The initial idea of Physician Assistants (aka. Physician Associates) was a good one. Many of the tasks doctors do – particularly junior doctors – are heavily administrative. Removing these tasks from doctors’ workloads means doctors can spend more of their time on direct clinical activities. Physician Assistants (PAs) were brought in to take off some of these clinical administrative duties.
It sounded like a win-win. Patients would get more time with their doctors and doctors would have more time for their ultimate role of clinical decision-making. There was also the real possibility that PAs could – by relieving the burden of clinical administrative tasks from doctors – help to reduce waiting lists.
And, to some degree in some places, this is how PAs work. They take notes, take blood, write out test request forms, and even, in some cases, take the initial part of the history. This all enables doctors to focus their time on the decision-making part of their job. But sadly, in many places, this potential of the PA role has been squandered.
Physician associates are replacing medical doctors
Increasingly, instead of strengthening and expanding the NHS team, PAs have been used to replace members of it. Instead of plugging the holes in continuity and forging a better, more efficient service for patients, they are being redirected into providing a service that is simply less specialised, less professional and ultimately less effective than what it was before.
There are now reports that PAs are simply replacing doctors. Bearing in mind most have had only two years of training (versus five or six years for a doctor) and that none of them is compelled to undergo a further five years of training before being able to work independently, it is a terrifying prospect. It is difficult not to see this trend in using under-qualified, under-trained personnel to do quite advanced clinical tasks as simply taking shortcuts with our health.
There are a number of reasons why this has happened. At each echelon of the Health System, there is a slightly different motivation. But the central reason, the driving force behind the shoehorning of PAs into clinical posts, is probably the desire to move the UK further toward an algorithmic form of medicine.
The ‘algorithmic medicine’ and its danger to health
Emanating from the hyper-privatised health system of the United States, ‘algorithmic medicine’ is when the patient journey is automated. Crucially, it is when even the initial clinical assessment is automated. For example, let us say you are over 50 years old and have blood in your stool, the automated algorithm would simply request a colonoscopy for you. You have met the predetermined criteria for a colonoscopy. No need for a consultation or to even see a doctor.
This of course leads to many more colonoscopies (hence the preference for private providers to use it) but also leads to an increase in complication rates post-colonoscopy and missed diagnoses.
Let us say you are 49 years old and have blood in your stool. The automation says no colonoscopy for you. But the GP knows you rarely visit a doctor and on examination detects a small mass in your abdomen. The GP orders a colonoscopy. A life saved.
There is also an alternate scenario where the 50-year-old does have blood in the stool but the GP takes a careful history and examines the patient, finds haemorrhoids and decides to treat the haemorrhoids before ordering the colonoscopy – saving the patient and the health service from undertaking an unnecessary colonoscopy.
You can see how deep a spiral we end up in. Using an algorithm to make clinical decisions about whether or not to order investigations leads to too many inappropriate tests and too many missed diagnoses. The health system – already overwhelmed – becomes even more overwhelmed. The cost of healthcare – already soaring – soars further.
The hidden agenda: prioritising profit over patient outcomes
NHS Leaders facilitate this tectonic shift in how we provide healthcare in part because NHS Leaders have a long track record of fulfilling the will of Ministers, even at the expense of standards of care. For many senior NHS managers, PAs provide a quick plug in the massive vacancy gaps. It is also too tempting for some short-sighted managers to switch PAs from a supporting role to a service delivery role. After all, reporting a fall in procedural waiting lists to their seniors (regardless of how successful or appropriate such procedures are) is the surest way to progress their careers.
Of course, from a business perspective, increasing the demands makes good sense. What if we end up undertaking colonoscopies on those who don’t need them? And what if some of those who didn’t need a colonoscopy end up with a complication from the procedure?
PAs sit perfectly here as qualified enough to follow the algorithm but not qualified enough to see when it should be overruled. And, of course, they are much cheaper than having advanced nurse practitioners or Consultants delivering such care. A win-win for private providers (and short-sighted NHS managers) as we now have increased demand and reduced delivery costs. A push of demand up and a driving down in the delivery cost in order to maximise profits. Unfortunately, patient outcomes are largely irrelevant in such a model.
Lack of quality control for implementing this ‘new’ algorithmic approach in medicine
For reasons that remain elusive, there has been no requirement for quality control studies prior to implementing this new type of medicine. That’s right, you heard me correctly – there is very limited evidence of how safe or effective this ‘new’ algorithmic approach is in medicine. Indeed, if we take the example of ‘111’ – one of the first algorithmic forms of patient diagnosis in the UK –, we can see that it was implemented without evidence of its efficacy. Indeed, recent studies suggest it actually burdens the health system more and misses important cases that need urgent attention.
This ‘111’ fiasco is similar in some other ways to the emerging PA fiasco. Relying on an algorithmic approach allows ‘111’ to replace trained nurses or doctors with cheaper, less qualified staff. The end result, is a cheap (in the short-term) and less effective healthcare triage system. The new role for PAs is, as was the case for ‘111’, a massive shift in how healthcare is delivered in this country, the safety of which has not yet been tested.
Misappropriation of Physician Associates and ‘111’: illusions of cost-savings
Of course, much like the ongoing ‘111’ saga, the illusion of cost-savings dissolves if you look a bit closer. The inevitable over-investigation culture, (similar to the U.S.), will bring with it a substantial bill – paid for by the taxpayer. The greater costs though, lie in the missed diagnoses. Stage one cancer is much cheaper to treat than Stage two cancer. Sepsis caught on day one can be managed in a day or two without high dependency care, but delaying the diagnosis of sepsis can lead (beyond death and disability) to weeks in hospital and a huge strain on resources. The same is true for heart attacks, strokes, frailty, dementia, delirium, and most other acute illnesses.
The misappropriation of PAs from supportive roles to replacement roles is a disaster for patient care but also heralds another step in the commercialisation of healthcare in the UK. Without consent, discussion or debate, the UK government – aided and abetted by short-sighted, career-driven senior NHS officials – has determined that our health no longer needs careful consideration or even a discussion with a professional. Instead, our health outcomes will be determined before we even set foot in a doctor’s office.
I for one reject my health needs being reduced to ones and zeros. When I am concerned about my health, I wish to speak to the most qualified and experienced professional available, and I wish for my individual situation and my opinion and beliefs to be taken into consideration before being reassured or being assigned to a treatment pathway. I want to be able to ask questions and share other symptoms I am concerned about. And yes, I want to develop a relationship with my doctor that I can rely on in the future. It may cost a bit more now, but it will more than pay for itself throughout my lifetime. If only politicians and NHS Leaders were as concerned with my entire lifetime more than their career prospects.
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