists. Some partners continued to look for GPs to recruit with no success, but others said they could not afford to recruit GPs. One GP partner said that they are ‘down on doctors’ but have ‘no money to recruit more’, while another said they ‘can’t afford any more and don’t have room’. And a further GP partner said they ‘took on ANPs instead of GPs’.

The history of physician associates in general practice

PAs have been working in the UK since 2003, but the role was first developed in the US sixty years ago. The aim was to remedy the shortage of primary care doctors, and the first class of PAs was put together in 1965 in North Carolina.

Three years after they first started working in the NHS, the Government released a Competence and Curriculum Framework for PAs – developed in collaboration with the RCGP. And in 2007, UK university courses produced the first PA graduates. (We will be covering this more in the second part of our series).

But until 2013, the role went by a different name: physician assistant. The Government backed the change to ‘associate’, suggesting that the name ‘assistant’ would ‘hold the profession back from becoming regulated’.

During their first decade in the NHS, PAs were few and far between. But the number in general practice has accelerated quickly over recent years, driven by ARRS, which provides central funding to hire 17 ‘new’ primary care roles. According to NHS figures, there were only two recorded PAs working across the nascent primary care networks in March 2020, and this has risen steadily to reach 1,164 by April this year. NHS England has implied that it’s likely most were employed using ARRS funding, although the data cannot verify this. The growth is clear in PAs hired directly by practices too – in March 2019 there were around 150 PAs employed by practices, and now there are 788.

And it’s not just PAs – ARRS has driven increases across a range of ‘direct patient care’ roles. Last year, the Government announced it had met its target to recruit 26,000 more primary care professionals one year early. Between 2021 and 2023, the number of paramedics working in practices and PCNs jumped by almost 60%, and the number of pharmacists by just under 50%.

Pulse has reported that agencies are pushing PAs over GPs as a cheaper alternative. One agency included wording on its website which pointed to ARRS staff as a ‘cost-effective alternative to expensive GP locums’. And some GPs had received emails from a locum agency claiming that PAs ‘can work like a GP and an ANP’, which they felt was ‘misleading’.

The claim that PAs work like GPs – while worrying – is perhaps unsurprising given how the role is presented. In recent months, NHS England has been emphatic that PAs ‘cannot and must not replace doctors’. But NHS communications continue to describe the role as ‘medically trained, generalist healthcare professionals’. To many – especially patients – this description may not seem a far cry from the GP role.

A 2022 study into the ‘skill mix change’ in primary care backs this up. It found that the patient-facing work carried out by PAs ‘appeared similar to much of the patient-facing work carried out at the first point of contact by GPs and ANPs’, with a focus on acute problems.

Additional roles reimbursement scheme

Nottingham GP partner Dr Irfan Malik says the ‘wider picture’ to the PA debate is that ‘many doctors are now out of employment because of ARRS staff’. He also attributes this to financial pressures: ‘Because the practices aren’t being adequately resourced now, the money is flowing through the PCN – so it’s either take these staff or nothing.’

One GP locum, Dr Andrew Felthouse, tells Pulse he has seen his general practice workload ‘wither noticeably in the past few years’ due to practices being ‘shored up with ARRS at zero cost’. ‘My personal strategy is to move into private practice,’ he says.

This does not bode well for GP registrars who will qualify this summer and look for jobs. Dr Malinga Ratwatte, chair of the BMA’s GP Registrars Committee, warned at the LMCs Conference in May that ‘thousands of GPs’ could be unemployed in August as they enter a ‘nearly non-existent’ job market. Like many others, Dr Ratwatte blames the ARRS for this as it does not allow practices to hire GPs. At the same conference, Worcestershire LMC member Dr Gill Farmer said that in a recent discussion with local GP trainees it was ‘clear that they feel really threatened by the existence of physician associates and increasing use of ARRS staff to substitute for GPs’.

The reason partners and PCNs are recruiting PAs and other staff is due to government policy. There has been a huge cut in real-terms funding during the cost-of-living crisis. This year’s contract imposition by the Government saw funding increase by only 2.2%, much less than the BMA’s ask of 8.7% to cover inflationary pressures.

Yet one area that has been funded is the ARRS. For many partners, this means hiring a PA to take on some work that might be traditionally be done by GPs. Dr Shamit Shah, GP partner at the Coastal Medical Partnership in Hampshire and Wessex LMC member, tells Pulse that practices are ‘forced into a corner’ with hiring ARRS staff due to the ‘quite frankly insulting pay offers’ over recent years.

‘We’re making a loss, more of a loss every single year, income is dropping in practices. So no practices are sensibly going to invest in staff, because if they do, they may well be in the red, and they may well have to close down. And that’s far worse for patients.’

In Liverpool, Dr Roger Scott describes a similar situation: ‘Our current salaried GPs would rather we employed a GP than other roles, but in the current climate we’re struggling to afford that, despite losing partners.’

Even with more funding, there would still be an issue of space in surgeries. Doctors’ Association UK (DAUK) spokesperson Dr Steve Taylor says ‘a lot of GP practices have just not got the space for all these extra bodies’. His own practice is a ‘very big building’ made up of two Victorian houses, but they have recently run out of space, which is ‘absolutely bizarre’. ‘I never thought we’d ever get to the place where we wouldn’t have enough consultation rooms, but we have got to that place.’

For the moment, these issues seem exclusive to English general practice. In the devolved nations, where there is no ARRS, problems with recruitment remain. Northern Ireland GPC member Dr Arnie McDowell says they have ‘not so far seen medical unemployment’ and in fact still have a ‘medical workforce crisis’. He told UK LMC members: ‘What’s the reason for that? I think you can all probably guess – we hardly have any PAs, no surprise there.’

GPC NI chair Dr Alan Stout said the ‘Celtic nations’ have not seen the same trend towards GP unemployment. But he warned that they need to ‘watch really carefully what is happening in England’ to avoid a similar situation. ‘We can’t allow anything that looks like the ARRS scheme to come to us.’

NHS England says that ‘it is up to GPs on whether they hire a physician associate’, and since partners are independent contractors, they can use practice funding as they see fit. An NHS spokesperson emphasised: ‘Physician associates are trained clinicians who help doctors – they are not doctors and are not replacing doctors.’ The Department of Health and Social Care was also approached for comment.

For some, under-employment of GPs may not be a strong enough argument to stem the tide of PAs. Professor Azeem Majeed, professor of primary care and public health at Imperial College London, argues that the NHS ‘doesn’t owe anyone a job’. According to him, the prospect of GPs becoming unemployed or less secure is ‘not at all a valid argument against PAs’.

‘If PAs actually worked well, and were cost effective, I would say “great, employ more, employ fewer GPs”. If the evidence points in one direction, that’s the way we go – and if that means some doctors lose their jobs, then that’s unfortunately the way things work in market economies.’

Professor Majeed’s comments might be hard reading for GPs out of work, but it seems like the Government shares this sentiment – which might make life far tougher for the next generations of GPs.