Physician Associates in
Primary care:
Fisher Medical Centre
Experience 2014
Dr James Thomas (GP) &
Ria Agarwal (Physician Associate)
Fisher Medical Centre
Skipton
North Yorkshire
PAs in Primary Care
Fisher Medical Centre
2013

Partnership of 14K patients

Semi -Rural Practice/ Own building / in house
pharmacist / 30 Admin staff.

7 FTWE GPs 9 Partners and 1 Salaried doctor

5 PNs

3 HCAs

No ANPs

Teaching practice- medical students, FY and GPRs
and GP returners.

High QOF achievers
Why the need for
PAs?
2013
 Retirement of partners leaving 11
clinical sessions to be covered.
 Poor response to Salaried GP
advert.
 Reducing income.
 Increasing workload.
 Managing partner’s expectations
work-life balance
 Innovation
Next steps:
What did we do ?
Outcome:
 Different models of working.
 Employed 3 FTWE PAs Band
Low 7-low 8.
 Information on PAs and ANP:
Partner experience/USA/
Aberdeen.
 Contacted and met with
SGUH PA course director.
 Advertised for PA and APN
 Assessed and meet the
challenges and Barriers.
 2 from SGUL (Just
Qualified)
 1 from Alaska USA (15 years
experience)
 Implemented change within
the organisation and for the
patients and community.
MEET THE PA TEAM @ FMC
What are these Physician
Associates?!?!
“a new healthcare professional,
who, while not a doctor, works
to the medical model, with the
attitudes, skills and knowledge
base to deliver holistic care and
treatment within the general
medical and/or general practice
team under defined levels of
supervision”
(DOH Competence and
curriculum framework)
Ria Agarwal
Fisher Medical Centre
How are we trained?
 PG Dip: diverse backgrounds and ages; 21-43yrs old!
 Ex nurses, ex radiologists, Biomedical science graduates
 OSCE- style interview following personal statement and
reference checks: In 2011 there were 200+ applicants for
24 seats
 Generally taught by GPs or GP PA’s
 Small cohort size: interactive teaching
 Courses currently in London, Birmingham, Aberdeen, and
due to start in Plymouth/Peninsula
 100% employment rate
 Assessments/training based on DOH Competence
Framework for Physician Associates
1st year:
 1st year: Theory+ prep for 2nd year: 9-5 and homework!
-Anatomy and Physiology (revision for most!)
-Pharmacology (100 medications and 15 prescribing guidelines e.g.
hypertension, dyspepsia, depression, diabetes, warfarin)
-Foundations of Clinical Medicine (disease)
-OSCE skills: history taking, examination, 20 explanation stations e.g.
hypertension, antidepressant initiation, contraceptive pill initiation
-Evidence based Practice; analysing papers
-PBL for consolidation of learning weekly
 GP attachment; 120+ hours in first year (1 day weekly) and 180+
hours in 2nd year (6 weeks full time)
 Initially shadowing a GP then seeing patients with GP supervision
2nd year: new levels of
exhaustion!
Hospital rotations e.g. General Medicine (180 hours), AMU (180 hours),
Mental Health (90 hours), Paeds (90 hours), Surgery (90 hours), A&E
(180 hours), Obs and Gynae (90 hours), plus electives (3x 90 hours
each) e.g. ENT, Dermatology. Total 1650 hours which exceeds DOH
criteria.
Then back to GP for 180 hours
Special topics week to kick it off: taught by current PA’s for the
students
Professional Development Portfolios: learning and development
reviews from placements, case histories, reflections from challenging
cases, PBL feedback, multi-source feedback, DOPS, hours sheetsreviewed
One day every 3 weeks at University for tests, revision classes for
exams, mock OSCEs
 National Exam upon graduation: OSCE + 200 MCQs, MCQs to be
repeated every 6 years (recertification) to re-test broad knowledge
Portfolio paperwork example- essential DOPS
What do other PA’s do?
Our cohort of 18
6 GP PA’s
3 PA interns on hospital rotations
1 Research PA
1 Haematology PA
1 IBD clinic PA
2 Orthopaedics PA
1 Neurology PA
1 A and E PA
1 AMU PA
1 Paeds PA
SGUL Pas more keen for primary care as keeping up with
broad knowledge and skills, but not enough jobs
Annual census to keep track of which professions PA s
are in
What do we do at FMC?
 Work in a Same Day Service system- Book on the day
 All 3 PAs Work with one GP.
 GP Triaging calls whilst working with PAs
 PAs now see 21 appointments per day each, equivalent to 315 appointments per
week / 15120 per annum.
 Previous GP appointments were equivalent to 165 per week, or 7260 per annum.
 A proportion pre bookable.
 Telephone consultations.
 Review of investigations and correspondence.
What don’t they see and do?
 We decided to look at what they shouldn’t see
E.g. <6/12, pregnant, complex patients, severe mental
health problems.- but safety net in place.
 They do not prescribe.
 They can not organise radiological investigations apart
from USS.
What do they do?
 BREATH OF FRESH AIR!!
 Extended arm of the GP
 Manage most straight forward patients and more!
 Arrange further investigations were appropriate and to work cases up
who then are reviewed by their own GP.
 Work well with other clinical staff- ecgs, dopplers, ecg etc.
 Referral – Non elective and Elective after discussion with GP.
 Developed roles with ACP.
 Contribute to educational meetings
 Keeps the GP up to date by questioning your management plan.
Opportunities with the PA role in
Primary care:
 Multitude of roles in primary care:
 Book on the day
 Chronic Disease
 ACP
 Visiting
 Work patients up to see GP
 Collaborative care role
 Excellent team working skills
 Develops leadership skills within the team
 Teaching opportunities
Next steps:
 Employed a further PA to work with a ANP for a collaborative
project between a group of practices. This is an initiative
from a partnership with health and social care to look at ACP
in care homes and training care home staff.
 Look at their role in extended hours.
 Developed links with the PPG and NAPP.
 Develop links with HEYH/ Workforce group.
 Develop their role in primary care and look at recruitment for
further projects and training.
 Submitted a research project for Health Foundation Project
to evaluate their role in primary care.
So what have we found so far?
 Change management is vital with all stakeholders: in house/
patients/ organisations/press etc...
 Yes it was a risk but the climate forced it.
 Their training needs to involve primary care from the start to
ensure they consider primary care – do not make the same
mistakes we have done in the past with primary care training
of health professionals, given the current shift in care to
primary care.
 They are part of a team and part of a solution with workforce
but not alone.
 They should not be seen as a threat to professions- GPs/ APNs
HCAs etc. they compliment us all.
And…
 THEY ARE GOOD!
Clinically.
Communication skills.
Patient feedback has been very positive.
They are productive- appointments numbers and cost.
Fitted into the Primary care team easily.
Willingness to learn and develop skills.
Supportive to the team.
“The physician assistant role has been an
overwhelming success in the United States. There is no
reason why it could not be so here, given good will and
the desire to see it succeed.5 My own research among
general practitioners clearly indicates that they would
regard physician assistants as a welcome addition to
the primary care team.”
THANK YOU
Any Questions?
Contact Details:
Fisher Medical Centre
Skipton
North Yorkshire
01756 799622
jamesthomas2@nhs.net