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NOEL J. GENOVA, MA, PA-C, SERIES EDITOR

General practice in the UK’s National Health Service

John E. Lopes Jr, DHSc, PA-C

The author works at Dr. Andreou and Partners, Oldbury Health Centre, Oldbury, West Midlands, UK. He has indicated no relationships to disclose relating to the content of this article. Noel Genova works in a private GP surgery and in a Foundation Practice serving primarily asylum seekers and refugees, both in Birmingham, West Midlands, UK, for Heart of Birmingham Teaching Primary Care Trust.

There is increasing interest in the recruitment of US-trained PAs to work within the National Health Service (NHS) of the United Kingdom (England, Wales, Scotland, and Northern Ireland). The UK, like many countries, suffers from inequitable distribution of health care providers and difficulties with patient access to care. To address this problem, an innovative medical practice in the West Midlands decided to see if US-trained PAs could fill the service delivery gap. After the successful recruitment of two PAs, the local health organizations decided to expand the experiment by recruiting another 14 PAs to work in primary care and emergency services. As stories of the success of this initial pilot project spread, other regional bodies became interested. At the same time, the Department of Health was examining expanded roles for nurses, pharmacists, and allied health professionals, including the development of a PA-like provider in order to draw new science graduates into the health service. Advertisements for UK positions may now be found in the classified sections of JAAPA and AAPA News and on the PA Job Link on the AAPA Web site (www.aapa.org). Many of the ads are for PAs to work in primary care. Although the practice of medicine in the United States and in the UK has many similarities, there are also significant differences in the ways that health care is delivered. With this in mind, PAs may find it helpful to have a primer on general practice in the NHS.

A bit about the NHS

An Act of Parliament in 1946 established the NHS in the United Kingdom.¹ The NHS replaced a private system in which health care was accessible primarily to those who could pay with one intended to provide health care services to all residents of the UK, free at the point of service. The NHS, almost 60 years later, continues to meet this goal.

Under a structure established in 2002, Primary Care Trusts (PCTs) control the distribution of about 80% of the NHS budget.² PCTs are locally controlled organizations serving a defined geographic area.³ They are charged with commissioning or contracting for health care services within the borders of their area. These services include community-based primary care, hospital-based secondary care, and dental, community mental health, and community nursing care. The board of trustees for a PCT is composed of community members, and a chief executive hired by the board leads day-to-day operation. The Professional Executive Committee, made up of representatives from the clinical services, advises the board on clinical matters. Programs like smoking cessation, outreach to ethnic minorities, and health promotion are also provided by the PCT. Information on individual PCTs may be accessed online by going to www.nhs.uk and typing PCT into the search function.

The general practitioner

The general practitioner (GP) is key to the delivery of primary care. This primary care doctor provides the majority of care in the NHS and serves as a gatekeeper for secondary care services.^4,5 All other medical and surgical specialty care is provided by physicians and surgeons employed by hospitals and is by referral only. GPs are called doctors, hospital-based medical providers are called physicians but are addressed as Doctor, and surgeons are titled Mister, Miss, or Mrs, as they prefer.

GPs provided more than 300 million consultations in the UK in 2003; patients average five visits per year with their GP. When the NHS was established in 1948, GPs agreed to provide services to a defined list of patients and provide 24-hour accessibility. With the establishment of the NHS, all residents of the UK were required to register with a single GP, thus providing universal availability of primary care services for the UK population for the first time

In 2004, the General Practice Council of the British Medical Association and the NHS Confederation, the representative body of NHS managers, completed the negotiation of a new national contract for General Medical Services (GMS).⁶ The new contract contains several major changes in the way GPs are paid and in the services they are required to provide.⁷

The new contract redefines services into essential, additional, and enhanced categories.⁸ All GPs are required to provide essential services. Additional payments are available for GPs who agree to provide enhanced services, which include substance abuse treatment prescription monitoring, minor injuries service, service to the homeless, and anticoagulant monitoring. Probably the biggest change in the payment methodology is a “pay-for-performance” provision called the Quality Outcomes Framework (QOF), which will be discussed in a future article in this series.

In 1948, when the NHS was established, the UK had approximately 18,000 GPs, mostly male, single-handed, and working out of their homes.⁹ That number is now closer to 35,000, but many GP offices—called surgeries—continue to be operated out of converted residences. Recognizing the inadequacy of many of these structures, the NHS has committed funding to renovate or replace many old buildings and to improve working conditions for primary care providers.¹⁰ As an example, most examination rooms are furnished with a flat, padded table similar to those found in physiotherapy departments. No stirrups are provided, so pelvic examinations are done with the patient in the frog-leg position and the examiner on the side of the exam table.

GP practice

GPs continue to be considered independent contractors within the NHS, even though they operate under the guide of a nationally negotiated contract. Normal working hours (called in-hours) are generally between 8:00 AM and 7:00 PM weekdays and between 8:00 AM and 1:00 PM Saturdays.⁵ A full-time GP is expected to work at least 26 hours per week, although the average is closer to 39 hours per week. The new contract relieved GPs of their responsibility for providing 24-hour services to their patient list.

Noel Genova and Kiran Kumar discuss a patient’s care at Heart of Birmingham’s Lansdowne Health Center.

The workday is divided into a morning session of about 3 hours and an afternoon session of 2 hours. A full-time GP will work at least eight sessions per week. The clinical day usually starts at 9:00 AM, and the morning session will run until noon with patients typically scheduled at 10-minute intervals (10 minutes is the minimum length of time allowed under the NHS Plan). After the morning session, the GP will tend to paperwork, dictate referral letters, sign the morning’s repeat prescriptions, and check returned lab and x-ray reports. After time out for lunch, house calls are conducted in the early afternoon, with the afternoon session starting at about 4:00 PM and ending at 6:00 PM.

The length and timing of the sessions may be adjusted to account for seasonal demand or out-of-office meetings and responsibilities. If the GP will be out of the office during normally scheduled hours, he or she is responsible for arranging for and paying a locum GP to cover the session. This coverage ranges from single session for a meeting to 2 weeks for a vacation.

Medications are licensed for use by the Medicines and Healthcare products Regulatory Agency (MHRA) (www.mhra.gov.uk). The official publication listing the licensed indications and dosing regimens for medications is the British National Formulary, available online at www.bnf.org, produced by the British Medical Association and the Royal Pharmaceutical Society of Great Britain. Prescribing of certain high-cost medications and the off-license use of medications may be limited and require the recommendation of hospital consultants. GPs tend to follow the licensing and dosing recommendations quite strictly. Drug names conform to the Recommended International Non-Proprietary Name, and spellings may be confusing at first. Trade names for some medications are also different in the UK. As unregistered practitioners, PAs working in the NHS are not currently able to sign prescriptions, so waiting in the hall for a signature is part of PA practice in England.

Medications are free for children up to age 16 years (18 years if the patient is attending school full time), pregnant women, patients older than 60 years, patients with diabetes or hypothyroidism, and patients claiming certain social or tax benefits. Otherwise, a prescription charge of £6.50 (approximately $11.35) applies for each medication.

American PA Noel Genova labels a culture tube as part of her preparation for seeing a patient.

In-office laboratory services are usually limited to dipstick urine testing, pregnancy tests, and finger-stick blood glucose determinations. The local hospital provides a courier service to transport other specimens and to deliver supplies and reports. Laboratory values are reported in millimols per liter, so some review of basic biochemistry may be in order. PAs will recognize most of the laboratory tests, but the makeup of organ-specific testing panels is different from that in the United States. As noted previously, PCTs commission health care services, and this includes laboratory testing. PCTs may limit the availability of some testing in order to reduce costs. Some practices offer ECGs and spirometry, while others refer these tests to local diagnostic centers. Because of time constraints, GP training and interest, and issues with facilities and personnel, the range of in-office procedures available varies widely within the NHS. PAs are likely to find that many of the procedures they are used to providing in primary care—including minor surgery, wound care, fracture care, and point-of-care testing—will be unavailable in the UK.

Almost all radiologic services are provided by hospitals, even in community-based imaging centers. Access to services such as CT, MRI, and ultrasonography are generally limited for the GP because of lack of access to staff and equipment. Scanners and other equipment for complex diagnostic procedures are located in hospitals and are generally restricted to use only on the request of a consultant. One of the difficulties the lack of GP access to diagnostic services presents is the need to refer patients with undefined conditions to the hospital for a specialist consultation. This often lengthens the time before a definitive diagnosis and appropriate treatment are provided since the GP must make the referral decision based only on clinical acumen and intuition. Investment programs proposed by the government are in place to increase the number of diagnostic centers available in the NHS.¹¹

Practice nurses and health care assistants provide nursing services within the GP surgery. A GP may have one or more part-time or full-time nurses and health care assistants, depending on patient demand. Unlike in a US physician office, where nurses assist physicians with patient care and handle most telephone interactions with patients, practice nurses in a GP surgery provide much of the chronic disease management, some acute care services, family planning services, and cervical (Pap) smears, depending on training and qualifications. Nurses have their own scheduled patient load each day. If a nurse is out for a vacation, meeting, or illness, the GP may not have any nursing support for that period of time unless a locum nurse is brought in.

District Nurses provide the equivalent of home health nursing services.⁵ District nursing services are commissioned by the PCT and may be accessed directly by patients, without going through the GP. Infant and child developmental services before school age are provided by Health Visitors, specially trained nurses who provide clinic and home-based services for developmental reviews and immunization services. During primary school, a school nurse will monitor vaccination compliance, hearing and vision status, and developmental milestones. Community nurse-midwives and Health Visitors provide training and support for new mothers and their children. Nurses are often the first contact point in the health system for infants, children, and pregnant women. District Nurses, Health Visitors, and midwives often refer patients to GPs to address concerns raised during home or clinic visits. Some nurses are called nurse practitioners, but they generally do not fit the US model for an NP. The Nurse and Midwifery Council is working on standardizing the practice of nursing.

All information technology services, hardware, and software became the responsibility of the PCT under the new GMS contract. Therefore, almost all GP practices are computerized, and most use an electronic records system. Although the clinician can use a point-and-click system based on key words to document a visit, documentation in free text under general or specific diagnostic headings is generally quicker, so brushing up on keyboard skills may be in order.

In place of the two separate coding systems (ICD-9-CM and CPT) familiar to US providers, the UK uses a single system of Read Codes (devised by a Dr. Read) that uses alphanumeric codes to describe procedures, diagnoses, conditions, signs, and symptoms. The goal of the NHS is to have a universally accessible electronic health record in place for every patient.¹² Before the advent of the electronic record, notes were kept on Lloyd-George cards (approximately 4x6 inches) and were minimal at best. Even now, the extent of documentation present in UK records is significantly less than that expected in the United States.

Referrals for hospital consultations are generally done on letterhead and forwarded to the hospital’s appointment department. Under the current NHS Plan, the government’s goal is to reduce waiting times from GP referral to definitive treatment to 18 weeks or less. Referrals for urgent conditions such as suspected cancers, heart failure, breast lumps, and cardiac chest pain are usually made on a special form and faxed to the particular hospital department, and the patient is expected to be seen within 2 weeks.

If a GP determines that a patient requires immediate inpatient care, the GP will contact the local hospital and arrange for an emergency assessment. The patient will go to the hospital (or be transported by ambulance), where house staff will do an evaluation. Urgent evaluations normally conducted in the office or other outpatient setting in the United States are conducted in hospital-based emergency assessment units in the UK. Problems a PA would normally expect to manage in the office are now referred to the hospital. Except in some rural general hospitals, GPs do not provide inpatient care.

Conclusion

An article such as this can provide only a snapshot view of the operation of a GP surgery. Although many functions are common to all GP surgeries, each surgery is unique, depending on the personality of the GP, the locality in which it operates, and the patient population served. The limited access to diagnostic modalities means that good history taking and physical examination skills are essential, as is the ability to provide empiric treatment after a provisional diagnosis is made. PAs are likely to feel some frustration over differences in the operation of the US and UK systems, but they must make adjustments to accommodate those differences. My experience working in the UK has been most rewarding. I hope that this review will give PAs considering a move to the NHS a bit more information on which to base their decision.

The author would like to thank Helen Serbousek, PA-C, Black Country Family Practice, Tipton, West Midlands, for reviewing the manuscript.

REFERENCES

1.
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2.
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3.
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4.
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7.
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8.
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