MA MRCP MRCGP
Jeremy is a GP in Battersea, South London. He is also director of the Wandsworth Primary Care Research Group and clinical lead for the Battersea practice-based commissioning cluster
Thinking one day about the amount of my workload related to paper or communication, I realised I could benefit from more support in this area. GPs, who currently earn a salary equivalent to a chief executive, do not routinely have a personal assistant (PA). Practice managers might consider what additional services might support their GPs and other clinical staff to be more productive.
In my job, I do five clinical sessions a week. I also direct the local research group and am clinical lead for our practice-
based commissioning (PbC) cluster. I was finding that I had a lot of meetings to arrange and attend, and a lot of clinical and nonclinical paperwork.
Certainly, personal organisational skills are not part of the medical curriculum. It was in fact a book on organisation skills – Getting Things Done: The Art of Stress-Free Productivity by Dave Allen (not the comedian!) – that set me on the path to organisational nirvana.(1)
I decided to employ a PA: Yemi, a qualified doctor from Nigeria, who works with me for approximately one hour a day. Yemi did house jobs and senior house officer (SHO) jobs in Nigeria before coming to the UK. Yemi is 30 years old and aims to work as a full-time GP. However, he didn't get onto the last round of the GP vocational training scheme, so he is currently applying for SHO work.
I considered the list of jobs that could be done by someone other than myself and came up with a list of nonclinical (see Box 1) and clinical tasks (see Box 2).
Nonclinical tasks for a PA
I use nhs.net for my email address and at the surgery it is connected to Outlook, which makes it much faster. It is, however, plagued by junk mail. Yemi deletes all the junk every morning. He forwards wanted mail into the inbox. He allocates "always accept" labels to those emails that we know are not junk and, by creating a large number of inbox subfolders (current tally: 139 boxes), email can be quickly filed.
Nhs.net has a good diary function that can make new appointments and carry forward meetings that occur each month. It also alerts you of meetings in advance by text. Yemi arranges meetings and puts them in the diary, letting me know in advance what is happening at our biweekly meeting. Before Yemi started running my diary, I had four outstanding appraisals to do that stacked up over four months – he managed to clear them within a fortnight.
We use a dated, expandable file that holds all upcoming appointments, letters, advertising meetings and conferences. These are moved forward from sections devoted to future months into a section devoted to the current month, so they can be reviewed in time to book the conference or attend the meeting. Doing this achieves a sense of being in control of future events.
A central tenant of the Getting Things Done philosophy – "do, defer or file" – is feeling confident that you can find a document when you need it. We have built a filing system of hanging files, containing just one document folder in each hanging file, labelled by the trusty Brother printer.
So far we have created 54 clinical files and 103 management files. The documents within them can be accessed much faster than those available on my computer and can be taken to the relevant meeting. Yemi files used documents and keeps an index of document names and file names for cross reference.
Clinical tasks that a PA can do
The tasks that a PA with some clinical training could do are listed in Box 2.
Sorting hospital letters
Yemi sorts outpatient letters by: new appointments; follow-ups; follow-ups that are being discharged; and A&E attendances. Seeing all the A&E letters together brings home the number of attendances that my patients are making. The letters are highlighted and diseases are coded, and any actions that I need to take are brought to my attention, which can be on the same day as the letter arrives – but without me having to read all the other letters first!
Checking electronic results
I ask Yemi to approve for filing all results that come back as "normal". Although many GPs would like to see their normal results, doing so can delay the results being cleared for approval by the clinician, which allows the receptionists to tell patients who ring up that they are normal.
These can build up and tend to have the lowest priority on my desk. Yemi can help with some of the queries by reviewing the medical records and I can sign them off when he has done this.
Yemi contacts a small number of patients that I select – he phones them to maintain contact and give extra support as required, and can easily alert me to any problems these patients have. This is perhaps the most rewarding part of the job for Yemi. Again, it is perhaps unnecessary to have a clinician do this because there is no clinical responsibility for the decisions involved. I recognise that some of my patients need more input than I can give them. A PA can present the problem to myself much more quickly than the patient and get a decision as to what needs doing.
Another group of patients may not have a specific request but value the benefit of regular contact. Currently, Yemi telephones four patients weekly. We are currently expanding this group as the concept gains ground. This method could prevent acute hospital admissions – for example, in chronic obstructive pulmonary disease (COPD) patients. It could also enable individuals to achieve exercise targets, for instance, which could reduce diabetic requirements for insulin or achieve abstinence in alcoholics.
Overall benefits of a PA
I have estimated the time saved by having a PA doing the jobs I have described. On balance, I think it might take me up to two hours a day to do all the tasks listed. However, the main advantage is not the time benefit but the sheer number of different tasks a PA can perform, which releases your brain for more creative energy.
Job satisfaction for the PA
Yemi's role has evolved over a number of months and has meant that he has remained in clinical contact while looking for a substantive post. While some of the work is repetitive, he is a member of the primary care team and gets an insight into its function.
Working for a senior clinician also gives him an insight into the research world and into NHS management. He has contributed to a research publication, giving him authorship that should help him get a job in the near future. There are many doctors like Yemi around, who could benefit from initial work as a GP PA.
Other approaches to supporting GPs
The tasks outlined above involve no autonomous decision-making on behalf of the PA and as such require no formal medical training. However, the letters PA can also stand for Physician Assistant, a separate vocation to the one outlined here.
Physician assistants work in primary care, where they see unsorted nonspecific patient groups.(2,3) They can also obtain medicolegal cover from the Medical Defence Union (MDU) at rates equivalent to a nurse practitioner.
Physician assistants are becoming gradually established in this country – roughly 20 are currently working – although their employment has been slower than was originally anticipated. The UK Association of Physician Assistants promotes their work (see Resource).
Another novel approach to increasing the workforce in primary care would be to employ qualified doctors – perhaps from overseas, like Yemi – who would normally be looking for SHO jobs in secondary care.
Such doctors are eligible for General Medical Council (GMC) registration once they are employed and can therefore prescribe. They cannot work as GPs, as they will not have been vocationally trained, but can nevertheless do specific work, such as chronic disease clinics. Section 46 of the GMC handbook allows for this possibility and, again, the MDU may be prepared to indemnify such individuals.
Things can sometimes evolve very slowly in primary care but I have tried to show in this article that there is potential for additional support for GPs – both organisational and clinical support – and that a change in working practice may need to be facilitated by the practice manager.
With thanks to: Vanita Patel, PA to Wandsworth PCT Chief Executive, who advised us on the role of a chief executive's PA; Lindsay MacKenzie, GP, Wootton Vale Healthy Living Centre, who advised on the role of a PA in primary care.
UK Association of Physician Assistants