The (not a) doctor will see you now. Is there a non-doctor problem in NE London?

NE London Save Our NHS (NELSON) ¹ – which brings together four groups affiliated with Keep Our NHS Public – is currently mapping and monitoring the use of Physician Associates across the NE London Integrated Care System.

Summary
Physician Associates (PAs), who qualify after just two years of study, following a degree that may be entirely unrelated, are increasingly taking over the work of doctors in our hospitals and GP surgeries.

Where PAs are actively being used to substitute for doctors, instead of assisting doctors, patients are regularly getting poor quality care and some have even died.

Our NELSON umbrella group decided to map their use in the area covered by NHS North East London.

Through Freedom of Information (FOI) requests sent out in April 2024, we learned that:

• Barts Health NHS Trust (five hospitals) has 14 PAs in emergency care and trauma, renal, oncology and neurology. They see undifferentiated patients (who need their symptoms diagnosing) and sometimes hold emergency bleeps.
• BHRUT (Barking, Havering and Redbridge University Trust – two hospitals), which took a staggering 102 working days to respond to our FOI, has 19 PAs rotating between acute and emergency medicine. In acute medicine, they do not see undifferentiated patients or work on a doctor’s rota. However, in the emergency department, they are part of a ‘mixed’ rota and are ‘counted towards the number of medics on shift in the Emergency Department’. They see undifferentiated patients who are also seen by a senior decision maker (a consultant or registrar). They are not on the on-call rota and do not hold bleeps.
• Homerton Healthcare (one hospital) has no PAs.
• NELFT (NE London Foundation Trust) has two PAs on a patient ward.
• ELFT (East London Foundation Trust) has five PAs in three outpatient departments.

Through desk-based research in May 2024, we found 84 PAs working in GP surgeries:

• Three in Barking and Dagenham
• 13 in City & Hackney
• Five in Havering
• 28 in Newham – including one twinned practice with eight PAs and only four GPs to serve a growing patient list of 15,000 – a patient is following this up with  FOI response from these surgeries
• Nine in Redbridge
• 19 In Tower Hamlets
• Eight In Waltham Forest

Our FOIs and research have given us useful baseline data for local campaigning.
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[FULL ARTICLE]

The (not a) doctor will see you now. Is there a non-doctor problem in NE London?

Background

Physician Associates (PAs) and Anaesthetic Associates (AAs) have been hitting the headlines in recent months, as patients and doctors wake up to the dangers of having people with very limited training taking over the work of medics in our hospitals and GP surgeries. There are detailed articles about this issue on this website here and here.

Where we stand

Our NELSON group is clear that employing lesser trained staff is not the way to tackle skills shortages. We need to train and recruit more fully qualified doctors – and we need to retain the staff we have by paying them properly and treating them better, so they don’t drop out of the NHS workforce.

The political storm over the use of PAs is growing in momentum, as medics in the BMA and various medical colleges are working to get the roll-out and training of new PAs put on pause.

We need to be sure that existing PAs are only working to their skills level. They should not be seeing ‘undifferentiated’ patients – who are presenting their symptoms for diagnosis. They should always be fully supervised by a doctor who is on the premises. We need to ask hard questions about whether we should be training more PAs at all.

We don’t blame PAs or AAs for the current crisis. We think they were sold a lie – that becoming an associate could be a short-cut to becoming a doctor. Whatever happens next, these are staff who may need support to work differently or to rethink their options.

In the meantime, we think local campaigning groups can play an important role by keeping track of what is happening in their areas.

How we are tracking PAs/AAs in NE London

HOSPITAL TRUSTS

In early April 2024, we sent out freedom of information requests to the five NHS Trusts that operate in the area covered by the ICS (Integrated Care System) for NE London.

We wanted to know how many PAs and AAs they employed and in which departments. We asked whether they ever used non-doctors on medical rotas or counted them towards the minimum safe number of medics on shift. We asked whether their PAs are clearly identifying themselves to patients as non-doctors.

We also asked if their PAs/AAs had ever prescribed medications or ordered ionising radiation. Although this is not permitted, some trusts have been allowing this to happen.

Crucially, we also asked:

Do the Trust’s PAs or AAs ever work unsupervised (without a supervising medical practitioner in the same or nearby room), see undifferentiated patients, act as on-call medics, or hold emergency bleeps?

What we learned: acute hospital trusts

Barts Health NHS Trust covers St Bartholomew’s, the Royal London, Whipps Cross, Newham University and Mile End Hospitals. They responded that the Trust has no AAs, but it has a total of 14 PAs in emergency care and trauma, renal, oncology and neurology across all sites. They say their PAs are not used as on-call medics. They do not work unsupervised: a senior clinician “will always be available to provide support and guidance”. But they failed to confirm that their PAs are always being supervised by someone on the premises. They also confirmed that their PAs do see undifferentiated patients and do hold emergency bleeps.

BHRUT (Barking, Havering and Redbridge University Trust) covers the King George and Queen’s Hospitals. They responded very late (102 working days) to confirm that they employ 19 PAs and no AAs. Their PAs rotate between acute and emergency medicine. In acute medicine, they work in the Medical Assessment Unit at King George and in the Sky ward (short stay) at Queens. They do not see undifferentiated patients and they have not worked on a doctor’s rota. However, in the emergency department, doctors, advanced clinical practitioners and PAs are part of a ‘mixed’ rota and are“counted towards the number of medics on shift in the Emergency Department”. In an article published on 15 March 2024, The Telegraph found a PA working both on a non-doctor rota and taking a locum shift as a junior medic at the Queen Elizabeth Hospital in Woolwich. The trust described this as rare and a last resort “to ensure patient safety”. In their FOI response to us, BHRUT confirmed that PAs in the Emergency department do see undifferentiated patients but that all patients arriving in the ED are also seen by a senior decision maker (a consultant or registrar), who makes the initial plan. PAs are not on the on-call rota and do not hold bleeps – they do work day and night shifts. There is a 24-hour consultant presence at Queens and at both hospitals they are always supervised by a senior doctor.

Homerton Healthcare told us that they employ no PAs or AAs at Homerton Hospital.

What we have learned: foundation trusts

Our two foundation trusts, which operate mainly in NE London, focus mostly on mental health, as well as providing other services.

NELFT (NE London Foundation Trust) has confirmed that it has two PAs on a patient ward at Goodmayes Hospital.

ELFT (East London Foundation Trust) reported that it has five PAs: in forensic inpatient services, the community eating disorders service, and the child and adolescent ADHD pathway.

PRIMARY CARE

More than half of PAs are employed in primary care via Primary Care Networks. Following a series of critical articles in the Daily Telegraph, in March 2024, NHS England issued new guidance about their use to all GP practices, copied to their Integrated Care Systems.

We referred to this guidance in an FOI to our ICS – NHS North East London – in early April 2024.

We asked whether the ICS tracks the number of PAs being employed in general practice in NE London and if it could provide a recent headcount, with a breakdown by borough. We asked detailed questions about how the ICS would monitor the way PAs are being used in general practice, in line with the guidance. We also asked whether it would meet wider concerns by ensuring PAs do not see undifferentiated patients or replace GP roles, and whether it would make sure each practice provides an appropriate number of appointments with fully qualified GPs.

What we learned from the ICS

The ICS said we could get this information elsewhere and unhelpfully referred us to NHS Digital. However, they did tell us that NE London’s Primary Care Networks (PCNs) had submitted funding claims for 72 PAs by December 2023. (This contradicted NHS Digital’s March 2024 tables 6a and 6b, which gave a figure of 47 PAs – with 45 full-time equivalents.) The ICS answered none of our other questions on the grounds that monitoring is a PCN responsibility. They did, however, state that they intend to develop criteria for the use of PAs in the near future.

What we learned via PCN and surgery websites

We decided to find out more by checking the websites of every GP surgery and PCN in NE London. In all, our desk-based research came up with 84 PAs. Note that it was sometimes difficult to determine whether PCN and GP websites were referring to the same staff, or to decide which practices operating at different sites were separate.

In Barking and Dagenham (c33 practices), many practices are very small, typically with one or two GPs and perhaps a nurse. Where they had no website to check, we assumed they would have no PAs. In all, we found two PAs based at one practice and one at a PCN.

In City & Hackney (c39 practices), some practices listed one or two PAs, for a total of 13 in the borough.

In Havering (c38 practices), we found five PAs.

In Newham (c46 practices), we found 28 PAs. Shockingly, one twinned practice employs eight PAs and only four GPs to serve a growing patient list of 15,000. A patient has followed this up with questions to the practices involved – which it is treating as an FOI request.

In Redbridge (c42 practices), we found nine PAs. Four are based at one practice, formerly owned by a US health giant and now by a private equity company.² (This practice also lists 11 GPs.)

In Tower Hamlets (c30 practices), we found 19 PAs. Four are based at a practice formerly owned by the same US health giant and now by a private equity company.² This practice also lists 11 GPs.

In Waltham Forest (c39 practices), we found eight PAs.

What happens next

This has been an important piece of work for the NELSON group.

Our FOIs (some still outstanding) have strongly flagged our concerns and given us useful baseline data, which we can now match to the stories we hear when out campaigning, or when we are talking to our neighbours.

We will continue to track what is happening locally, so that we can also respond as the situation develops nationally.

Footnotes

1. NELSON is the regional umbrella group for: Hackney KONP, Newham Save our NHS, Tower Hamlets KONP and Waltham Forest Save Our NHS.
2. The Centene Corporation, through its UK subsidiaries Operose Health and AT Medics, took over a large number of surgeries in 2021, before selling them on to a private equity company in December 2023. The poor quality of care offered by this company was highlighted by a Panorama documentary.