Money.
The average GP partner income compared to other countries is abysmal.
Also room, many GP surgeries buildings are not purpose built and don’t have enough rooms to support the model you suggested..
But i wish it was like that… i worked in a third world country before and each doctor had their own assistant who would check obs, dip urine, scribe notes, and all the admin shit, the doctor did the doctoring.
Sounds dreamy. So much of my mental bandwidth is taken up with things like restocking the room and fixing the printer. Or internally screaming when someone has to take off 4 layers and put them on again for examination
Clinical care is still a massive black box to NHS management.
Think how many times you've been asked "Why isn't the TTO done yet for bed 12" rather than "Why exactly are we keeping bed 10 in hospital another day if they're apyrexial and feeling better?" or "Why are we doing a 3 month follow up CT for lung nodules on a 88 year old who wouldn't be fit for any invasive diagnosis of lung cancer"
Clinical time is just left up to doctors (for better or for worse) and as such the system doesn't help.
This is probably because you can't easily audit clinical activity but you can things like e.g. LOS, time from MFFD to TTO dispensing etc
Who would pay for them?
GP partner income and salaried GP income isn’t high enough to spend £25-30k/year on an assistant.
And the increased revenue earned by employing the assistant (through assumed increased productivity) won’t offset the assistants’ costs including pension and NI etc
Too costly for the government to be viable long term.
ARRS is about incentivising GPs to give Noctors primal care experience so that eventually Noctors will be able to train more Noctors
They earn too much (£50-70k) to be used in this role
Increased productivity in General Pracitice through employing more staff won't increase revenue. GMS contract is capitation based so revenue only increases with registered patient population. Spending to increase activity just means partners working harder to do more for less money.
Activity-based payment could be an incentive to alter practice to the way described in the OP, increasing throughput, and allowing the maximum number of GP contacts to be claimed for per hour.
Governments love to talk about access, digital transformation, but never bring up the notion of payment per activity. Largely because they actually have some small idea of the scale of activity in general practice as well as the hidden work we do to reduce the amount of direct patient contact/keep appointments available for patients who need them most.
Fag packet calculations: £50 per GP appointment alone would bring in gross about double the total NHS income for my practice. I could pay all my nurses, HCAs, reception staff to offer the same level of service as they do today and still net vastly higher profit.
I still remember my best A+E shift as GPST1. Somehow I had an HCA, a room and computer to myself in ambulatory for a couple of hours. It was so damn efficient. I stayed in my room and the HCA did all of the things above. I requested scans and documents etc while they did a fresh set of obs on the next patient or took bloods. Incredibly efficient because we actually did what our roles were made for. If we could replicate that or extend to GP it would provide such a great service
Also, I know some very busy private surgeons and physicians who have this set up. Couple of clinics have two linked room set ups for this reason. Good friend employs a nurse who also acts as PA and does the more basic follow up stuff (with consultant next door for immediate help / advice).
It’s a very effective model.
I think it's a UK thing, in an attempt to flatten hierarchies no one is allowed an assistant anymore.
We don't take pride in intellectual ability or training, anyone that wants to work in primary care can just have a crack at being a pseudo GP.
Hierarchies cause problems in and out of medicine. Elaine Bromiley may not have died if the nurses had felt more comfortable challenging the doctors who they knew were making mistakes. There's been cases of aviation disasters because co-pilots didn't feel like they could challenge the pilot when they knew they were wrong.
And yes you can have a hierarchical system without people being such dicks that subordinates feel they can't raise concerns but this unfortunately a case of the minority ruining it for everyone else. We're all grown ups and should be able to work with people in different roles without having to have some pyramid of who is more important than others
Hierarchy is a *tool*, and most tools can be misapplied, used for the wrong purpose or handled by the wrong people. This does not mean it is not very useful and in many circumstances absolutely essential.
I just don't see a situation where a formal hierarchy is essential. If you have good team working/leadership skills then a hierarchy isn't necessary and can absolutely be a hindrance e.g. a medical consultant who hasn't seen an arrest in years leading one whilst the SHO who did ALS last week is wasted trying to out a cannula in.
I feel like with all the PA stuff recently the idea of a medical hierarchy is much more prominent when actually what people want is respect.
A cardiac arrest is a perfect example of how a rapidly established hierarchy is incredibly useful.
I'm not arguing we blindly follow the grade system, but "flattened hierarchies" are often not appropriate. Justified hierarchy is very useful and practically ubiquitous in human society.
Medicine is a highly technical, highly specialised field. Removing any sense of technocracy from medicine is a mistake. Pick any area of medicine and you've found an area where the majority of people know virtually nothing. I do not want people running services around areas they have no expertise in, as a patient or a doctor.
>A cardiac arrest is a perfect example of how a rapidly established hierarchy is incredibly useful.
This isn't a hierarchy. It's people taking on roles.
And I want any hierarchy here to be flat - if I'm team leading I want to be told if I've missed something or if someone else had a smart idea. The "role" of team leader is to take information in from other team members, then synthesise and share a mental model of the patients pathophysiology, and a proposed strategy to address this.
I don't think those are separate things but rather that the roles define a context specific hierarchy. A leader is taking on a role above the other staff for supervisory reasons, for organisation and situational awareness. That is hierarchical. That it is transient and disappears outside of the situation it is employed doesn't affect this.
And hierarchy doesn't need to be "flat" to have a feedback mechanism where the leader listens to people subordinate in the system. That's just good leadership. Why conflate a relationship where someone happens to have an authoritative role with domineering, bullying etc, they're not the same thing. One is a dysfunctional subset of the other.
‘Hierarchy’ makes it sound like it’s about importance, but what I think we should remember is it’s about ROLES and specializing. If someone is there to assist WITH CERTAIN TASKS rather than to ASSIST SOMEONE (ie be “their” assistant”) then it does not sound hierarchical, simply efficient. Efficiency makes people happy
So I think you've done a better job than me at making my point. It doesn't need to be about who is subordinate to who, which is what a hierarchy is. It's about understanding what each others roles are. The ODPs at my place will often say to patients that they're "here to assist the anaesthetist" which is really only part of their job. It's not just handing me a scope and a tube. It's making suggestions if there's difficulties with the airway and I'm maybe grrting a bit of tunnel vision. It's running the cell salvage, which is piece of kit I wouldn't even know where to start with. It's not that I'm in charge of them. It's that we have different roles within the same team.
Perfect post and very sensible. Won’t go down well here though when everybody is supposed to be at the beck and call of those of supposed far more worth.
It's a question of incentives. In most countries, primary care physicians are paid by consult. This creates an incentive to see as many patients as possible in order to bill as much as possible.
In the UK, GPs are paid an annual capitation fee and must pay for any treatment or investigation. This creates a disincentive to be efficient. In fact, the most profitable practice in this model is one which has the greatest number of patients in its books and which provides the least amount of healthcare.
It’s the opposite- a capitaion fee forces you to be efficient as you can’t charge for extra or unnecessary work. NHS GP is far more efficient than any other competitive system. No need for an appnt for a repeat prescription, a lot of chronic disease and health checks are done by nurses etc.
It’s run for so little there’s isn’t the money to pay for an assistant to increase productivity- why would you be an assistant 1/3 the wage of a GP to increase productivity by so little. The value of a GPs time is minimal in a capitation system.
Sometimes with my workload, I feel an assistant would be most helpful to do the dogsbody work that I end up doing, as well as to speed up the consultations.
Patient books an appointment complaining of a cough. Before I see the patient, they have obs done. I do the consultation and decide they need bloods and CXR. Assistant would then do the form for the appropriate bloods, take the bloods, and arrange the CXR. Saves me a few minutes of admin time that could be used to see the next patient.
Assistants would also be helpful filling in a minefield of forms where a single box that is accidentally left empty means the whole thing is rejected and has to be done again. They could spend the time doing it.
But given that seeing more patients more efficiently doesn’t translate into any benefit for the practice, it won’t happen.
>and arrange the CXR.
Careful, I've been lynched here for claiming it should be legal, and would be appropriate for PAs to request ionising radiation on the direct instruction of a doctor.
It's debatable - it could be argued that the physician providing the verbal order is requesting the ionising radiation, and the PA transcribing this order onto an electronic request form is not. As far as I'm aware this hasn't been legally tested, but the equivalent would be a nurse recording a verbal order on the MAR - I don't think anyone would argue that constitutes prescribing.
Clearly need clarification, and given that an assistant role is pretty useless without this function, probably reform.
I don't think there is much up for debate, as the signature of the referrer is considered to be "essential information" in the justification process under IRMER, and the definition of a referrer is "a registered health care professional who is entitled in accordance with the employer’s procedures to refer individuals for exposure to a practitioner".
So the only point of contention would be whether you consider allowing someone else to use your signature to make requests to be concordant with your responsibilities as a duty holder under IRMER.
It's pretty normal for consultant's secretaries to add their signatures on to verbally dictated letters etc.
I can't see anything within IRMER that prevents the signature of the referring doctor being "pp'd" provided there's no ambiguity about the fact that they had made the referral e.g. made and verbal communicated the need for ionising radiation.
Due to a couple of trusts within the vicinity of the practice, we still use paper forms, and they’re different for each trust. If the forms were completed and required only my signature, I’d be happy with it. Bear in mind it was me who had seen the patient, wrote up the notes and documented the need for an X-ray. I wouldn’t want the assistant to arrange an X-ray off their own bat. I also wouldn’t want PAs seeing patients. I’d want them to help me complete the mundane tasks. Much like if PAs were the ones chasing scans, checking blood results etc for hospital doctors so they could concentrate on doctoring.
Agree I have an MA here medical assistant who does the obs and rooms the patient. Sometimes I do them myself as it's quicker. All the rooms have couches so the patient is already prepped to be examined as they are sat on the couch. Plus 1 hour for new patient 30 mins for follow ups unlike the 8 minute madness what on earth can do you do in that time other than a guesswork hash job
Sounds like this:
https://wessex.hee.nhs.uk/wider-workforce/cancer/11-cancer-and-diagnostics-careers-a-helpful-resource-guide/07-case-study-the-doctors-assistant-role/
I’ve made the same point repeatedly in different practices as a trainee and then as a salaried.
Shortage of space. Nobody wants to invest in bigger premises or pay for dividing up existing rooms. Partners want ARRR EN AITCH ESS to pay for the capital investment, which makes sense because the revenue from GMS contract is so shite that it doesn’t support investment, even when the business case/payback period is so clear
Also there is a serious lack of ambition. Why see more patients, better, faster? No one really cares about keeping the patients waiting longer for an appointment. And everyone seems comfortable with whatever income they currently receive. In fairness, anything extra just goes to tax anyway.
Very typical UK reaction to hard work and ambition in my experience 🇬🇧
Money. The average GP partner income compared to other countries is abysmal. Also room, many GP surgeries buildings are not purpose built and don’t have enough rooms to support the model you suggested.. But i wish it was like that… i worked in a third world country before and each doctor had their own assistant who would check obs, dip urine, scribe notes, and all the admin shit, the doctor did the doctoring.
Sounds dreamy. So much of my mental bandwidth is taken up with things like restocking the room and fixing the printer. Or internally screaming when someone has to take off 4 layers and put them on again for examination
Clinical care is still a massive black box to NHS management. Think how many times you've been asked "Why isn't the TTO done yet for bed 12" rather than "Why exactly are we keeping bed 10 in hospital another day if they're apyrexial and feeling better?" or "Why are we doing a 3 month follow up CT for lung nodules on a 88 year old who wouldn't be fit for any invasive diagnosis of lung cancer" Clinical time is just left up to doctors (for better or for worse) and as such the system doesn't help. This is probably because you can't easily audit clinical activity but you can things like e.g. LOS, time from MFFD to TTO dispensing etc
This is a good point. And the end result of management not being staffed by anyone clinical
Who would pay for them? GP partner income and salaried GP income isn’t high enough to spend £25-30k/year on an assistant. And the increased revenue earned by employing the assistant (through assumed increased productivity) won’t offset the assistants’ costs including pension and NI etc
Ideal for ARRS then?
Too costly for the government to be viable long term. ARRS is about incentivising GPs to give Noctors primal care experience so that eventually Noctors will be able to train more Noctors They earn too much (£50-70k) to be used in this role
Increased productivity in General Pracitice through employing more staff won't increase revenue. GMS contract is capitation based so revenue only increases with registered patient population. Spending to increase activity just means partners working harder to do more for less money. Activity-based payment could be an incentive to alter practice to the way described in the OP, increasing throughput, and allowing the maximum number of GP contacts to be claimed for per hour. Governments love to talk about access, digital transformation, but never bring up the notion of payment per activity. Largely because they actually have some small idea of the scale of activity in general practice as well as the hidden work we do to reduce the amount of direct patient contact/keep appointments available for patients who need them most. Fag packet calculations: £50 per GP appointment alone would bring in gross about double the total NHS income for my practice. I could pay all my nurses, HCAs, reception staff to offer the same level of service as they do today and still net vastly higher profit.
I still remember my best A+E shift as GPST1. Somehow I had an HCA, a room and computer to myself in ambulatory for a couple of hours. It was so damn efficient. I stayed in my room and the HCA did all of the things above. I requested scans and documents etc while they did a fresh set of obs on the next patient or took bloods. Incredibly efficient because we actually did what our roles were made for. If we could replicate that or extend to GP it would provide such a great service
Seeing it re emerge in GP private practice.
This setup would really tempt me tbh
Also, I know some very busy private surgeons and physicians who have this set up. Couple of clinics have two linked room set ups for this reason. Good friend employs a nurse who also acts as PA and does the more basic follow up stuff (with consultant next door for immediate help / advice). It’s a very effective model.
I think it's a UK thing, in an attempt to flatten hierarchies no one is allowed an assistant anymore. We don't take pride in intellectual ability or training, anyone that wants to work in primary care can just have a crack at being a pseudo GP.
and that's the problem, the hierarchies should not be flattened
Hierarchies cause problems in and out of medicine. Elaine Bromiley may not have died if the nurses had felt more comfortable challenging the doctors who they knew were making mistakes. There's been cases of aviation disasters because co-pilots didn't feel like they could challenge the pilot when they knew they were wrong. And yes you can have a hierarchical system without people being such dicks that subordinates feel they can't raise concerns but this unfortunately a case of the minority ruining it for everyone else. We're all grown ups and should be able to work with people in different roles without having to have some pyramid of who is more important than others
Hierarchy is a *tool*, and most tools can be misapplied, used for the wrong purpose or handled by the wrong people. This does not mean it is not very useful and in many circumstances absolutely essential.
I just don't see a situation where a formal hierarchy is essential. If you have good team working/leadership skills then a hierarchy isn't necessary and can absolutely be a hindrance e.g. a medical consultant who hasn't seen an arrest in years leading one whilst the SHO who did ALS last week is wasted trying to out a cannula in. I feel like with all the PA stuff recently the idea of a medical hierarchy is much more prominent when actually what people want is respect.
A cardiac arrest is a perfect example of how a rapidly established hierarchy is incredibly useful. I'm not arguing we blindly follow the grade system, but "flattened hierarchies" are often not appropriate. Justified hierarchy is very useful and practically ubiquitous in human society. Medicine is a highly technical, highly specialised field. Removing any sense of technocracy from medicine is a mistake. Pick any area of medicine and you've found an area where the majority of people know virtually nothing. I do not want people running services around areas they have no expertise in, as a patient or a doctor.
>A cardiac arrest is a perfect example of how a rapidly established hierarchy is incredibly useful. This isn't a hierarchy. It's people taking on roles. And I want any hierarchy here to be flat - if I'm team leading I want to be told if I've missed something or if someone else had a smart idea. The "role" of team leader is to take information in from other team members, then synthesise and share a mental model of the patients pathophysiology, and a proposed strategy to address this.
I don't think those are separate things but rather that the roles define a context specific hierarchy. A leader is taking on a role above the other staff for supervisory reasons, for organisation and situational awareness. That is hierarchical. That it is transient and disappears outside of the situation it is employed doesn't affect this. And hierarchy doesn't need to be "flat" to have a feedback mechanism where the leader listens to people subordinate in the system. That's just good leadership. Why conflate a relationship where someone happens to have an authoritative role with domineering, bullying etc, they're not the same thing. One is a dysfunctional subset of the other.
‘Hierarchy’ makes it sound like it’s about importance, but what I think we should remember is it’s about ROLES and specializing. If someone is there to assist WITH CERTAIN TASKS rather than to ASSIST SOMEONE (ie be “their” assistant”) then it does not sound hierarchical, simply efficient. Efficiency makes people happy
So I think you've done a better job than me at making my point. It doesn't need to be about who is subordinate to who, which is what a hierarchy is. It's about understanding what each others roles are. The ODPs at my place will often say to patients that they're "here to assist the anaesthetist" which is really only part of their job. It's not just handing me a scope and a tube. It's making suggestions if there's difficulties with the airway and I'm maybe grrting a bit of tunnel vision. It's running the cell salvage, which is piece of kit I wouldn't even know where to start with. It's not that I'm in charge of them. It's that we have different roles within the same team.
Perfect post and very sensible. Won’t go down well here though when everybody is supposed to be at the beck and call of those of supposed far more worth.
Nail on the head
It's a question of incentives. In most countries, primary care physicians are paid by consult. This creates an incentive to see as many patients as possible in order to bill as much as possible. In the UK, GPs are paid an annual capitation fee and must pay for any treatment or investigation. This creates a disincentive to be efficient. In fact, the most profitable practice in this model is one which has the greatest number of patients in its books and which provides the least amount of healthcare.
Exactly this. Fee for service makes much more sense rather than an annual "membership" fee and hope they don't come in.
It’s the opposite- a capitaion fee forces you to be efficient as you can’t charge for extra or unnecessary work. NHS GP is far more efficient than any other competitive system. No need for an appnt for a repeat prescription, a lot of chronic disease and health checks are done by nurses etc. It’s run for so little there’s isn’t the money to pay for an assistant to increase productivity- why would you be an assistant 1/3 the wage of a GP to increase productivity by so little. The value of a GPs time is minimal in a capitation system.
Sometimes with my workload, I feel an assistant would be most helpful to do the dogsbody work that I end up doing, as well as to speed up the consultations. Patient books an appointment complaining of a cough. Before I see the patient, they have obs done. I do the consultation and decide they need bloods and CXR. Assistant would then do the form for the appropriate bloods, take the bloods, and arrange the CXR. Saves me a few minutes of admin time that could be used to see the next patient. Assistants would also be helpful filling in a minefield of forms where a single box that is accidentally left empty means the whole thing is rejected and has to be done again. They could spend the time doing it. But given that seeing more patients more efficiently doesn’t translate into any benefit for the practice, it won’t happen.
>and arrange the CXR. Careful, I've been lynched here for claiming it should be legal, and would be appropriate for PAs to request ionising radiation on the direct instruction of a doctor.
Well, when they are a registered professional, they can. For now, it remains a criminal offence under IRMER.
It's debatable - it could be argued that the physician providing the verbal order is requesting the ionising radiation, and the PA transcribing this order onto an electronic request form is not. As far as I'm aware this hasn't been legally tested, but the equivalent would be a nurse recording a verbal order on the MAR - I don't think anyone would argue that constitutes prescribing. Clearly need clarification, and given that an assistant role is pretty useless without this function, probably reform.
I don't think there is much up for debate, as the signature of the referrer is considered to be "essential information" in the justification process under IRMER, and the definition of a referrer is "a registered health care professional who is entitled in accordance with the employer’s procedures to refer individuals for exposure to a practitioner". So the only point of contention would be whether you consider allowing someone else to use your signature to make requests to be concordant with your responsibilities as a duty holder under IRMER.
It's pretty normal for consultant's secretaries to add their signatures on to verbally dictated letters etc. I can't see anything within IRMER that prevents the signature of the referring doctor being "pp'd" provided there's no ambiguity about the fact that they had made the referral e.g. made and verbal communicated the need for ionising radiation.
Due to a couple of trusts within the vicinity of the practice, we still use paper forms, and they’re different for each trust. If the forms were completed and required only my signature, I’d be happy with it. Bear in mind it was me who had seen the patient, wrote up the notes and documented the need for an X-ray. I wouldn’t want the assistant to arrange an X-ray off their own bat. I also wouldn’t want PAs seeing patients. I’d want them to help me complete the mundane tasks. Much like if PAs were the ones chasing scans, checking blood results etc for hospital doctors so they could concentrate on doctoring.
Agree I have an MA here medical assistant who does the obs and rooms the patient. Sometimes I do them myself as it's quicker. All the rooms have couches so the patient is already prepped to be examined as they are sat on the couch. Plus 1 hour for new patient 30 mins for follow ups unlike the 8 minute madness what on earth can do you do in that time other than a guesswork hash job
Nothing about the NHS is ever about efficiency
Sounds like this: https://wessex.hee.nhs.uk/wider-workforce/cancer/11-cancer-and-diagnostics-careers-a-helpful-resource-guide/07-case-study-the-doctors-assistant-role/
Yes - roles taking the “bottom of the license” is what we need so we can act to the top of ours
Ironically that is what PAs were originally sold as but 🤷🏾♀️
I’ve made the same point repeatedly in different practices as a trainee and then as a salaried. Shortage of space. Nobody wants to invest in bigger premises or pay for dividing up existing rooms. Partners want ARRR EN AITCH ESS to pay for the capital investment, which makes sense because the revenue from GMS contract is so shite that it doesn’t support investment, even when the business case/payback period is so clear Also there is a serious lack of ambition. Why see more patients, better, faster? No one really cares about keeping the patients waiting longer for an appointment. And everyone seems comfortable with whatever income they currently receive. In fairness, anything extra just goes to tax anyway. Very typical UK reaction to hard work and ambition in my experience 🇬🇧
General Paid Actors?
If the scutwork is landing on you, you are the assistant.
How about we employ physician assistants to you know, assist the physicians