General practice will improve despite falling GP numbers, says CCG leader

Growing numbers of primary care staff such as physician associates can drive improvements in general practice despite falling numbers of GPs, a clinical commissioning leader has said.

Dr Ken Aswani

Waltham Forest CCG clinical director, Dr Ken Aswani, who is helping to implement an east London-wide plan to transform the primary care workforce, said he would rather increase practice workforce skill mix than run practices entirely with GPs.

The Leytonstone GP, who sits on the physician associate steering group for the east London Transforming Services Together (TST) programme, told the GP Podcast that workforce skill mix - recruiting more physician associates, healthcare assistants and other roles - was a ‘better solution’ than running practices with only GPs. Although, he said, more GPs were still needed.

Physician associates bring ‘inherent skill[s]’ to practice teams which ‘GPs don’t have’, he said. Other clinicians are able to provide a ‘holistic’ approach, looking at social prescribing, for example, as an alternative to general practice’s tendency to ‘over medicalise’.

Primary care team

‘I'd much rather look at a team approach, rather than just have one professional,' he said. ‘GPs clearly have an important role but it's not exclusive these days in terms of a good primary care team.’

GPonline revealed details of the Transforming Services Together (TST) plan earlier this year, including its forecast that GP numbers in the area will fall by a third over the next decade. Commissioning leaders in Waltham Forest, Newham and Tower Hamlets have drawn up the plans which include recruiting more pharmacists, physician associates, and nurses to help offset the dramatic loss of GPs. The first 24 PA trainees will begin their two year training programme in 2017.

Last month Tower Hamlets CCG chair and north east London STP clinical director Sir Sam Everington said GP numbers would fall by half over five years across the wider eight-borough footprint.

Dr Aswani, whose own Allum Medical Centre has pioneered the use of physician associates over the last decade, said that increasing skill mix in primary care would benefit patients and GPs and make practices more sustainable.

Local LMC leaders have warned that patient care could be put at risk by plans to use more PAs to fill gaps in the GP workforce. Tower Hamlets LMC chair Dr Jackie Applebee has said the plans meant ‘downgrading’ GP services for patients. GPs would not have time to supervise them, she said, and ‘diagnoses could be missed’. Dr Applebee said she was concerned NHS leaders could use falling GP numbers as a ‘smokescreen’ for cost savings.

GP Podcast: can skill mix ease GP workforce crisis?

But Dr Aswani said while there were ‘legitimate concerns’ over the plans, GPs should have the vision and courage to ‘improve for the future’. He rejected fears that patient safety could be at risk. ‘High quality service and a safe service is absolutely top of [the] list for us, very, very paramount,' he said. ‘So we wouldn't compromise that.’

The system would ensure physician associates were properly trained, and part of that meant ensuring they understand what they don't know and when to get support from the wider practice team. ‘We've got the evidence - 10 years' evidence,' he said. ‘I can't recall a single incident that was a significant event or a safety issue, that was a concern, that ... our associate didn't act [as] they should have done. And the level of complaint is definitely definitely no higher than any other clinician, so we've got some good evidence to support that.’

Dr Aswani said physician associates could improve continuity of care for patients because they were more likely to be recruited from the local community and therefore to stay with the practice for longer than GPs. ‘Physicians associate are often locally based and very ,very committed. Our physician associate could have left long ago, but she stayed and I'm very, very sure it's a commitment to the team, commitment to the ethos, so I think it's a positive for that,' he said. GPs, he said, ‘tend to move around, tend to leave, so retention is harder.’

Physician associates could also in time start to deal with more complex patients, rather than just minor conditions. ‘Physicians associate are not just seeing minor minor illness,' said Dr Aswani. ’I think that they may start off at that spectrum but they will also develop their level of complexity.’

Increasing the skill mix was also more ‘cost effective’, said Dr Aswani, allowing practices to ‘provide a greater range of services for the same amount of funding’.

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