To think Physician Associates are (mostly) a false economy?

[bumblenbean]

I know there have been a few threads about PAs lately and I’ve shared concerns about how well equipped they are to diagnose/ treat patients. After my experience today, I really feel they are (at least in some cases) something of a false economy.

Filled in an appointment request at my GP surgery recently due to breast symptoms (nipple pain, possible small lump). Receptionist called back and said ‘the doctor has reviewed your form and wants you to come in within a week’. Appointment made for today.

Upon arrival, the clinician introduced herself as a physician associate which was the first time I was aware our surgery even used them, let alone that I was seeing one for a supposedly urgent appointment- but hey ho, didn’t have much option but to go ahead.

Tbf, the PA was very friendly, thorough and tried to put me at ease, and she listened attentively to everything I said about my symptoms. However, the breast exam took a very long time as she seemed unsure if she could feel a lump and she kept checking and rechecking. She also didn’t know what the glands on the areole are (I’m not sure what they’re called either, but I know what they are!). Eventually she said she’d refer me for an ultrasound just to be sure - fine. I came away feeling satisfied it had been dealt with.

Few hours later, I get a call from the PA saying she’d checked with a GP colleague for a ‘second opinion’ and the Gp doesn’t think a referral is likely to be needed but wants me to come in again so she can repeat the exam. So I now have to return in a couple of days for a repeat appointment.

I mean - I’m not messing around with my boobs so am happy to go back, but it’s frustrating to take time off for two appointments and to be told something will happen which then doesn’t, and basically have the same appointment twice.

It surely would have been a hell of a lot quicker and more cost effective for me to just see the GP first time around (as I was expecting)?! If the doctor has to give a second opinion on everything the PA does then surely the PA should only be doing routine things like UTIs, skin conditions etc?

I understand cost saving measures are needed, but I do think surgeries need to be more open about when a PA is assigned to an appointment and ensure that they are fully equipped to actually deal with the presenting issue.

Anyone had any experiences with a PA, either positive or similar to mine?

Maybe the GP would have wanted to see you twice before referring for a scan?

Did the PA know in advance what you'd be asking about?

Even GPs ask for second opinions - many of them have particular interests/specialties and their colleagues may seek a second opinion from them.

A physician associate appointment is estimated to cost £7. A GP appointment is estimated to cost £36. So two physician associate appointments is less than half the cost of one GP appointment.

A PA would still need a second opinion on UTIs, skin diseases because they are not currently allowed to prescribe.

This worries me. What with pharmacists and physician's associates, I'm terrified for the health of the nation.

It worries me. An USS, in this context, should only be done as part of a properly constituted breast clinic. Your GP clearly wants to find out if you have enough indication to refer to one. Which is commonly done on the first visit (though occasionally on a second).

Physican associates are a complete false economy. No idea where you have these numbers from, because they are so very wrong. Physician associates are paid Band 7, it is centrally funded ( by our taxes) to encourage GP practices to take them on at no cost to the practice.

The whole role is being misused in the NHS- they are dependent practitioners who must be supervised- so unlike a Gp, and not in any way like a doctor seeking a second opinion.

If they want to work as doctors, they should just train as doctors. That’s surely the answer if we want appropriate healthcare for the public.

But that’s not what the tories want.

I would insist on seeing a doctor

@MereDintofPandiculation fair point, but in this case it will be the GP cost plus the PA cost, so not 2 x £7. She did know what I was there for as she’d reviewed my consultation request form before I arrived.

I’m grateful to have been seen so quickly but you’d think for something like this cutting straight to the GP would have been preferable.

I also think it’s unhelpful that the receptionist didn’t tell me it was a PA- when we arranged the appointment I asked which doctor it was with, and she gave me a name, not stating it was actually a PA. I’d assumed it was a locum doctor or one I hadn’t seen before.

I have never heard of this role before but it sounds like a waste of time and money.

I am not adverse to different types of roles at GP surgeries. We have a nurse practitioner and a pharmacist at our GP surgery who are great in their respective roles. Eg the pharmacist does asthma reviews and is available to talk about medication concerns but this sounds pointless.

It is accepting people who have watered down medical skills because there are not enough GPs/dentists whatever.

There are so many staff below the level of nurses doing jobs nurses once did and now consider beneath them that it's hard to know who/what they are. I posted last week about the experiences of my 90+ year old aunt in Cramlington A and E.

Her 'obs' were being taken by someone who wore a nurses-type uniform but who was not a nurse. She missed that the arm which she had measured her blood pressure on 5 x (because it was high) was also the arm filling up with fluid from the IV because the drip had torn the blood vessel. There was a balloon of fluid filled skin the size of an orange, like a giant blister. When I pointed it out she did not know what to do so called a nurse. She told the nurse she had taken my aunt's blood-pressure 5 x on that arm and not noticed and the nurse said 'It doesn't matter.'

The next day I asked a nurse about my aunt's weight and whether she could have a shower- as she was too weak to even sit up in bed and had not been showered for over a week or had her teeth cleaned. She said she did not know the answer to either question and got someone who, again, looked like a nurse but wasn't. That person was one of two washing, showering, cleaning, changing patients while thenurses chatted in the 'reception hub'. She suggested my aunt got out of bed and went into the bathroom to clean her own teeth- I had to say 'She can't walk or even sit up.'

It was as if the nurses felt those 'care' jobs were beneath them even when they had nothing else to do. They don't even seem to share info beteween the different staff.

It will become the same with Drs and things will be missed. The NHS is fucked.

So is adult social care. My aunt has a social worker who was 'on leave' from 22nd Dec until 8th January. She is now 'on leave' again from 30th January until 12th Feb'. She managed to see my aunt once in that gap between 8th-30th January. Couldn't see her from mid-Nov until 22nd Dec as 'too busy'. No one else will deal with her case.

Meanwhile my aunt is stuck in a care home paying :
£1300 a week (£5200 a month)for care there,
£800 a month rent for her sheltered housing type accommodation ,
plus £760 a month for additional care at her sheltered housing type accommodation,
plus has paid £700 to have a stairlift installed which she can not use as it is too cumbersome and heavy for her and an ongoing rental fee for the equipment which she can't use.

£7000 a month wasted money on unused/unnecessary care and none of it can be cancelled because we don't know where she is going to be able to live and the social worker is not at work long enough to make something actually happen or meet with us to give us timescales/possibilities.
So far she has been there 10 weeks - it's £20,000 of wasted money so far. Money she will need for her future care.

I was told today she will have to pay 4 weeks notice for the care and rent at her sheltered type house when it is cancelled- another £1500 of her money wasted.

That sounds horrendous Lulu

just on your first point, there is no actual shortage of doctors. There is a shortage of funded posts of doctors in the NHS. Literally thousands of doctors have not gotten training posts because the government chooses to fund non- doctors such as physician assistants. Even while the public want to see a GP, they turn away thousands of doctors who want to train to be GPs.

This is an active choice by the government

This is not a great experience but as someone who works in a hospital I just want to address a few things. The jobs are not “beneath nurses” it’s just that nurses are doing all the other jobs that HCAs are not qualified to do, such as giving medication and carryin out specialist procedures. The “three nurses chatting” was more than likely them talking about patients or giving nursing handover i.e. exactly the thing you are asking of them to do - communicating about patients to each other and other staff members. It’s true that a good HCA is worth their weight in gold and are in short supply. Gven staff shortages, I highly doubt nurses had nothing to do…
As far as not being seen by the right professional at the GP surgery, it happened to me once and it wasn’t great. Consequently, I see many people complain about receptionists at the GP surgeries “interrogating” the callers about the reason for an appointment. Well…. this is done exactly so that you are booked in with the right person.

I think the issue here is scope of practice, and one I do agree is a safety issue with regard to PA's (I work with them regularly as part of a team).

We all have times when we're not sure, need to ask etc even with tonnes of experience.....however here the PA cannot order investigations and therefore shouldn't have stated that was part of the management plan when technically they need to discuss a management plan with their supervising GP - as PP said they are dependant practitioners.
With issues where cancer is a possibility, referring into diagnostic pathways such as breast clinic etc I think this is outside this person's scope and therefore they could/should have just got the GP to pop in while you were at the surgery. Or this shouldn't have been our on their appointment list in the first place.

Unfortunately what seems to be happening is surgeries are happy for PA's to act as a kind of triage system seeing anything and everything even if their scope of practice and/or experience doesn't reflect this and then discuss with a GP - your case is a key example of how this is distressing for the patient, puts the PA in a difficult position, wastes time and resources etc. PA's have a place in the team however they are certainly not 'mini doctor's.

Completely agree on scope of practice. I think until that can be fully determined, the push for the GMC to regulate these non-doctors should be halted. PAs have already been involved in some incidents that led to serious injury or death due to missing things and misdiagnosis. An overworked GP could also do this, of course. But they've at least had the required years of training to enable them to work in a complex, multidisciplinary area of medicine in the community.

My surgery has one and they said on the phone she was a doctor - she then had to explain she wasn't when I asked. Fair enough if you want to use one as triage for minor ailments, but at least tell patients.

It’s very frustrating to see a PA instead of the dr as if you’re prescribed something then the GP has to sign off on the prescription. My son had an appointment last week at 11:30. At 4:30 I had to call the surgery to push for the prescription to be done as the chemist closes at 6.

It’s not efficient and is quite misleading.

Agreed. DD is an F1, ie a first year Doctor. She loves her job, despite nights and 80 hour weeks, and seems to be doing well. However she is very gloomy about future training prospects and can see locum posts drying up as PA are recruited instead.

Unless she is very lucky she fears her options will be to leave the profession or leave the country.

I filled a form in today for heel pain. I had suspected plantar fasciitis and have done physio exercises for two months and worn insoles etc. It's not getting better and feels like stabbing pain now. Like glass in my foot.

Said this on the form and asked for a face to face appointment and referral for an xray.

Email back said I need physio.

They haven't looked at my foot or even called me. I've told them I have done that and it hasn't worked. They should have at least had a poke.

Utter waste of time.

OP I feel so bad for you now having to go back. It’s like the appointment with the PA was a complete waste of your time and has done nothing to allay your concerns.

We don’t have PAs in Scotland, to my knowledge, but many Nurse practitioners. The last time I needed to speak to a GP. I was put through to a NP who would not help me at all! I was looking for support with a long-standing problem I have with anxiety about hospital appointments. On a couple of occasions in the past a GP has prescribed a sedative to help me get through the door of the hospital. But the NP became very argumentative with me (this is when I knew I wasn’t talking with a professional) and I had to leave the call as I was so upset and I now feel it’s pointless calling the surgery again, if I’m not going to be able to consult a GP.

I am totally opposed to anyone but a qualified doctor dealing with health concerns in the first instance. Perhaps after assessing a patient, a PA or NP could be the most appropriate clinician to deal with someone if further appointments are needed but that’s really not the role of the receptionist to make that decision.
If I could afford private healthcare, I would surely be making that move now.
Good luck with your GP appointment. X

I don't think PAs should be working in general practice at all. Diagnostic skills, prescribing, arranging appropriate tests and referral to secindary care are the most important aspects of GP and PAs can't do any of those things.
The other important things in GP are managment of chronic disease, eg asthma, health screening, for example. This can all be done very well by specialist nurses. PAs can't do that either.
That said, I had a positive experience of a PA in hospital. She introduced herself and explained her qualification. I was reassured when she told me she had been a senior nurse for 10 years previously. Her role was doing lumbar punctures and she did around 10 to 20 a day. She asked if I was happy for her to do mine. I was, she was excellent.
This is the sort of thing I would expect PAs to be doing.

It's an awful experience rather than 'not a great experience'.

Sorry if I am firing questions at you and I appreciate all hospitals may not do things in the same way but:

1. Does each patient have a 'named' nurse and dr who are the people who have an overall 'grip' of what the picture is of the patient and responsibility for the daily medical care?
2. Is there an agreed plan for each patient that is worked towards?
3. Does anyone takes responsibility on hospital wards for what actually happens to a patient and for knowing a patient?
4. Who takes responsibility for ensuring and monitoring the quality of the provision on a ward on a daily basis- from cleaning to patient care, that staff are doing their jobs and not wasting time?

I am asking because none of those things were apparent to me.

It seemed to me that everyone- from the HCA to the consultants- was only interested in their bit of the job and not in the patient and the quality of what happened to them on the ward. Everything was disconnected and no one seemed to think that was a problem, as long as they knew they had done their 'bit' it didn't matter if any other professional had done theirs.

No one had an overall picture and there was no 'plan'.

Let me give you some examples.
After 14 hours on the ward no one had read her notes and realised she was blind. It was significant because she is very frail and there is clearly a 'falls' danger in an unfamilliar place, her condition was causing hallucinations which were very confusing to her and she had many people she did not know and could not see approaching her with medical equipment/to do quite invasive procedures. After 14 hours on the ward a Dr assumed that, because of her age, the confusion was alzheimers/dementia when she is normally very sharp. He confirmed both pieces of info were in her notes. Do staff not read patient notes? Neither nurses or Drs appeared to.

After 36 hours in the hospital I again had to tell another Dr about her blindness and that she does not have alzheimers/dementia because they were unaware.

After 4 days in the hospital we were told she was 'a very sick' person and 'not out of the woods'. 3 hours later a consultant told me she was 'well enough to be discharged' and was unaware she was so weak she could not even sit up in bed, or get out of bed. Surely he should know an overall picture of her condition not just the blood test results and x rays showing infection levels? He did not even know where (home or care-home) she would be discharged to until I told him. His whole thing was 'I need this bed for someone sicker'. Wasn't rude but he'd got the infection level down, and needed the bed. As a patient she was irrelevant.

No one on the ward was being showered unless they could walk into their wet room and stand independently . I was told this was because the ward did not have a 'shower chair' and 'had no way of getting one'. Surely this is a non-issue. Surely someone 'senior' can order couple of plastic hospital chairs that patients can be moved from either their wheelchair/walking frame onto and be showered on? They all had a wet room and were just having their hands and faces washed with a flannel and bowl. Their teeth were not even being cleaned if they were too frail to do it. Does anyone check the standards of patient personal care on a ward?

One of the wards was filthy- horribly filthy. Her room floor when she arrived was littered with clumps of phlegm filled tissues. her table over her bed was unclean- dried on gunge, removed dressings, her own phlegm filled tissues. Her sandwiches were put on it (directly, removed from packaging, no plate) in the midst of this stuff. Staff came in and out and no one cleaned it. She had spilt water on it and the tissues and dresses were soaked and so was the food. Surely someone - HCA, nurse, dr should have dealt with that and not just ignored it? Infact the nurse added to it by leaving dressings in it. It must be an infection issue.

It felt like no one cared, no one took any responsibility for anything.

Nurses wasted time. No doubt about it. On both wards nurses wasted significant amounts of time just gossiping, laughing, giggling over stuff on their phones, sitting in the central hub- she was next to the hub in both wards and I heard the conversations and watched them.

A physician associate appointment is estimated to cost £7. A GP appointment is estimated to cost £36. So two physician associate appointments is less than half the cost of one GP appointment.

you forget the patient's cost in your calculation. the patient now has to take another half day (as that is realistic given waiting times) off work to attend another appintment.

I actually think many (most) of the cunning strategies to reduce contact with a doctor are self defeating and wasteful of time and resources. Each time I have been channelled to a nurse or clinical pharmacist etc I have to speak to them several times, only by phone and only at their convenience, while they check various things. Then they consult a doctor, then I get a call from the doctor, which takes the exact same time it would have taken to call me or see me in the clinic for five minutes without all the previous steps and manpower.

@LuluBlakey1

• Does each patient have a 'named' nurse and dr who are the people who have an overall 'grip' of what the picture is of the patient and responsibility for the daily medical care?

Ideally, yes. Ideally there is a consultant on the ward and each patient will have a named nurse. This doesn't mean that the nurse will be spending the whole day with the patient. There is usually a nursing handover at every shift change and there is a meeting first thing in the morning where consultants, nurse in charge and other professionals will discuss every patient on the ward. The consultant will also then make a review list, all the jobs that need to be done with and for the patient will be outlined in a diary and, after the meeting, nurse in charge will allocate non-medical jobs to HCAs.

• Is there an agreed plan for each patient that is worked towards?

Typically, timely discharge

• Does anyone takes responsibility on hospital wards for what actually happens to a patient and for knowing a patient?

A consultant has an overarching responsibility. Nurse in charge for the day has a responsibility for allocating tasks.

• Who takes responsibility for ensuring and monitoring the quality of the provision on a ward on a daily basis- from cleaning to patient care, that staff are doing their jobs and not wasting time?

The ward manager

• No one had an overall picture and there was no 'plan'.

There should have been a care plan for the patient which is updated daily. I can tell you from my own experience that Bank staff usually don't check it/have no means of checking it. If the ward has no core staff to rely on, this is hugely problematic. Same goes for patient notes. HCAs won't routinely read them. The updates on patient's notes are given in the ward meeting in the morning and it is up to NIC to update the rest of the staff on important information.

• He did not even know where (home or care-home) she would be discharged to until I told him.

He should have but, technically it is Discharge Coordinator's job to deal with this. So unless DC was present at the morning meeting, the Dr wouldn't have been told. DC's notes are not usually part of clinical records.

• 'I need this bed for someone sicker'. Wasn't rude but he'd got the infection level down, and needed the bed. As a patient she was irrelevant.

She was very much relevant as we know that risk of hospital-acquired infection and poor patient outcomes as far as regaining function increase exponentially with lengthy stays.

• Surely someone 'senior' can order couple of plastic hospital chairs that patients can be moved from either their wheelchair/walking frame onto and be showered on?

There should have been chairs provided, however there also needs to be other equipment and training in pace to manually transfer patients. If the ward was short on staff, they would not be able to transfer safely. Elderly patients especially are encouraged to mobilise where possible as it significantly improves outcomes. So to your previous comment about being asked if she could go to shower, it's what I would expect the HCA to ask/encourage patient to do rather than barging in and manhandling the patient on the assumption that they are not able to do anything for themselves.

These are tangible issues that can and should be addressed with PALS' support. I am not happy about them either.
As far as nurses chatting.. again, we received abuse from patients for sitting down, drinking tea and "chatting" to each other whereas in fact, I was completing a SS referral and my nursing colleague was updating obs charts on the computer. We had our first cup of tea having both forfeited our lunch breaks and we exchanged a few words about the world while we were cracking on with the tasks on hand.

Thanks for taking the time to answer. I appreciate it but sadly it seems like it is all about allocating tasks for other people to complete.

What is a Ward Manager? A nurse? A non-medical professional?

What is an NIC?

I don't expect a named nurse to 'spend all day' with a patient but I think it is reasonable that they know if she has been weighed, that she has lost over a stone, that she has not been bathed or showered or had her teeth cleaned for 5 days, that her room is filthy, whether or not her bowels are working, whether she is still having IV antibiotics, what her chest x-rays and blood tests show.

I wasn't suggesting an HCA 'manhandle her into a wheelchair' just that the ward should have the ability to shower patients occasionally who need or want a shower. Can't see the point of a new hospital being built with every room having ensuite wetrooms if they are then not used because it's too much trouble to put the system in place to make them useable.

The Ward Managers were not doing their jobs.

The nurses wasted time- lots of time. I listened to the conversations and was next to them while they did it. For example, there was a period of about 10-15 minutes where they were searching Facebook for videos on their phones to show each other, laugh at/discuss. 3 nurses and another one in a different coloured uniform

No one was unpleasant or rude, but no one took responsibility or gave any indication they cared about the quality of what was delivered. It was awful.

I think I will contact PALs to relay our experience.

I am very aware that there are not enough doctors for everyone to see one when they want one. I have had 2 positive experiences with a PA. I suffer from bad chest infections. The PA prescribed antibiotics for me but asked me to take a sputum sample. On one occasion the chest infection went with the antibiotics on the second occasion I was then contacted by my GP to say that I needed to take different antibiotics as the infection was not treatable from the antibiotics I was given. She only knew this as she had the results back from the sample.

@LuluBlakey1
A lot of it is about allocation of tasks to an appropriate member of staff. But this is because no one member of staff can do all the care that needs to happen for the patient. Where I used to work before, it was not uncommon to have only two nurses on any one shift. Nurses give out medication, carry out clinical procedures, they also book any procedures outside of the ward i.e. X-rays, blood tests and what not. They then need to communicate with families, organise other professionals responsible for treatment and discharge (OTs, PTs, SS and DCs), book patient transport, discharge and intake new patients, organise clerking in of new patient with a junior doc or consultant. Multiply that by 20 patients on the ward and you can see how the day fills up very quickly.
If they were also doing cleaning the rooms and bathing patients, this wouldn't be a very good use of their time. Which is why we have HCAs and housekeeping to fulfil these tasks.
As an OT I will be lucky to see two patients a day. An assessment can take up to two hours, then I need to speak with a DC, write up accommodation referrals, speak to care staff in the new accommodation, potentially do a home visit to make sure someone can actually manage to look after themselves at home.
I am sure most people think "I am nowhere to be seen" but that is because I have crucial tasks to complete that can't be completed by anyone else. I also need to make sure that issued equipment (shower chair, toilet raisers etc.) are actually fit for purpose and adjusted to patient's measurements. And I have had instances in the past where a piece of equipment was taken out of storage without me knowing and the patient was harmed due to it being inappropriately adjusted. So it's not as simple as whacking any old plastic chair for showering.
The system is broken, patient's wellbeing is compromised but it's not the staff's fault in the vast majority of cases. We can all do our jobs better if we had sufficient staffing levels and lower core caseload. In 2016 I was working in a small hospital and we had 6 OTs for two wards. That's 4-5 patient each and I could see them nearly every day. In 2022 I was the only OT covering 5 wards of 15-20 patients each.
But when nurses go on strikes over poor quality of care and unsafe staffing levels, they are being vilified. When they do their best to work within the system as it is at the moment, they are being vilified again and told they are wasting time on a job...
By all means take your complains to PALS, that's what they are there for. But please try not to make it a personal vendetta against hospital staff.

P.S. a ward manager is almost always a nurse.

It takes a minimum of 10 years to become a GP.. 5 in medical school, then F1 and F2 years then three years GP registrar ..all the while sitting exams (that the individual pays for) doing competencies, portfolios ..and much more.

For a PA... two years.
They are not qualified doctors and nothing like doctors and there are already very many well documented dire outcomes from PAs making wrong judgement calls.
There IS a place for them in the system, but the goverment are trying to use them as cut price doctors when they are simply do not have the skills.

My dd1 IS a GP. She sent me a sample final PA exam paper to see how I would do on it... I'm not a medic, but quite knowledgeable for a variety of reasons.
I passed quite easily. I would not want me diagnosing or treating anyone... I have knowledge but not enough.

The NHS needs more properly funded GPs...not bargain basement ones.

I filled in an online form about an urgent issue and was given an an appointment with a PA. The appointment went seemingly as normal until the end, when she proceeded to make me another appointment to see the GP, who repeated exactly what the PA had done.
It left me wondering firstly what was the point of the PA and secondly, whether anyone actually reads the big descriptions you are asked for on the onine form.