Ever since interest rates soared to historic norms, many doctors have been struggling to afford the payments on their second yacht. With Rachel Reeves dishing out a 22 per cent pay rise to junior doctors, it was unsurprising when GPs recently voted for industrial action for the first time in 60 years. Not only is the average GP having to sit around chatting to people for a measly £88,000 a year, but — as they never tire of telling us — their surgeries are overstretched and they have to see too many patients. 

I’m being facetious, of course (or am I?) but everyone agrees that GPs spend too much time doing work below their pay grade — repeat prescriptions, dishing out paracetamol, dealing with cuts and bruises, malingerers, lonely old people, etc. — and yet the medical establishment is curiously resistant to any attempt to lighten their load. This week’s proposal from the Tony Blair Institute to replace some GP consultations with artificial intelligence was not met with rapturous applause from our medical overlords. In fact, they hated it. And yet if you speak to any family doctor privately, they will tell you that they spend too much time talking to people who have such trivial or routine ailments that a chimpanzee could diagnose and treat them. Patients, meanwhile, often see GPs as unnecessary gatekeepers to specialists and antibiotics. The solution is obvious: triage patients and send the low level cases to more junior personnel.

Physician Associates (PAs) are one part of that solution. There are around 4,000 PAs working in the NHS, of whom half work in GP surgeries. To become a PA you need a life sciences degree and two years of training. That is less than the five years that is typical of a medical degree, but it is the same as the two year course in nursing for graduates and only a year less than the typical training course for paramedics and advanced clinical practitioners. None of these professions are equivalent to a fully trained doctor, but you don’t alway need to see a doctor when you’re ill and there is good evidence that patients benefit from the use of auxiliary staff. 

Working under the supervision of a doctor, PAs can carry out many diagnostic tests and physical examinations, but they cannot prescribe. If they are uncertain about a diagnosis, they call in a doctor. PAs have been working in the NHS for 20 years and have never been controversial — until now. In 2021, the BMA published a report in which it said “clearly our health services do not only need more doctors; we also need other clinical professionals, including nurses and MAPs (medical associate professions), to deliver high quality care to the population and manage growing patient need.” In February 2024, however, they demanded “an immediate halt to the recruitment of Medical Associate Professionals (MAPs) in the UK, including PAs and AAs [Anaesthesia Associates”. In June, they launched legal action against the General Medical Council because it objected to PAs (and AAs) being described as “medical professionals” (the GMC issued a robust response). 

What changed? Follow the money. Locum doctors have been bleeding the NHS dry for years. Rather than take the responsibility of being a salaried GP or a partner in a surgery, it has paid more to drop out and become a locum. Since there is always a shortage of GPs, especially in the countryside and in less desirable towns and cities, locums have been able to take advantage of a seller’s market in which a wage of £14,000 per month is not unusual. They have to arrange their own pension, but they can come and go as they please, live where they want and make a fortune. 

You can get three PAs for the price of one locum GP

It seemed as if this grift would go on forever. As recently as December 2022, locum doctors were boating on TikTok about making £17,000 a month. One final-year medical student told the Daily Mail that he was “100% going to locum after training” because “the NHS is always short-staffed so locum jobs will always be available”. But it was not sustainable. The locums were pricing themselves out of the market. Unable to afford £14,000 a month for a locum’s casual labour, GP surgeries turned to medical associates to deal with patients who came in with routine complaints. You can get three PAs for the price of one locum GP and by 2024 the locums were whining to the Guardian about being unable to find work for the wages they had become accustomed to.

Fortunately for these doctors, they were represented by a trade union that had become increasingly belligerent. In 2022, the Doctors Vote campaign was formed and led to an effective takeover of the BMA leadership by the hard left. Lured in by the promise of what they dubiously described as “Full Pay Restoration” for junior doctors in the ongoing strikes, the membership voted for Doctors Vote candidates in extraordinary numbers. After the spring 2022 BMA election, 59 out of 60 regional junior doctors representatives were fully signed up to the hardliners’ agenda. Less dramatically, but no less profoundly, there were changes at the top of the Royal College of General Practitioners (RCGP), where Clara Gerada stood down in 2023. Both Gerada and the RCGP had always been supportive of PAs but in June 2024, now under new management, the RCGP called for an immediate “halt to recruitment of Physician Associates in general practice”.

The anti-PA campaign seeks to win hearts and minds with two arguments, both of which are spurious. When NHS workers are protecting their privileges, it is never officially about money but about “patient safety”. To this end, the BMA and their outriders have weaponised the death of a 30 year old woman who died of a blood clot in 2022 after her shortness of breath was wrongly diagnosed as anxiety by a PA. It was a tragic case, but medics at all levels make mistakes, which is why the NHS paid out £2.8 billion in compensation in 2023/24. Earlier this year in Ayrshire, there was a carbon copy of the incident. A patient suffering from breathlessness was wrongly diagnosed with anxiety and prescribed beta blockers, only to die from a pulmonary embolism later in the week. The person who made the misdiagnosis was a GP. Neither the GP nor the patient were ever named and the story was not reported outside the local news. No one suggested that there should be a halt in GP recruitment.

Anyone who defends Physician Associates in public risks facing an onslaught of abuse

The second argument is that the expansion of the PA role is, in some unfathomable way, part of a plan to privatise the NHS. This makes no sense. GP surgeries are already privately owned and the funding model of an NHS hospital is not affected by how many Physician Associates or Nurse Independent Prescribers it employs. The only rational explanation for invoking the deathless bogeyman of NHS privatisation is that it summons midwits to the cause like moths to a flame. Sure enough, professional NHS appreciators such as Daniel Goyal, Rachel Clarke and Julia Grace Patterson have climbed aboard the bandwagon and been amplified by useful idiots like Carol Vorderman and James O’Brien.

Anyone who defends Physician Associates in public risks facing an onslaught of abuse from anonymous accounts claiming (quite plausibly) to be doctors, many of whom tweet about little else. Clare Gerada says the abuse has been “disgraceful”. Wes Streeting has complained about the “the toxic political debate online that is leading to bullying of PAs”. Lord Bethell, a former health minister, says that he has never experienced abuse like that which he received after he supported the expansion of PAs in the NHS:

Rotas and private personal details have been leaked to anonymous accounts. Individuals have been named, victimised, and defamed on social media for being a medical associate. Negative briefings turned into Twitter threads that make implausible claims about patient safety. Some were even publicly falsely accused of crimes. I am told this behaviour has escalated to such extremes that some PAs have received death threats. Doctors showing support are targeted with the same vigour.

This relentless intimidation has led many GP partners to think twice about employing PAs. Sources tell me that over 100 PAs have lost their jobs as a result. On the face of it, the bilious campaign is vastly disproportionate to the “threat” they pose to doctors’ livelihoods. There are 188,000 doctors working in the NHS and only 4,000 PAs. But there are plans to increase the number of PAs to 10,000 in the next 15 years and the medical establishment is thinking ahead. PAs are the tip of an iceberg of emerging professions in the NHS and the campaign against them is the first step in a broader effort by doctors to nobble what they see as cheaper competition. Anaesthesia Associates have already been targeted and other roles, such as advanced nursing practitioners, could be next. As one contributor to a doctor’s forum put it, advanced clinical practitioners (ACPs) are “more difficult to attack” but “if you nail the PA argument (as they are much weaker a cohort) it’s easier to pivot to ACPs”.

The Doctors Vote faction which now dominates the BMA sees the rise of every type of medical associate as a threat to their interests. The interests of patients are rather different. We do not necessarily want to see a doctor when we are ill. We just want to see someone who is going to make us better. That has been notoriously difficult since 2020 and will not get any easier now that GPs are working to rule. The Labour government has so far been happy to dish out pay rises to medics without demanding reform in return. Any future pay settlements should come with the condition that the vicious war on Physician Associates must come to an end.