A ‘cautionary’ tale: Pitfalls of the UK physician assistant model

A fresh warning has emerged about Australia following down the path of the United Kingdom’s physician assistant (PA) model, with research highlighting its failing should act as a ‘cautionary lesson’ for other countries.
 
The new research from the UK examines the outcomes of PAs embedded in the country’s National Health System (NHS), revealing its pitfalls and future consequences.
 
PAs are described in the research as a ‘contentious intervention to support the medical workforce’, with the authors noting their introduction in the early 2000s as a new occupational role to assist doctors and relieve their workload amid shortages.
 
As the scope of PAs evolved and their responsibilities expanded, the authors say this occurred in a ‘largely unregulated manner’.
 
‘By 2024, some were undertaking complex procedures or managing undifferentiated patients in primary care,’ they state.
 
The expansion, and associated failings within the NHS, led to concerns over patient safety and uncertainty around scope of practice for the medical workforce.
 
‘This has led to a widespread grassroots backlash by the medical profession,’ the authors note.
 
Late last year GPs in the UK voted to phase out PAs, prompting the RACGP to call for Australia to follow suit after the model had previously been suggested.
 
But this comes as Australia edges closer to rolling out the position locally, with the Queensland Government recently announcing the model is still being considered. The RACGP reiterated its warnings that any expansion would ‘undermine good general practice’.
 
Speaking to newsGP in response to the latest UK research, RACGP President Dr Michael Wright says this latest study shows ‘more evidence of the sorry tale’ of PAs in the UK. 
 
‘Rather than supporting general practice in their work, this report shows that they fragmented care, caused patient harm, and made general practice harder,’ he said.
 
‘This is a cautionary lesson from the NHS about what not to do. Australia needs a better supported GP workforce, and patients need affordable access to care.
 
‘We do not need expensive fragmentation worsening access to a GP.’
 
Dr Richard Sturrock is a British-born GP who studied in the UK and worked in the NHS for two years before coming to Australia to gain his Fellowship of the RACGP. He believes PAs must not be introduced in Australia ‘at all costs’.
 
‘While they were originally billed as admin assistants for doctors, they are most definitely not,’ he told newsGP.
 
‘They’re not rotating to different teams, and they’re not independent enough to be able to complete ward rounds, complete documentation or refer.
 
‘This de-skills doctors and leaves them to do all the admin – the exact opposite of the intended purpose of PAs.’
 
Dr Sturrock has spoken to many of his GP colleagues who still work in the NHS and describe the situation as ‘frustrating and annoying’.
 
‘My colleagues tell me that PAs are making decisions on undifferentiated patients, ordering investigations, and giving potentially dangerous advice, despite only completing two years of study,’ he said.
 
‘Patients are often under the impression they are seeing a doctor, when in fact they are seeing a PA.  The GP is also ultimately held accountable for decisions and prescriptions made in their absence.’
 
While he acknowledges the original attention of PAs was a good idea where they would be carrying out more administrative tasks, Dr Sturrock believes PAs are ‘not quite well qualified’.
 
‘For example, to be able to order scans, they’re not well skilled enough to decide what scans need doing, and also can’t write referral letters quite like a doctor can – so that then gets passed back to doctors,’ he said.
 
‘I can see the logic in them in hospitals, actually doing admin tasks. But the danger is that you get creep of what their role is, because hospitals are understaffed and too busy.’
 
In the general practice setting, Dr Sturrock says he cannot see how embedding PAs would be useful.
 
‘Wouldn’t it make more sense to use the money spent training and paying PAs to increase general practice registrar pay and allow them to have paid study leave so that general practice training is more attractive?’ he said.
 
Rather than role substitution, the RACGP says one way the workforce shortage can be addressed is through more incentives to train GPs, with the college releasing data this week demonstrating the benefits of incentivised training places.
 
In the past, the RACGP has instead pointed to existing models such as medical assistants who are health professionals trained to work under supervision of doctors rather than independently – supporting multidisciplinary team-based care.
 
Dr Sturrock adds that in the UK, general practices are financially incentivised to employ PAs.
 
‘Their salary does not come out of the practice budget – such that there is now a shortage of GP positions, and I have GP friends who are unable to find full-time work,’ he said.
 
‘PAs also have a higher base salary than the interns and medical officers.

‘Why should I, with 15 years of experience, tolerate this? Why should we devalue GPs, and expect them to supervise and be accountable for PAs? It’s truly astonishing.’

The UK experience of PAs offers ‘cautionary lessons’ for other countries, the authors conclude.
 
They echo the RACGP’s calls for the importance of clear role definitions within a healthcare team, adequate regulatory oversight, and to avoid any risks to training future doctors.
 
‘This case study highlights the need for a carefully thought-out approach that considers both the potential benefits and pitfalls of integrating new roles like physician associates into a healthcare system,’ the write.
 
‘The failure to do so has created a new occupational group with unrealistic expectations and has further demoralised an already unhappy medical profession.’
 
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general practice reform medical workforce NHS physician assistants role substitution scope of practice