The role of physician associates in secondary care: the PA-SCER mixed-methods study

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 14/19/26. The contractual start date was in October 2015. The final report began editorial review in April 2018 and was accepted for publication in October 2018. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Simon de Lusignan is a Professor of Primary Care and Clinical Informatics and reports that the University of Surrey runs a physician associate course. Jim Parle chairs the UK and Ireland Board for Physician Associate Education and is director of the physician associate programme at the University of Birmingham. Phil Begg is an honorary faculty member at the University of Birmingham and has taught on the physician associate programme since 2008. James Ennis teaches part time on the University of Birmingham physician associate course. Vari M Drennan was a Health Services and Delivery Research Board Member in 2015.

Copyright statement

© Queen’s Printer and Controller of HMSO 2019. This work was produced by Drennan et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

2019 Queen’s Printer and Controller of HMSO

Rationale

Physician associates, previously known in the UK and elsewhere as physician assistants, are a new and rapidly growing occupational group in the UK NHS, with the first significant number of UK-trained PAs graduating in 2009. 1 From 2012, the employment of PAs in medical teams in secondary care was advocated by bodies such as the Royal College of Physicians (RCP),2,3 the College of Emergency Medicine4 and the Department of Health-commissioned Centre for Workforce Intelligence. 5 The increase in the employment of PAs was supported by the doubling of training places to > 200 per annum, as announced by Jeremy Hunt, the Secretary of State for Health, in August 2014, and the increasing number of universities offering PA courses. 6

Although the response from The Patients Association and the British Medical Association to the announcement by Jeremy Hunt was mixed, expressing caution and concern,7 the increase of PAs in the UK was supported by NHS workforce policy and medical royal colleges. Health Education England (HEE), the body responsible for the planning and education of the NHS workforce in England, included PAs in its workforce plans for the first time in 2013 and created a national PA development group. 8 The medical director (MD) of HEE publicly spoke of the need for 5000 PAs in the NHS and the expectation that there will be 500 PAs graduating each year in England by 2018. 9 In Scotland, the inclusion of PAs in NHS workforce planning was agreed in 2012 and PA training was subsequently commissioned from Aberdeen University by the NHS. 10 The Council of the Royal College of Physicians (London) agreed, in March 2014, to establish a Faculty of Physician Associates (FPA) in collaboration with the UK Association of Physician Associates (UKAPA), HEE and other royal colleges to support and develop the role. 11 At least 30 NHS hospital trusts were early adopters of PAs in their medical staffing1,12 and demand was reported to outstrip the supply of UK-trained PAs by 2014. 9 Key drivers of the policy and employer initiatives have been the pressures on the medical workforce, particularly in emergency medicine,4 but more widely linked to the implementation of the EU’s Working Time Directive,13 which currently controls junior doctors’ working hours. 2,3,5,14 PAs were seen as one type of mid-level practitioner (i.e. non-physician clinicians trained to undertake some of the diagnostic and clinical activities of doctors15) that could help address these problems in the immediate and long term without recruiting from another, already-pressured workforce, such as nursing. 5,9,16

Despite this growth of interest and policy support, there was very little published evidence regarding PAs’ contribution to patient care and effectiveness in the secondary care setting. There was, however, published evidence of their contribution in primary care. 17 The National Institute for Health Research (NIHR)-funded study,17 led by the same principal investigator as this report, reported that ‘physician assistants were found to be acceptable, safe, effective and efficient in complementing the work of general practitioners (GPs). Further research is required as to the contribution PAs could make in other services’.

Hospitals are very different from general practice in organisation as well as in type of treatment and care provided to patients. The evidence established in the general practice setting could not automatically be applied to a hospital setting. The primary care study demonstrated that NHS managers, senior clinicians and commissioners were seeking hard evidence to inform their decision-making as to the benefits or otherwise of including PAs in medical teams. 17,18 Patients and representatives from patient organisations also wanted evidence that this professional group was safe and did not result in some patients receiving an inferior service or unnecessary double-handling (i.e. being seen by one professional prior to repeating the consultation with a doctor). 17,19 This study was funded by NIHR as a follow-on study to the primary care research,17 recognising the need for evidence in the hospital setting, where there was increasing employment of PAs in England. 1,8,12

We turn now to provide more detailed information on PAs, PAs in the UK setting and the evidence of their contribution in hospital settings in 2015 (the starting point of this study).

Physician associates

Physician associates are trained at postgraduate level in a medical model to work in all settings and undertake medical history taking, physical examinations, investigations, diagnoses and treatments and to prescribe within their scope of practice as agreed with their supervising doctor. 20,21 PAs have a 50-year history in the USA. 22 By 2014, about 94,000 PAs were employed in US health services;23 of these, an estimated 30% worked in hospitals. 24 A growing number of high-, middle- and low-income countries have developed or are developing PA roles within their health-care workforce to varying degrees, including Ghana, Liberia, South Africa,25 the Netherlands26 and Canada. 27

Reviews of mainly pre-2013 US studies found patients to be very satisfied with PA care and that PAs can provide equivalent and safe care for the case mix of patients they attend. 28–31 The two systematic reviews (one general30 and one specific to primary care31) noted that the quality of most studies was weak to moderate and there was limited evidence on resource utilisation, costs and cost-effectiveness. Three small US studies of PAs in hospital settings published in 2013 and 2014 provided new positive evidence as to the contribution that PAs made to patient outcomes and resource use in a trauma–orthopaedic setting32 and in low- and high-acuity emergency department (ED) settings. 33,34 One study35 had reported that the indirect impact of employing PAs in a general surgical residency programme was to reduce the resident doctor workload, increase the doctors’ ability to attend their training activities and improve results in their American Board of Surgery in Training Examination. In 2014, a study protocol was published for research investigating the substitution of medical doctors with PAs in hospitals in the Netherlands. 36

Physician associates in secondary care in the UK

Health policy, NHS funding and concomitant organisational arrangements are devolved to the respective country administrations within the UK. 37 In England, where this study was undertaken, there were 163 NHS trusts (organisations providing NHS services) providing acute secondary care in 2017. 38 The medical workforce in these NHS organisations was formed of doctors of different grades, including training grades. Of the 94,045 full-time equivalents (FTEs) in the medical workforce in these acute secondary care trusts in 2017, 39,993 FTEs (43%) were consultants and 11,871 FTEs (11%) were Foundation Year doctors39 (Figure 1). The NHS workforce descriptor ‘hospital practitioner/clinical assistant’ may include, but is not exclusive to, PA staff; 425 FTEs were recorded in this occupational group. 40

FIGURE 1.

The medical workforce by grade in NHS trusts (excluding psychiatry and community staff). Data were sourced from NHS Digital. 39 HCHS, Hospital and Community Health Service.

In 2015, there was very limited published evidence about the contribution of PAs to hospital care in the UK. A Department of Health-supported pilot project of PAs in England included two PAs in hospitals,41 who worked in EDs. The evaluation concluded that they could make a range of contributions working at the clinical assistant level. 42 A similarly supported pilot project in Scotland included 11 USA-trained PAs working in emergency medicine, intermediate care and orthopaedics. 43 It reported that the PAs were well received by patients, were working safely and at the level of a trainee doctor (in some instances, almost at the level of a specialist trainee). The advantages of their employment were noted to be increased consultant productivity, increased continuity in the consultant team and positive impact on patient throughput. There were, however, issues with PAs’ lack of authority to prescribe medicines and order radiographs (both consequences of a lack of a statutory regulation) and also assuring appropriate medical supervision when there were shortages of medical staff. 43 A commentary in 2013 on the introduction of PAs in one English paediatric intensive care unit described a positive impact on patient care and continuity in the running of the unit and that initial, predictable, implementation problems were soon resolved. 44 A survey,45 conducted in England in 2012, of doctors supervising PAs in primary and secondary care reported that they considered the PA as a flexible member of their team, who was well received by patients and made a positive contribution to patient outcomes and efficiency. The issue of a lack of regulation was seen as the major problem, which also resulted in increased requirement for time from the supervising doctor.

In the UK, there were positive evaluations of US-trained PAs in pilot projects in primary and secondary settings in 2005 (England42) and 2009 (Scotland43). These reports, combined with the first validated PA programme at the University of Wolverhampton in 2004, led to a nationally agreed competency and curriculum statement20 (which was subsequently updated21) and postgraduate programmes in a growing number of universities. PAs were not (and continue to not be) regulated by the state, although application has been made for regulation, supported by HEE and the RCP. 11 The lack of state regulation means that, among other issues, PAs cannot prescribe or order ionising radiation. At present, PAs maintain a voluntary register and undertake revalidation every 6 years. 46 In October 2017, the Department of Health and Social Care announced a public consultation on the inclusion of PAs in UK state regulation processes. 47

There has been an increase in PA employment in UK hospital settings. In 2012, Ross et al. 1 reported that > 200 PAs were employed in 20 hospitals and within 15 medical and surgical specialties. Two years later, in spring 2014, evidence on the UKAPA website (the UKAPA has since disbanded to create the FPA at the RCP and the website has been closed down) showed that PA employment in hospitals had increased by ≥ 50 PAs and in > 30 hospitals. 48 PAs were reported to be in 20 adult and paediatric specialties, including psychiatry, geriatrics, paediatric intensive care, infectious diseases, cardiology, neurosurgery and genitourinary medicine. 48 In 2012, the greatest numbers of PAs were employed in emergency medicine and the medical specialties of respiratory medicine and cardiovascular medicine. 1

Although the rapid spread and growth of PAs in different hospital settings suggested that the role was seen as advantageous by early adopters, there was little evidence available for the public, patients or health service leaders as to the deployment, acceptability, effectiveness and costs of PAs in different types of hospital medical teams. This study aimed to address the evidence gap.

Aims and objectives

The aim of this study was to investigate the contribution of PAs to the delivery of patient care in hospital services in England.

The research questions that have been addressed are:

1. What is the extent of the adoption and deployment of PAs employed in acute hospital medical services?

2. What factors support or inhibit the inclusion of PAs as part of hospital medical teams at the macro, meso and micro levels of the English health-care system?

3. What is the impact of including PAs in hospital medical teams on patients’ experiences and outcomes?

4. What is the impact of including PAs in hospital medical teams on the organisation of services, working practices and training of other professionals, relationships between professionals and service costs?

The full study protocol was published on the NIHR Journals Library website (www.journalslibrary.nihr.ac.uk/programmes/hsdr/141926/#/; accessed 5 February 2019). The study team had the benefit of both an advisory group and patient and public involvement throughout (see Appendix 1). The patient and public voice was important to this study and is detailed in Chapter 2.

The following chapters provide details of the study methods and findings. The report concludes with the discussion and recommendations.

Patient and public involvement

The patient and public voice was important to this study. The public and patient representative forum for the previous primary care study17 stressed that the innovation of bringing in a new group of professionals was of concern to the public. Key issues that the forum emphasised in discussion concerned (1) patient choice of the professional to consult or be attended by, (2) whether or not some groups of patients will receive a ‘second-class ‘or inferior service, (3) how patients will judge if this new professional is competent and (4) the ways in which the public and patients are informed of and understand this new role in different settings. Those issues were incorporated in the design of this study.

Within the study itself, the patient and public voice was interwoven in the following ways. First, Sally Brearley, as a public voice representative, was a co-applicant and member of the research team and the study paid for her time. Second, the study advisory group had two public voice members who were reimbursed for their time, following NIHR INVOLVE guidance. 55 Third, two patient and public voice groups were formed: one in London and the other in the West Midlands. Invitations to join were sent to the members of the patient and public group forum involved in the previous primary care study, through the public and patients network of the Centre for Public Engagement (at the Joint Faculty, Kingston University London and St George’s, University of London). Invitations were also circulated through an established patient involvement group of the University Hospitals Birmingham NHS Foundation Trust, Birmingham. Members of these groups who attended research meetings were reimbursed for their time, again following NIHR INVOLVE guidance. 55 The patient and public voice groups met first of all to hear about the study and meet a PA, who was able to describe their work and education and answer questions. The early meetings were used to inform the interview topic guides and interview questions. Later meetings brought members together to help inform the analysis and interpretation of interview transcripts. All patient and public representatives were invited to participate in the final emerging-findings workshop (workstream 4).

We now describe the methods in detail.

Workstream 1: investigating the extent of the adoption, deployment and role of physician associates in hospital medical teams

Two electronic, descriptive, self-report surveys56 using Survey Monkey^® (San Mateo, CA, USA) were conducted to map and describe the employment and deployment of PAs in secondary care services in England.

The first survey was of NHS MDs. It was designed by the research team and piloted by a MD. The survey addressed questions of employment and factors supporting or inhibiting that (see Appendix 2). The sample was of MDs in all acute and mental health NHS trusts in England as listed by NHS Choices (the NHS information portal) in December 2015. Contact details were obtained from Binley’s database. 57 The invitation was sent by e-mail in December 2015, and two reminder e-mails were sent.

The second survey was sent to the UK voluntary register and/or UK-trained PAs. It was adapted from the primary care study58 by the research team and piloted by a PA board member of the FPA (see Appendix 3). The questions addressed the PAs’ work settings, activities and supervision. E-mail invitations were sent in February 2016 by the FPA to its members and by university course directors to their alumni. Two reminder emails were sent.

Anonymous responses to both surveys were imported into IBM SPSS Statistics Version 23 (IBM Corporation, Armonk, NY, USA). Data from closed questions were used to produce frequency counts and open responses were analysed for thematic groupings.

This workstream was approved by the Faculty of Health, Social Care and Education Research Ethics Committee at Kingston University London and St George’s, University of London.

All respondents were invited to complete a separate Survey Monkey page (following a link from the completed survey) to provide contact details if they wished to be kept informed of the study progress and outputs.

The findings from this workstream informed workstreams 2 and 3.

Workstream 2: investigating evidence of the impact and factors supporting or inhibiting the adoption of physician associates in the literature and policy

We undertook a systematic review and a policy review.

Workstream 3: investigating the deployment and contribution of physician associates at the micro level of the health system

A mixed-methods case study design70 addressed all of the research questions at the micro level of the health-care system through investigation in six NHS trusts that employed PAs in their acute care hospitals. Similar methods have been used in other studies investigating new staff groups in NHS hospitals. 71,72 The mixed-methods approach within a multiple case study design70 was designed to both describe and, as far as possible, quantify the impact of PAs in the context of secondary care. The aim was to achieve diversity in the hospitals by geographical location, size and type. At the time of the application for funding, the research team had agreement in principle to participate from trusts in the West Midlands and London that employed PAs. The intention was also to have diversity in the medical and surgical specialties within which PAs were employed. The final decisions regarding the inclusion of hospital trusts in the study was informed by the surveys in workstream 1, as well as the willingness of the trust senior managers and PAs and their consultants to participate. In addition, as PAs are a relatively small staff group and, therefore, potentially identifiable, the design ensured that volunteer PAs came from a specialty in which more than one PA and more than one trust participated. The aim was also to include more than two hospitals employing PAs in emergency medicine (being the acute specialty reported to employ the largest number of PAs). 1 The intention was to report the evidence from the multiple case studies in the manner described by Yin70 as the ‘fourth way’, that is to only present cross-case analysis of the issues of interest rather than from each individual case study site. With this understanding of the reporting intentions, the research team approached hospital executive staff to explain the research and gain formal permission to undertake the study; this was gained from a NHS trust board-level executive (chief executive or MD). Initial meetings were then held with PAs and their consultants to explain the study and ask for volunteers to participate. The sites were recruited sequentially but with data collection being undertaken in two or three sites at a time over a period of between 4 and 6 months. Permission to start data collection was in the control of each hospital research governance team and, in some instances, it took 6 months from the point of overall permission being given to agree. Characteristics of the six hospital trusts are provided in Table 1. At the time of the study, the Care Quality Commission (CQC) rated the overall quality of one of the trusts as ‘outstanding’, one as ‘good’ and the other four as ‘requires improvement’.

The characteristics of some aspects of the medical staffing and training in each of the hospital trusts are given in Table 2.

In overview, data collection in each hospital trust included:

• interviews with senior managers (including operations directors and human resources), lead consultants, members of the health-care teams (medical, nursing and support staff), PAs and patients

• requests for relevant routine management information (data and reports) as well as any internal documents, reports or audits on the work or impact of the PAs

• work activity diaries and observation of the PAs at work

• for those with PAs working in the EDs, anonymised patient records to allow comparison of patient outcomes and costs for the treatment of patients by PAs and FY2 doctors in the ED, a setting where individual clinicians are allocated to conduct an assessment and propose a plan for the patient.

An overview of the numbers of PAs volunteering to participate and the data collection in each site is provided in Table 3.

Workstream 4: synthesis of evidence

The evidence from workstreams 1, 2 and 3 was developed into an overall synthesis against the research questions by the research team. This was then discussed in an emerging-findings seminar (see Appendix 9). Participants included those who had advised the research team (patients, members of the public, health professionals and non-clinical health service managers) as well as some of those who had participated. The workshop was organised into presentations followed by round-table discussions in small groups. The presentations were then discussed as a whole group, led by the patient and public representative on the research team. A member of the research team took contemporaneous notes, which were then typed up and circulated to participants. The views, questions and issues raised in the seminar were then incorporated into the final report.

The systematic review

From 5472 references identified through the search strategy, 161 papers were selected for full-text reading, of which 16 papers32,94–108 met the inclusion criteria (Figure 2). Brief characteristics of each of the included studies are presented in Table 4 and in full in Appendix 10. The studies were all from North America (mainly the USA) and addressed different types of questions using a range of methodologies with different outcome measures. Seven studies were in emergency medicine,94–100 six were in trauma and orthopaedics,32,101–105 two were from internal medicine and one was from mental health. 106–108 No studies from acute medicine or care of the elderly were identified.

FIGURE 2.

The PRISMA60 flow diagram of the included papers. Adapted with permission from Halter et al. 109 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

Adapted with permission from Halter et al. 109 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

The studies were of variable methodological quality. The most important methodological flaws in the included studies were the failure to adjust the analysis for confounding variables, the absence of information to evaluate participants’ selection adequacy and the lack of information about baseline and/or demographic information of the investigated patients or PAs. The evidence in the following sections is presented by specialty and framed by the quality dimensions of interest. 50

Summary

Sixteen papers were included; four were published in 2017. 98,102,103,108 Most were from emergency medicine and trauma and orthopaedics specialties, with two from acute medicine and one from mental health. All studies were observational, and quality varied widely. The synthesis was further complicated by the difference between studies in which the PA was a substitute for doctors or was an additional staffing resource, or in which the introduction of PAs was only one of a number of contemporaneous service changes.

Although every paper reported the contribution of PAs as positive overall, it is important to contextualise within these issues of method and methodological quality. Summarising across the specialties, we have reported five studies in which PAs were an addition to the team. 32,95,103,104,108 In these studies, more patients are reported to have been treated; waiting times, time in EDs and time in operating rooms are said to have been shorter and mortality to have been lower; however, assessment of the contribution of PAs as opposed to any increase in team capacity is limited. Eight studies that compared outcomes of care by PAs and physicians when either one or the other was providing care or when PAs were substituting overall for physicians94,97,98,100,101,105–107 presented mixed results: either no or a very small difference in length of stay, reduced resource use but at equal or reduced cost, some time savings to senior physicians, lower analgesia prescribing, no difference in wound infection rate, inpatient mortality or re-attendance or acceptability to staff and patients. In three of the studies carrying out secondary data analysis, we do not know if the PAs were additions or substitutions, but two studies reported higher prescribing by PAs96,99 and one reported no difference in negative outcomes from fracture. 102

The strength of this review was its systematic method. Although it may be considered a weakness that only some specialties were included, this strengthens its applicability to the UK in that these are the specialties most frequently employing PAs in the NHS. We excluded any studies including intensive care data as these overlapped with acute medicine in many abstracts and we could not separately draw these out. Similarly, we excluded studies with medical and surgical specialties combined. We note that this literature appeared to include a greater proportion of studies with stronger study designs, including prospective and randomised designs; in particular, we have excluded the recent matched controlled large study from the Netherlands in which several specialties – some within and some not within our inclusion criteria – were studied. 110,111

A meta-analysis was planned but the heterogeneity of papers precluded this. Although narrative review is more limited in its precision, in following a framework for this, we have aimed to provide a clear rationale for the synthesis and conclusions we draw from it.

All of the included papers were from North America, with the majority from the USA, where health service organisation and the PA role may differ from that in other countries developing the PA role. In the USA, PAs can prescribe and order ionising radiation, and are, as a body, more experienced than those in countries more recently embracing this role.

The studies included in this review can be seen as complex interventions in complex systems and yet this has not been considered in the conclusions drawn by the authors. Well-controlled studies are needed to fill in the gaps in our knowledge about the outcomes of PAs’ contribution to secondary care. The review is published in full elsewhere. 109

We now turn to consider the evidence from the macro level of the policy context in England.

The policy review

At the point when the policy review was finalised in the preceding primary care study17 (in August 2013), it was concluded that ‘there was no reference to PAs in English policy documents’. By the end of the year, that had changed. In response to an acute shortage of doctors in emergency services, HEE (the executive non-departmental body responsible for NHS workforce planning as well as funding of training in England) had identified PAs as one of a number of non-medical roles that it would support to address the shortages. 8 Over the subsequent 4 years, we identified 17 published statements of policy intent at the macro level regarding PAs within the NHS workforce in England. 6,112–127 These are listed by type in Table 5.

In all the policy statements, the problem being addressed was a shortage of doctors. Initially, this was in emergency medicine;6,120 later, GP shortages were the identified problem that a state-supported increased supply of PAs was aimed at addressing. 6,112,115,117–127 In all the policy documents, increased supply of other groups were also specified as in this exemplar from the GP workforce plan. 119

NHS England, HEE and others will work together to identify key workforce initiatives that are known to support general practice – including e.g. physician associates, medical assistants, clinical pharmacists, advanced practitioners (including nursing staff), healthcare assistants and care navigators.

Reproduced with permission from NHS England. 119 Contains public sector information licensed under the Open Government Licence v3.0

The state support for the training of PAs became marked in 2015, with financial support for numbers of PAs in training increasing by 854% from 24 in 2014/15 to 205 in 2015/16. 121 This was quickly followed by a growth in English universities providing PA courses. 128 The only other group with a large increase in financial support for training over the period was paramedics, with numbers increasing from 853 in 2014/15 to 1231 in 2015/16 (44%). 121

The limitation of the PAs not being within the state regulation framework and, thus, being unable to prescribe or order ionising radiation was noted in the 2014 HEE workforce plans. 120 Two years passed before the intention to consult on the state regulation of PAs was announced113 in November 2016, and a further year passed before this actually commenced (in October 2017). The reasons for this gap between problem identification and action is not apparent in the documents.

At the macro level of the health-care system, sustainability and transformation plans (STPs) were developed in the winter of 2016 across 44 areas of England. 129 These were plans for the NHS and beyond, agreed and informed by health and social care partners across defined geographies. Among other issues, the workforce had to be considered in the plans. We analysed the 41 publicly available plans130 for stated policy intent to develop the PA workforce. We identified that under half were planning to increase the employment of PAs and were specified mainly in support of primary care (Table 6).

In summary, the policy review identified macro-level support for the development of the PA workforce to address the problem of clinical workload and the immediate and predicted shortages of doctors. The support included not only positive statements but also state funding for training places to increase the supply to employers, particularly general practice. At the meso level, using the STPs as the evidence source, not all plans included the detail of planned growth of advanced clinical practitioners, although this may have been an artefact of the way these were written rather than actual intent. Of those specifying growth in advanced clinical practitioners, four plans did not include PAs and 18 plans did. The majority of plans that specified a sector for support of growth of PAs referred to primary care rather than secondary care.

We now turn to examine the employment of PAs in the secondary care sector through views from the meso and micro levels of the health-care system.

Survey of medical directors

At the time of the survey, there were 214 NHS acute and mental health trusts in England; MDs from 33% of trusts (n = 71) replied. Of these, 68% (n = 48) were acute trusts.

Physician associates were employed in 20 of the responding trusts, only one of which was a mental health trust. Most trusts (n = 16) employed fewer than five PAs but three employed more than 10. MDs reported that PAs were employed in a total of 22 specialties, both medical and surgical (adult and paediatric). The most frequently reported specialties for PA employment were acute medicine (n = 7 trusts), trauma and orthopaedic surgery (n = 6 trusts) and emergency medicine (n = 5 trusts). The majority reported that the supervising doctor was a consultant. Eight MDs reported that their trust was expanding its number of PAs owing to a positive experience to date.

Of the remaining respondents, 61% (n = 44) were considering employing PAs at their trusts and 10% (n = 7) were not considering employing PAs.

Respondents were asked to report supporting and inhibiting factors to the employment of PAs. In general, MDs at trusts employing or considering employing PAs reported multiple supporting factors whereas those at the seven non-employing trusts reported only inhibiting factors.

The most frequently reported supporting factor was to address gaps in medical staffing and to support medical specialty trainees. Other common factors were to improve workflow and continuity in medical/consultant teams, to help address the management of junior doctors’ working hours to be compliant with the EU Working Time Directive,13 and to reduce staff costs.

It was also reported that a number of trusts were piloting or testing out PA roles. Some had specific strategies to increase the numbers of PAs they employed through linking with university PA course providers.

The inhibiting factors that were cited most frequently were the lack of statutory regulation for PAs and the consequent lack of authority to prescribe. The relative lack of PAs to recruit was another commonly reported problem, as was resistance to their employment from (some) consultants. Seven of the 20 respondents reporting PA employment also indicated that PAs had left and not been replaced. Most indicated financial reasons or lack of PAs to recruit. One stated that the consultant considered that a doctor was more effective and efficient than a PA in that particular team. The small number of respondents not considering employing PAs offered a slightly different perspective, suggesting that other professionals – either nurses or doctors – were better placed to meet their trust’s employment needs.

This survey provides evidence of the changing employment context for PAs in England at one point in time and, for this reason, offered insights, not available elsewhere, from those in medical leadership positions within NHS trusts. The survey was conducted at the time of the junior doctors’ strike in England,131 which may help explain the low response rate, although other surveys of NHS MDs report similar rates. 132 The supporting and inhibiting factors reflect those previously reported by us from our survey of the GP employers of PAs. 17 Shortages of doctors have also been the most commonly reported reason for employing PAs in the USA. 133 Although this survey suggested that there was an appetite for employment of PAs in secondary care, it also suggested that there were issues that needed addressing, such as state regulation. Eighteen months later, a consultation on regulation116 was launched; however, this survey suggested that there might be other issues that will need attention, such as senior medical staff resistance to employment.

A full account of this survey has been published elsewhere. 134 We now turn to report findings from the survey of PAs in secondary care.

Survey of physician associates

Out of the 223 PAs on the UK voluntary register and practising in primary and secondary care in the UK at the time of the survey, 63 PAs working in secondary care in England completed the online survey. Of these, 49 provided responses to all 18 questions. Three additional participants started the survey but were filtered out as they were practising in a country other than England.

The majority of respondents had trained in the UK (Table 7) and the mean length of time since qualification was 3.1 years [standard deviation (SD) 2.1 years]. Most worked in large acute hospital trusts. The respondents reported working in 33 medical or surgical specialties; the most frequently reported was acute medicine, followed by elderly care medicine and trauma and orthopaedic surgery (see Table 7).

The most frequently reported setting that the PAs reported working within was the inpatient ward (n = 38), with 25 describing multiple settings including outpatient clinics and operating theatres. Of the 54 PAs who provided information on their line management arrangements, 44 (82%) were managed solely by consultants. Day-to-day supervision was reported by 48 PAs as being by a consultant or other grade of doctor. Two PAs said that they did not have a day-to-day supervisor. PAs were working within variously configured teams; the most frequently reported team composition (n = 16) was consultant led with other grades of doctors and clinical nurse specialists. PAs were mainly working day shifts (only 1 out of 50 reported working night shifts) from Monday to Friday [although 14 out of 50 (28%) reported working at least one weekend shift during the previous 4 weeks]. Some reported that their work was shaped by the absence of others in the team, for example covering for the clinical nurse specialist or for the registrar when on annual leave or while training.

This cross-sectional survey provided a snapshot of the specialties, teams and working patterns of PAs in secondary care in England and, for this reason, provided new insights, even though the response rate could not be accurately established. The types of specialties reported mirrored those of the annual census by the FPA,59 giving some confidence in the breadth of coverage. The survey provided evidence around questions such as the nature of supervision, to be taken into the next workstream of the overall study, which we report on in Chapter 4. The full report of the PA survey is published elsewhere. 135

Summary

This chapter has presented international evidence as well as evidence from the macro and meso levels of the English health-care system. We now turn to report the findings from the micro level.

Factors supporting the employment of physician associates

In this section, we consider the themes concerning factors supporting the employment of PAs, including issues shaping the decision to employ PAs, decision-making on PA posts and factors for successful adoption and implementation of PAs.

Governance issues

It is worth reviewing comments made about governance issues, as these are relevant to both what was considered to work well in employing PAs and what was considered not to work so well in employing PAs. The lack of regulation of the profession was particularly relevant and linked to issues of clinical governance within trusts. The prospect of the regulation of PAs was seen as positive and, indeed, by some, as essential.

In so far as they were discussed, it seemed that trust boards generally were not profoundly involved with the governance arrangements. Typically, detailed work on PAs, including governance arrangements, was taken on by designated PA boards or committees, which had sometimes had changes in leadership. MDs were commonly the link between the PA board and the trust board.

The issues that PA boards or committees considered included:

• setting up structures (e.g. deciding whether PAs come within medical or nursing administration)

• the scope of PA roles (i.e. addressing what they could and could not do)

• clinical supervision arrangements

• reporting lines to management on non-clinical issues (e.g. leave and rotas)

• encouraging the organisation with using PAs

• issues in relation to PAs not being able to prescribe or order ionising radiation

• the ways in which PAs could work with others [e.g. advanced nurse practitioners (ANPs) and prescribing pharmacists]

• arrangements for PAs continuing education and study leave.

As mentioned previously, many of these issues linked to factors inhibiting the employment of PAs, which are considered in the following section.

Factors inhibiting the employment of physician associates

Senior managers and clinicians identified the following issues as inhibiting the employment of PAs in secondary care or making it more difficult. These were the lack of regulation with the concomitant lack of authority to prescribe and order ionising radiation, attitudes of others, the lack of PAs to recruit and lack of clarity on governance issues. It should also be noted that one MD thought that too many people focused on the negatives in relation to PAs and one senior manager perceived no negative factors in relation to employing PAs.

Contribution of the physician associates

The impact of PAs had not been specifically evaluated in any of the hospitals. The general view was that it was hard to separate out PAs from the rest of the team. None of the senior managers could offer routine management data or reports that could quantify impact or costs.

However, all interviewees were able to offer their perceptions of the impact of PAs in contributing to the safe running of the service, greater efficiency, continuity of care for individual patients and continuity across the organisation, and service improvements. In the context of a shortage of junior doctors, the presence of PAs contributed to the safety of the service:

I’ve had times when I’ve been on the wards and for various reasons . . . all the juniors have been away, I’ve had a PA there and actually with a consultant and a PA you can cope . . . so you know, having a PA is absolutely vital and I’ve certainly managed a ward for several days with myself and a PA and felt it’s all been pretty safe.

ID 27, senior clinician

The PAs were reported to contribute to service efficiency through supporting doctors and nurses. Specific examples were given:

• PAs working shift patterns to complement the junior doctors that enabled an outpatient clinic to extend its hours with greater patient throughput.

• Increased patient flow through the ED.

• Improved access for nurses to raise concerns about a patient to a member of the medical team (e.g. when all the doctors were in theatre).

• In some areas of work, PAs were considered to free up consultants’ time.

• PAs were also considered to contribute to the hospital meeting national quality targets (e.g. on discharge processes and ensuring policy).

Their presence on the inpatient wards was considered to offer continuity to the medical team that, in turn, supported good patient experience:

I think that they are the glue that pulls the team together, I think they’re a constant source for the nurses for advice and, you know, keeping the patients cared for.

ID 43, senior clinician

There were no quantitative data offered and there was a commonly held view that it was difficult to disaggregate the impact of individual types of staff in team and department provision. Generally, positive answers drew on the PAs’ apparent popularity with patients and the lack of complaints: in some hospitals, PAs were thought to be effective at nipping complaints in the bud. There had also been some positive feedback (e.g. on a hospital website and from surveys of patient satisfaction). In addition, one chief executive noted that the CQC was happy with PAs.

There was a suggestion that the satisfaction levels of junior doctors in one service area had improved because of the pressure being lifted by the presence of PAs. A few people made particular mention of the impact of PAs on medical education. One MD recalled that he had been initially aware of both positive and negative views on the possible impact on junior doctors’ training and that to some extent views remained mixed. However, generally senior managers and consultants felt that concerns about PAs possibly taking training opportunities away from junior doctors were unfounded, and it was more likely that the role of PAs in service delivery actually freed junior doctors for training. PAs were reported as also contributing positively to the training of junior doctors: in induction, in helping them to understand hospital procedures and sometimes in procedural skills.

Therefore, this group of senior managers and clinicians viewed the PA contribution as positive. However, some also cautioned that to develop the PAs to their greatest utility and also to retain them required investment from the organisation beyond the support for initial introduction. Some of these elements were identified in Governance issues, such as ensuring appropriate clinical supervision. We now discuss the interviewees’ perceptions of the longer-term issues of retaining this staff group.

Developing and retaining physician associates

Senior managers and consultants, with one exception, shared the view that PAs might feel that they lacked career development opportunities. Pay and other factors were considered as relevant, particularly in areas where the cost of living was high. Although recognising a relatively flat career structure, PAs were thought to enter at a relatively high NHS salary level. Some made the point that the assumption that PAs might rapidly leave in order to train as doctors had not been borne out. Some pointed out that the flat career structure of PAs was not unique within the NHS; for example, consultants also tended to have a flat career structure, typically taking a consultant post in their thirties. Although, taking a different view, a chief executive argued that that young people do not think so much in terms of careers for life, so doctors may not stay in medicine and all kinds of changes were needed to maintain a medical workforce. Some considered that it might not be helpful to make comparisons with doctors’ careers; rather, it may be more useful to look at some of the newer roles, such as paramedics and operating department practitioners, who faced similar issues.

Although noting that some PAs wished to continue as they were, with a focus on practical, hands-on care, a variety of observations were made as to how individual hospitals and services provided or were considering providing career development for PAs. These included:

• opportunities to work across different areas, thereby developing their skills and providing variety to their workload

• opportunities in quality improvement and patient safety projects

• senior PA roles for a group of PAs.

Training opportunities were considered essential, and there were examples of shared training with junior doctors and with nurses. One trust gave PAs an annual training bursary. A final observation from some was that career development may become a bigger issue once PAs have been in post for longer periods and more PAs are in posts.

Summary

Senior managers and clinicians described the shortages of doctors together with a need to ensure quality in services as the driving forces in introducing new roles at advanced clinical practitioner level. PAs were only one group that they were considering, but they were mindful of depleting other groups, such as nurses, that were also facing shortages. A variety of change management strategies were described, although not all in place in every hospital, to ensure the successful introduction of this new group. The main inhibitors to employment were thought to be the lack of regulation, with attendant lack of prescribing rights, and the lack of knowledge (with attendant puzzlement rather than hostility) about the role among other staff. Where PAs were employed, they were reported to make significant contributions to efficiency in the organisation and continuity of care for the patients. The lack of PAs for the growing number of jobs meant that PAs could easily move to jobs that offered greater career development. Introducing PAs into a workforce was known to require support structures, ongoing training and provision of appropriate clinical supervision and mentorship. None of the participants were able to quantify impact or costs. They all pointed to the difficulties of separating individual impact/contribution from a team endeavour.

Description of participants

A total of 43 PAs took part in the case study research. Eighteen PAs returned 23 weekly work diaries, 41 PAs were interviewed and 35 PAs were observed in practice on between one and three occasions each. They worked within 13 adult and paediatric specialties and emergency medicine. The characteristics of participating PAs are not presented individually as these would be likely to identify individual participants; summary characteristics are shown in Table 9.

The PA participants worked across a wide range of specialties, similar to what was reported in the annual PA census. 59 The median length of time since qualifying as a PA was 5 years (ranging from the very newly qualified, i.e. in practice for 6 months, to those with more experience, at 9 years) (Figure 3 shows the distribution).

FIGURE 3.

Number of years since qualifying as a PA.

Although a number of PAs had described being in their current post since qualifying, including those with lengthier experience, others described moving between several jobs/specialties in one or more than one trust. In addition, some reported being employed on a rotational basis within their trust (i.e. working in several specialties over the course of 1 to 3 years). The median length of time in their current post was 3 years (range 2 months to 9 years).

Some of the PAs worked in specialties employing clusters of PAs both within and across the trusts, whereas others worked singly or in smaller numbers in medical and surgical subspecialties. However, all the specialties covered by the participating PAs appeared in at least two of our six case study sites.

The physician associates’ working patterns: times and places

The work setting

In the interviews, PAs mostly described working in one specialty on hospital assessment units (e.g. the ED or medical assessment units) and specialty-based inpatient ward settings, although a small number described rotational/internship programmes across several specialties, either immediately post qualifying or on a continuing basis. Most described their main work taking place on the ward or unit, with outpatient and theatre duties also forming part of the usual workplace setting for a small percentage of PAs who were interviewed or who completed work diaries. A small number described work that spanned these settings, for example work in an inpatient specialty that included being called to assess patients in the ED or on GP referral units:

Other roles that we do is we also help our SHOs [senior house officers], so they carry our on-call bleep so when they’re busy we carry the on-call bleep or we help them out with it, and that involves seeing patients in [the ED], seeing patients that have [body part] injuries or simple fractures that need to be reduced or manipulated or plastered, we can see them.

ID 160, PA

The breakdown of the working hours by grouped activity setting as reported in the PA work diaries is presented in Figure 4.

FIGURE 4.

Percentage of time spent by type of setting.

The physician associates’ work activities

An overview of the types of activities that PAs reported carrying out in predefined work diary categories is given in Table 10. Four activities within these categories were commonly described by the PAs during interviews: ward rounds, patient assessment, clinical administration and procedures. Each of these is described here in turn, illustrated by interview quotations and observation note excerpts.

The physician associate as part of the medical team

The work activities and tasks previously described as commonly reported and/or observed give us some indication of the role of the PA in components of care but do not give us a picture of the PA’s overall role, nor of the nuances and variations to that role and place in the team, as observed. We describe this here briefly in terms of membership of the medical team, their place in the medical hierarchy and being a continuous and accessible presence.

Experience of the physician associates’ involvement in patient care

Within this theme, we describe the variety of ways that the PA had been involved in patient and relative treatment and care, the overall response to the PA involvement in their care and the contribution they observed the PA(s) making.

The extent of understanding of the physician associate role

None of the patients or relatives who were interviewed had met a PA prior to this hospital episode. None of them had an accurate understanding of what a PA was. We describe this first before turning to describe their views on the extent to which this concerned or mattered to them.

Summary

Most participants were not clear about the PA role but were very positive about the involvement of the PA and about the quality of the care they received. Not all patients or relatives knew that they had been treated by a PA, but despite this lack of understanding/awareness about the role, all patients said that they would be happy to be treated by a PA in the future.

Factors influencing the employment of physician associates

Most consultants described the main driver for employing PAs initially as a shortage of doctors to cover the medical rotas for their service. They indicated that this shortage had come about through a set of interconnected demand and supply issues: the enforcement of the working time directive on junior doctor hours, the 2016 junior doctors’ employment contract, changes in medical education requirements, reduced numbers of junior doctors in training, difficulties in obtaining visas for overseas doctors as well as the expansion of their service:

We introduced them because of junior workforce doctor issues. So fewer junior doctors being given training numbers and we foresaw that we were going to expand and that we would probably need more junior doctors or more, more people on a junior tier.

ID 89, consultant

Most accounts described the employment of PAs as addressing two main interconnected issues:

1. providing sufficient medical team presence, particularly on inpatient wards during the daytime, to ensure high-quality, efficient and safe patient care

2. ensuring that junior doctors in training were able to meet their training requirements without detriment to the service needs. ID 114, consultantID 68, consultantSeveral of the consultants described that although the initial impetus was to address staffing shortages, it had become evident over time that PAs, particularly experienced PAs, could contribute in a range of ways to service delivery:ID 125, consultantThey also described the way in which this innovation was then taken up by other consultants and services as they observed the contribution the PAs made:ID 119, consultant

   One is continuity of care at junior level. People are doing full shifts and so covering wards are quirky . . . You needed somebody who understands the team, who’s a member and part of the team, who knows the ethos of the team, to be able to be there at all times. That was our thought anyway before we employed them [PAs], in that they would be ward based, team based, and they will be there at all time.

   You can’t just have them [doctors in training] now doing ward work, that’s not seen as educational or part of their training. They have to be more involved in various other things . . . So that is where PAs come in, for ward work.

   [There was] a specific problem to do with excessively long clinic times for complex clinics, which I do one a week, my colleagues each do one a week, [PA name] will come along to these now and she will see these patients and, effectively, she’ll be like another SHO [senior house officer] or another registrar in clinic.

   I think consultants started seeing the possibilities as to where else you can use them [PAs] . . . and then everyone goes ’ah, oh they’re quite good, I want one of them, they could do all this and this for me’.

There were consultants who described their ideal team as one staffed with a skill mix of doctors, PAs and other advanced practitioners.

However, at the other end of the spectrum of opinion were a small number of consultants who, having tried PAs as an innovative solution to medical staffing problems, reported not favouring replacing them in their specialty when the current PAs left. Some other consultants reported that they were aware of PAs not being replaced in other departments when they left. These were specialties with high-dependency patients requiring frequent medical procedures and changes in medication. We discuss this in more detail in Factors inhibiting working with and employing physician associates.

Many of the consultants described trying out a variety of new workforce roles. Some consultants reported trying clerical support roles to doctors, such as medical assistants, but ceasing these in favour of PA roles, valued for their clinical knowledge and input. In many of their services, there were also a range of other mid-level posts, such as ANPs, clinical nurse specialists and prescribing pharmacists. In particular, many consultants preferred to use a mid-level profession such as a PA, with their training in the medical model to work in a medical team, because of the work and role they required of them. This was not to say that they did not value the other types of role and described the work as complementary in delivering high-quality and safe patient care. This links to the next theme of the actual work and role of the PAs.

The work and role of the physician associates

The doctors in all of the medical and surgical specialties, apart from emergency medicine, reported that PAs mainly undertook inpatient ward work:

I see our PAs’ role based on the inpatient workload, and delivering the inpatient work, and the quasi-medical management of the patient.

ID 185, consultant

So the main role of the physician associates is the running of the inpatients and the preoperative work-up for the patients coming for surgery that week.

ID 180, mid-grade doctor

The level that they worked at was described as equivalent to a spectrum across Foundation Year doctors and senior house officers (SHOs):

They’re pretty much equal to an FY2. Some of them are almost equal to senior SHOs, after finishing the core training level.

ID 150, consultant

Some of the consultants emphasised that the focus and clinical level to which PAs worked was dependent on the individual’s experience and in-post training. Newly qualified PAs were described as needing support and further in-work development to build their skills and knowledge in that specialty. In one trust, PAs were offered the opportunity to work in different departments to broaden their knowledge and skills.

Building trust in the competency of the individual PAs was a process reported by all three groups of doctors:

When our first PA started, clearly as doctors we weren’t entirely sure, I think a lot of us, what PAs could or could not do. And I think we’ve realised how competent our PAs are and how trustworthy, it’s been, you know, a revelation, we’ve been able to give them more and more jobs to do.

ID 173, consultant

Yeah. The good thing with [name of PA 1] and [name of PA 2] is that I know them, and I trust them and it’s a really good thing because I know they have deep clinical knowledge, so I don’t need to check again the patient if they’re telling me something about the patient.

ID 190, mid-grade doctor

I wouldn’t inherently trust them [PAs in a specialty she had just started working in] because of their job title. If I had asked the PA on the [specialty] ward I would trust him, not because of he’s a PA but because I’ve seen him, I’ve heard him, I know what he’s like and I trust him.

ID 206, early-career doctor

Consultants reported that there had been no patient safety incidents involving PAs. All of the doctors considered the PAs who they worked with to be clinically safe, often citing the PAs as appropriately seeking advice or alerting them to a patient’s deteriorating condition:

Yeah, and they are very careful, they know their limits and they will, you know, just ask for help.

ID 180, mid-grade doctor

All of the consultants and mid-grade doctors described their supervision of the work of the PAs and junior doctors as integral to the work of the team. The type of specialty and the organisation of the medical team were reported to determine the extent of clinical decision-making by PAs and others. For example, in some specialties, all clinical decision-making was undertaken by the consultants and senior registrars:

I think we are quite senior led, as a general rule . . . for example, where our sickest patients are, they would be seen every day by a consultant, and most of the decision-making is taken away from even the senior registrar . . . and then for the other patients, we do operate a system where our department wants the senior registrar to see every patient every day.

ID 51, mid-grade doctor

This senior-led decision-making contrasted with other specialties, such as emergency medicine, in which the PAs were expected to be able to assess, plan and manage certain types of patients, seeking senior advice as necessary:

They’re quite independent, they do a lot of the work themselves; sometimes they come and ask us as registrars like questions just to confirm certain things or like prescriptions. But on the whole, they pretty much do everything, see their own patients and they’re just like a normal member of the team really.

ID 144, mid-grade doctor

A few doctors reported some confusion regarding whether most junior doctors in the team were supervising PAs or working alongside them, a situation compounded by the junior doctors being asked to authorise prescriptions and ionising radiation for patients seen by the PA. We return to this issue in section Lack of authority to prescribe medicines and ionizing radiation. However, it was also linked to the extent to which the PA role was understood:

I think the challenges that we have had is when people haven’t understood what a PA is and what they’re not, and we’ve just had that a couple of times in that some of the doctors haven’t sort of understood what [name of PA] can do and how she sits within the team, and that’s created a little bit of tension that we’ve had to iron out just a couple of times.

ID 199, consultant

Some of the consultants described making it explicit to the new doctors in training about the role of the PA(s) in their team:

So when the junior doctors start, I explain to them what a PA is and how I view them in the team.

ID 119, consultant

Although some of the mid-grade doctors and early-career doctors also reported this type of introduction to the PAs in the team, others described a more ad hoc form of learning about the role, their place in the team and activities that they could (or could not) undertake. This was either from the PAs themselves or through observation of the PAs working in the team:

I think I’m kind of learning through being with them, but I don’t think anyone has ever said what their role is.

ID 207, early-career doctor

Many of the early-career doctors were familiar with the PA role through previous jobs or placements as medical students. They recognised that there was variation in what PAs were allowed to do and that this was something they had to understand early on in that job:

I just had to clarify . . . what they were and weren’t allowed to do, because I think depending on both experience and other bits and pieces, and also what the trust says a PA can and cannot do differs slightly between trusts.

ID 202, early-career doctor

One mid-grade doctor described uncertainty as to what the intended parameters of the role were and queried whether or not the scope of individual PAs had increased over time in an unplanned way. Some of the consultants reported that not all consultants agreed with each other as to the presence of the PAs, the procedures they were allowed to carry out or their position in the team:

I think there still is probably a split among the consultant staff as to what the role of a PA is precisely. I’m not sure that that’s even explicit within the consultant staff what people are happy for them to do and what people aren’t happy for them to do.

ID 89, consultant

We return to this point in section Some specialties with high-dependency patients. First, we consider the consultants’ views on the overall contribution of the PAs to the medical team.

Overall view of the contribution physician associates made

Most consultants provided a positive view of the contribution that PAs made within their specialty. This was echoed by the middle-grade and early-career doctors:

They work alongside our junior doctors, support the junior doctors, and are clinically very valuable. Well, almost invaluable now.

ID 185, consultant

So my experience with PAs has been very good, they are a really important part of the team.

ID 95, mid-grade doctor

The ones [PAs] that we have here are really good, yeah and they’re very useful.

ID 58, early-career doctor

As noted previously, there was a small number of consultants who had a less positive view, which we return to in section The negative views of some doctors and some senior nurses about physician associates.

The contribution of PAs was described by the doctors in terms of (1) supporting good, safe and efficient patient care and (2) supporting the junior doctors in training. The doctors described different ways in which they saw the PAs contributing to the medical team’s work, which we have grouped into five interlinked themes. These were:

1. providing continuity and stability in the medical team

2. undertaking some of the doctors’ workload and filling gaps in rotas

3. enabling doctors to focus on patients who were more acutely ill, were more complex or required assessment or procedures that only doctors could undertake

4. supporting patient flow

5. induction of doctors in short-term training posts and supporting release for training activities.

Patient responses to physician associates in the medical team

Most of the doctors reported that patients and family members were very positive about the PAs’ contribution to their care. They attributed this to factors such as communication style, constant presence on wards, accessibility and reliability:

They’ve got very good feedback from the patients . . . I’ve heard parents complimenting [name of PAs], the way they talk and the way that they’ve been looking after patients. I’ve never heard any of the doctors being complimented by the patients.

ID 186, mid-grade doctor

However, most doctors thought that patients, despite their best efforts in providing introductions, did not understand exactly who or what the PAs were, other than a member of the medical team. They reported that the PAs were always introduced and introduced themselves to patients as such. One doctor described formal introductions by the consultants as part of the ward rounds to separate doctors and PAs:

So normally I’m used to introducing myself as [interviewee first name], I’m a medical doctor, but when the consultants are introducing you to the patients it’s ‘This is Dr [interviewee surname] my medical registrar, this is [PA first name], the PA’, and making it really clear that [PA first name] is not a doctor.

ID 42, mid-grade doctor

Some doctors reported that patients very occasionally asked for explanations of what a PA was but most just accepted them as part of the medical team.

Factors inhibiting working with and employing physician associates

Overall, although the doctors were positive about the contribution of PAs, there were aspects they identified as negative and potentially inhibiting to their employment:

• lack of authority to prescribe medicines and ionising radiation

• some specialties with high-dependency patients in which the knowledge and skills of doctors, rather than PAs, were considered more useful to the overall work of the medical team

• lack of PAs to employ and issues in retention

• the negative views of some doctors and senior nurses about PAs.

Measurement of the impact and costs

Questions on available evidence about impact and how impact could be measured were particularly directed to the consultants and middle-grade doctors. None of the participants was able to offer any completed internal quantifiable assessment of the impact of the PAs. Most considered that it was a very difficult task to single out one person or type of professional from what was a team activity:

I think it would be extremely difficult to look at patient outcomes because you measure what teams do, you don’t measure what individuals do.

ID 84, consultant

They offered examples from ‘hearsay’ of high levels of patient and family satisfaction – some stating that this had improved since a PA had joined their team, as described in Overall view of the contribution physician associates made. The consultants within the ED setting were able to talk about outcomes for individual patients seen by PAs but pointed out that these were still within a consultant-led and supervised team. Chapter 10 provides this analysis.

Regarding cost, most consultants considered that the employment of PAs rather than doctors, particularly locum doctors, was cost saving. One consultant argued that because of the salary paid to PAs combined with the investment in developing them, particularly those who were newly qualified, the difference in cost between PAs and junior doctors was not as great as some may think. Nearly all of the consultants went on to point out that the major issue for them was not finance (although important) but ensuring that they had the right staffing to provide high-quality, safe and efficient patient care. Some were able to point to aspects of improved patient flow (and consequent reduced costs per patient) in which they thought that the presence of PAs had made a difference:

Overall they have improved our cost, I will say, helping us to reduce the patient stay [in elderly care] . . . but no, I haven’t any analysis for that.

ID 179, consultant

Summary

Forty doctors were interviewed across the six hospital study sites. Initially, the main driver for employing PAs was the shortage of junior doctors and the need to protect their time for their training requirements rather than routine medical inpatient work. Most PAs were employed to undertake the medical inpatient ward work and preoperative preparation as part of the consultant-led medical team. Within the ED, they attended patients independently but as part of the consultant-supervised team. Most doctors of all grades viewed their contribution to the team and patient care positively. However, a few consultants, in high-dependency specialties, considered that doctors were of greater utility in that setting and that they would not replace PAs that left. The continuity and stability the PAs brought to the team were described as an important contribution. This, in turn, ensured a smoother experience for doctors joining the team as well as maintaining or improving quality and safety in patient care. PAs helped junior doctors manage the workload and were missed when they were absent. The presence of PAs on the wards released early-career doctors to undertake training and meant that nurses had easy access to a member of the medical team. PAs were described as contributing to patient flow and patient experience. PAs were considered to increase or significantly contribute to inpatient satisfaction, although most felt that patients did not understand what the PA role was.

The inability of the PAs to prescribe and order ionising radiation was seen as a problem that could be managed, but for some it meant that working with PAs added to their workload, in comparison with a junior doctor who could prescribe. These doctors thought that the PAs should be given the authority to prescribe and order ionising radiation. The lack of supply of PAs to recruit was an inhibiting factor and retention was also reported to be difficult in some areas owing to a lack of development opportunities and no obvious career trajectory. A different problem was identified in the division of views among doctors themselves as to whether or not they supported the concept of the PA role. Tensions were sometimes reported between early-career doctors and PAs. Some differences were noted between doctors of different levels of seniority, with a few (but not all) of the most junior being more likely to perceive PAs as a threat to their training opportunities. A few senior nurses were also thought to view the employment and development of PAs negatively.

The overall consensus was that measurement of the impact on outcomes by individuals and individual roles within hospital teams was very difficult. None of the consultants was able to offer quantifiable evidence, but suggestions were made by some on patient satisfaction levels and shorter lengths of stay in the setting of care of the elderly. No quantifiable evidence was offered on costs, although many consultants argued that using PAs rather than locums to cover gaps would automatically reduce costs. Views were mixed as to the cost of PAs, including their development. The concern of most of the consultants was not about costs but about maintaining the quality and safety of their care to patients. Many of them directed the researchers to the managers for evidence of cost. The next chapter reports their evidence.

Factors supporting the employment of physician associates

The motivating and supporting factors for the employment of the PAs was described predominantly in terms of managing an ongoing shortage of junior medical staff:

So I’ve been doing a juggling act [to cover the medical staffing rota] for the last year and a bit with limited doctors [describes increased recruitment of doctors], which is obviously good, but PAs are still needed . . . For the last 2 years or so, I’ve had two F2s [Foundation Year 2 doctors], this year I’ve been told I’m getting one F2 with no explanation. So, I would not be looking to get rid of PAs anytime soon.

ID 203, manager

Other motivating factors came from the positive value they observed from the PAs’ contribution, which we describe in section Overall positive contribution of physician associates. These factors meant that managers considered that the PAs were in roles complementary to the medical staff and were not substitutes for junior doctors:

We’re not going to put the PAs in to replace the numbers of junior medical staff; we just recognise that there’ll be gaps in junior medical staff rotation and they’re there to support them as well.

ID 100, manager

There were variations in the ways that the PAs were budgeted for, perhaps reflecting the variety of motivating factors. Some of the managers described the costs of the PAs being covered from the medical staff budget through ongoing vacancies. Only one manager suggested that in one specialty the budget for some SHO posts had been permanently changed to support PA employment following changes in allocation from the deanery (part of HEE that allocates doctors in training to hospitals). Two of the managers reported that the PAs were paid from the overall service budget rather than the medical staffing budget. Only one manager was aware of a specific business case having been made within the trust to increase the service budget to include PAs as staff. One reported that business cases were being developed for funding for more PAs in different specialties.

Four managers had been involved in introducing PAs to their service or department. They described working with a lead consultant in managing the process. They reported that although there was initial resistance from other nursing and medical staff, this had dissipated quite quickly. One manager identified the ANPs as the most concerned about the introduction of this new group. Their concerns had been addressed by paying due attention to developing both groups (PAs and ANPs):

But from a starting perspective, it was difficult to manage the expectations of nurses, nurse practitioners, clinicians on what the role was of the PA . . . I think between the advanced practitioners and PAs, that was the biggest stress but the way we designed it, now, because we enhanced both [groups of staff] competencies . . . it has been pretty successful.

ID 205, manager

Aside from these accounts, the managers described good relationships between PAs and other groups of staff.

The three managers who had been involved in the introduction of PAs to a service or department described requiring a period of investment in supporting the PAs to gain the competencies required for that specialty. This was reported as a substantial period for those PAs who were newly qualified but was thought to differ between specialties, with longer training needed for those working with high-dependency or more acutely ill patients.

Overall positive contribution of physician associates

All of the operational managers viewed the PAs and the contribution they made in their services positively:

They’re [the PAs] a really valuable asset in the department now and looking at expanding into seeing how we can have more on the department to help.

ID 205, manager

I value our PAs and I think we need more of them . . .

ID 203, manager

The positive contribution was described within seven interlinking aspects: providing continuity in and accessibility to the medical team, supporting efficient patient flow through the service, supporting doctors in training, reducing the use of locum medical staff, increasing the capacity of senior doctors, contributing to service improvements and offering evidence of successful workforce innovation. The following example indicates the interlinking between these aspects:

They’re [the PAs] providing a good service and looking after our patients on the ward and supporting the doctors, I think those are all positive things, aren’t they?

ID 203, manager

The first and most frequently reported positive contribution the PAs were said to provide was that of continuity in and accessibility to the medical team for patients, nurses and service managers. Most of the managers described the importance of having permanent (as opposed to rotating or short-term) staff within the medical team. This meant that the PAs were familiar with the service and hospital processes, with consultants’ ways of working and with the other clinical and administrative staff:

I think what’s good about them is, they’re static members of staff – unlike your junior doctors that rotate through the department – so I think that’s really, really useful in that they know the department well. They know the processes in the department. They are a reliable firm pair of hands that can work at SHO level, really.

ID 110, manager

This presence on the wards, in particular, was viewed as supporting the patient experience and patient safety:

PAs providing ward cover – this has increased the support to our junior doctors and nurses, increasing the safety of our wards. Patients are seen more regularly, and issues are proactively escalated to senior reg [registrar] or consultant level in a timely fashion.

ID 81, manager

The continual presence of PAs on inpatient wards was contrasted with the doctors, who were described as moving between different areas, such as clinics and operating theatres:

They are ward based, they have fantastic relationships with the nurses and with the patients because they are constantly present, and they don’t tend to sort of float off doing, you know, they don’t get called down to [specialist procedural clinic] and things, which can disrupt continuity of care.

ID 103, manager

Closely linked to this was the contribution to patient flow through the service. Most of the managers described at the service/organisation level the ways in which the PAs helped ensure an efficient patient flow, which also aided patient satisfaction levels. This included not just being a member of the medical team (i.e. a pair of hands) but having a role in ensuring that the processes and medical administration of the team were efficient. Examples were given, such as preparing discharge summaries at the earliest point so that when the clinical decision was taken to discharge there was no delay in the patient leaving the hospital and releasing the inpatient bed for another admission:

PAs provide ward cover so discharge summaries are completed on time, meaning patients leave hospital without delay and bed capacity is released for other patients.

ID 81, manager

This example illustrates this aiding of efficiency in patient flow in a surgical specialty:

[Patient care is organised] . . . much more, much more smoothly, so, so for instance, yeah, patient [name of PA 1] will be highlighting all these patients on the ward up to the consultants [to pre-plan for future surgery], whereas without physician associates that patient on a discharge summary they would be discharged from the ward, they would go home and the discharge summary would slowly make its way across to the admin [administration] team, the patient pathway co-ordinators, and they’d bring the patient back in for a pre-op [preoperative assessment] and then they’d book them, and this whole thing would be delayed by a matter of 2 or 3 weeks . . . [name of PA 1] highlights on there, and then we can pencil them in for their surgery date here and which means that we can, we can line up all of the extra work . . . it’s so much smoother and probably a much quicker pathway for the patient, yeah, well that’s how it benefits me as a manager.

ID 136, manager

The PAs were described as a support to the junior doctors, in induction to the specialty and the hospital, in managing the patient workload, and in helping to cover wards while the doctors went to other areas for their training, hence facilitating junior doctor education:

So we’ve found they’ve been quite well received by the junior doctors . . . especially the ones that come straight out of medical school . . . they’ve [PAs] been quite a helpful support for the junior doctors so they orientate them around the ward, within the hospital as well.

ID 100, manager

Having PAs will stabilise a ward for an afternoon to allow the SHO to go to the clinic that they are required to attend when they’re training.

ID 103, manager

Most of the managers indicated that having PAs as part of the medical team reduced the use of locum episodes. For some, that was through PAs covering work; for others, it was the result of the PAs working additional shifts. All described the advantages in terms of the PA already knowing the service, the processes and the types of patients. From all of the managers’ perspectives, although the reduction in use of locum episodes reduced costs, more importantly it maintained efficiency and quality in the service and patient safety:

The [use of] locums profile has changed [over the period of employing PAs]. I’d have to track back to see if I can find it in the financial data but I know it’s definitely reduced here significantly.

ID 100, manager

For me it’s [having PAs who are permanent members of staff] a safety net and it’s what the department needs and it’s what the patients need . . . [in contrast to locum doctors]. The PAs know this department like the back of their hand and they’ve got the relationships with the consultants, and there’s so many pros to it.

ID 203, manager

A manager whose remit included the ED noted a limitation to rostering, in that, in their trust, the PAs could not be rostered after midnight when there was no consultant physically present.

A few of the managers considered that the employment of the PAs enhanced the capacity of the senior doctors and the medical team more broadly:

PAs have a positive impact on patient experience and outcomes by providing the following services: (1) follow-up clinics – this allows our consultant body to see a higher number of new patients, generating a higher tariff and reducing patient wait times. Follow-up capacity is also increased.

ID 81, manager

Three of the managers noted that PAs in their services were proactive in service improvement activities, undertaking clinical audits and making suggestions for changes in service processes. Two of the managers reported that individual PAs were active in hospital-wide service improvements, for example in relation to patient safety initiatives.

The final positive contribution reported by two managers was that the employment of PAs in one service acted like a pilot and test bed for others to observe and consider innovative ways of addressing workforce issues or longer-term development in staffing their service:

For other services they have that don’t have PAs, they’re saying ‘how can we get a PA into a service and what type of role would we make a PA to do within the service’ and I think it’s helping us to think out of the box.

ID 205, manager

It should be noted in this context that most of the managers described work to support the development of advanced clinical practitioner roles in their services – of which PAs were only one group they were seeking to recruit. The managers variously described this development in terms of a workforce group that was separate but linked to the medical staffing: ‘creating a second-tier rota’ (ID 198, manager) and ‘a brand new rota of PAs and ANPs’ (ID 203, manager). For some managers, this workforce development was specifically linked to the national shortage of doctors in emergency medicine. Others described a number of interlinked factors: providing support to the doctors in training, providing enough medical team staff to cover to all service areas at all times and providing continuity in the medical team staff.

Patient responses to physician associates in the medical team

Many of the managers thought that most patients were not aware that it was a PA attending them, rather than a doctor, despite the PAs introducing themselves as PAs. In some settings, such as the ED, managers thought that patients were more aware of, or accustomed to, being attended to by different types of professionals. They thought that most patients saw PAs as just part of their medical team. Some described positive patient feedback:

Have you had any sense of how patients feel about having physician associates attend them?

I don’t get any complaints from them; I get compliments.

One manager expressed a note of concern about the public confusion about PAs as doctors:

One drawback I’ve observed are patients confusing the PA as a doctor – there is a difficulty to distinguish them as they are wearing the same scrubs, they are part of the ward round, they are always on the ward with doctors and also many of our patients are elderly and confused because of their condition . . . The expectations of patients are that it will be a doctor. The PA even carries a bleep like the doctors.

ID 198, manager

This manager, on reflection, went on to describe the types of action the hospital could put into place to increase patient awareness and knowledge, along the lines observed by the research team in other hospitals, for example different coloured uniforms for PAs and posters around the site explaining PAs.

All of the managers reported that there had never been a complaint regarding the PAs in their service nor had any issues been raised concerning patient safety:

No, never had any – no, we’re quite a big culture of reporting incidents and concerns being raised but there’s nothing been raised with us, no.

ID 100, manager

Measurement of the positive impact and costs

All of the managers were asked about the impact the PAs had made on the service and all were able to state ways in which they observed positive impact, as described in section Overall positive contribution of physician associates. Some were able to be specific, as in these examples:

PAs assisting in theatres – this has seen a reduction in theatre cancellations and increased efficiency due to a lack of junior doctors being available to assist. Resulting in reduced wait times and complaints and income generation.

ID 81, manager

[Following the introduction of PAs] so, we saw more people, we saw them faster, but we didn’t admit more and we were getting them out. So, for us, for that particular case, that was a success and it did what we intended it to do.

ID 205, manager

The managers had mixed views on whether employing PAs reduced costs, were cost neutral, were an expensive staffing option or, as in the example above, increased service income. None, however, was able to share any internal data or reports to support these and similar statements or provide data for the research team to analyse.

Some of the managers identified the difficulty of measuring the impact PAs had within what was essentially a team endeavour and within an ever-changing context:

I know at the moment I don’t have PAs covering a Friday [on inpatient wards] . . . [discusses the value of comparing time of discharge between days the PA is working and Friday, when there are no PAs] . . . but then [that wouldn’t work as] the PAs prepare the discharge summaries for the SHOs for Friday.

ID 103, manager

[Describes implementing a business plan, with key performance measurements, for the employment of PAs] it didn’t quite go as planned because our admissions rose. Over the course of the year, we’re looking at I think we predicted 2 or 3 per cent and they rose by 26 per cent. So, it was hard because our baseline had changed so drastically, it was difficult for that one to say ‘OK, this resource had this impact’, because I was putting in a ton of resource just to deal with the day-to-day activity coming in the department, so it was more difficult to pinpoint exactly what impact the PA had.

ID 205, manager

Views on the reduced use of locum doctors is reported in section Overall positive contribution of physician associates and the cost consequences were described in terms of efficiency and safety rather than just the staffing finances. However, some of the operational managers reported that their PAs cost less than employing locum junior doctors:

The cost question is an easy one, because I’ve costed out quite a bit lately, working out what costs what, and what would equate to whole-time equivalent, I would get more for my money if I went with a physician’s associate as compared with an SHO.

ID 113, manager

It does definitely help with cost because; it’s definitely a lot cheaper to have a band 7 physician associate covering the rota than a locum agency SHO.

ID 98, manager

All indicated that the PAs had a positive impact on the service. They all argued that evidence of this positive assessment of the value of PAs that they and others held was demonstrated through their plans to replace those who left, for recruitment of more PAs and in the planned expansion of PA employment in a different part of their service or specialty.

Inhibiting factors to employing physician associates

When asked about factors that might inhibit the employment of PAs, the managers offered shortage of supply and to some degree the lack of authority to prescribe and order ionising radiation.

A small number of managers described difficulties in recruiting PAs due to the relatively small supply: ‘There’s not many PAs out there . . . so we are struggling with recruitment’ (ID 203, manager). Others described shaping their jobs for PAs in terms of types of work opportunities and career development available in order to be as attractive as possible in what they saw as a very competitive labour market.

A couple of the managers suggested that although PA authority to prescribe and order X-rays did not inhibit them from employing PAs per se, it did limit the overall numbers they would employ for a particular service or department:

The tricky part is the fact they’re not prescribers currently. So, I guess if you have too many, you almost become less efficient . . . I think it becomes difficult to work operationally if you had too many PAs. I think they probably need to keep a balance between how many PAs you have, how many prescribers and medical staff we have.

ID 100, manager

Most of the managers described their services as coping or managing around the PAs’ lack of authority to prescribe medications or order ionising radiation. They all considered it a limitation on using the full potential of the PAs and inevitably created inefficiencies, although they described practices to minimise this:

We always have them [PAs] working in teams [with doctors] so there’s always a way round it [not being able to prescribe], essentially.

ID 100, manager

They can’t do the actual TTO’s, which is the prescribing the actual bit, but you know, they can remind the SHO to do it and get the paperwork done for them to sign off on it.

ID 103, manager

All of the managers considered that having PAs who had the training and authority to prescribe and order ionising radiation would aid efficiency in the medical care of patients:

. . . but if anything was to come out of this [the research], my thing would be prescribing and requesting X-rays would tick many boxes. I’m sure it would help probably, it would definitely help our department 100 per cent and I’m sure it would help other departments as well . . . just being able to request those X-rays. I just don’t see why they can’t.

ID 203, manager

Summary

Overall, the managers who were interviewed were positive about the contribution that PAs made as part of the medical team staffing their services. A key motivating factor for their introduction was the shortage of junior medical staff. However, managers went on to describe the overall value PAs gave to the service in providing continuity and accessibility within inpatient wards for nursing staff, patients and administrators. All of the managers described processes to increase the workforce of advanced clinical practitioners, not just PAs. Although financial efficiency was important to the managers, their views about employing PAs were influenced by factors such as improving the quality and safety of their services. The PAs were not necessarily substitutes or funded from medical staffing budgets; some were in additional service posts that were funded differently. The measurement of impact was described as difficult and although managers could point to ways in which the PAs contributed to more efficient services and increased capacity, they were unable to share hard data on this. The PAs’ inability to prescribe or order ionising radiation was a limitation that was generally ‘worked around’. All of the managers wanted this limitation to be removed. In conclusion, these operational managers considered that the added value the PAs brought to their services outweighed any limitations.

The work undertaken by the physician associates

Nurses described the kind of work that PAs were undertaking in their specialties, which included both patient-facing and non-patient-facing work. As part of the medical team, they were described as participating in ward rounds and communicating with patients and relatives. The reviewing of patients was a frequently mentioned task that PAs undertook, and one nurse described how their PA was supervised through this:

I came to understand when they see a patient and assess the patient. After that they come to see the doctor or whoever the consultant is and discuss it. Like junior doctors, student doctors, to discuss the plan.

ID 77, nurse

The PAs were also reported to undertake procedures including taking blood, cannulation and more advanced procedures including central lines and removing drains. In terms of non-patient-facing tasks, PAs were following up and checking blood test results, attending multidisciplinary team meetings, liaising between specialties, and writing the bulk of discharge summaries:

The TTOs [to-take-out medicines], it’s very important and I’m feeling so sorry for them because most of the times the doctors don’t do the TTOs they are the ones who’s doing the TTOs.

ID 82, senior nurse

Although the PAs were seen as undertaking medical roles, many nurses commented on the overlap between the work carried out by PAs and themselves:

We help each other so at times for example if the patient needs blood. So, if the nurse can’t do bloods the PA will go and she will do, but for example if I’m working and if I’m free or if I’m, if, if the PAs are busy I’m more than happy to go and bleed them. So, doesn’t need to be just the nurse or the doctor or the PA, so who’s free will go and do it.

ID 82, senior nurse

Although she works within the medical team, she does take on some of the nursing roles as well as the doctor’s roles. When we fill out the checklists for patients that require further care, nursing home care, residential care, she helps us complete those checklists and also with our audits, our cannula care audits.

ID 66, nurse

We turn now to the nurses’ views on the contribution of the PAs.

The contribution of the physician associates

All of the nurses who were interviewed had positive things to say about their experience of working with PAs. This included general statements, such as:

They are very useful; I am pleased when they’re working.

ID 82, nurse

I think they’re really good, a really good asset to have as a member of the team and as a trust I would say that they’re fantastic to have around.

ID 118, senior nurse

Some examples of the interaction observed between PAs and nurses are provided in Box 7.

The nurses also gave more detailed comments on the specific ways in which the PAs had made a positive contribution. These are interlinked themes:

• the provision of stability and continuity in the medical team

• ease of access for nurses to the medical team for escalation of concerns about deteriorating patients

• detailed knowledge of patients

• bridging medicine and nursing

• relieving the workload

• enhanced the patient experience.

We now elaborate on these.

The most widely described benefits provided by PAs related to their provision of continuity and stability in the setting in which they were working. This was depicted in a number of ways. First, the majority of PAs were not on a rotational programme, unlike their junior doctor colleagues. This permanency meant that the PAs were recognised as having extensive knowledge of the workings of the particular setting/specialty/team, which made them a useful source of information for all of the health-care professionals with whom they were working.

We are the staff that are consistent, as are the PAs. So, you do get a certain level of knowledge and expertise and that, sometimes you’re like, oh thank goodness, there are other people that, you know, because it’s knowing that it isn’t just knowledge of injuries and patients in that sense. It’s knowledge of processes and the computer systems and the referral.

ID 177, nurse

The nurses reported that the PAs were predominantly working in a ward setting, unlike doctors who had other commitments (e.g. in outpatient clinics and operating theatres). The PAs largely remained on the wards they were attached to. This made them an accessible medical presence for nurses, which was important if they had concerns about patients.

The doctor went away on a cardiac arrest call, or to revive a patient, but there is somebody else on the unit who is more capable, like a doctor level, or they could kind of, if there’s any immediate concerns that we have they can come and take over and do it and nurses feel like there’s somebody around to help them.

ID 178, nurse

Nurses also frequently described using PAs as a means of contacting the doctors (Box 8).

The nurses reported that, in particular, they valued using the PAs as the first step in the escalation process for concerns about deteriorating patients, as illustrated in this quotation and in our observation (Box 9):

If we need any form of escalation, getting in touch with doctors, we can also get in touch with the PAs, the PAs chase the doctors, so their role is quite significant as well . . . to get things going so patients are not left for long hours waiting for a doctor because doctors are doing other things, doctors are in theatres. They’re like the middle person who get things done between both sides, nurses and doctors.

ID 71, senior nurse

The nurses considered that because PAs were present on a daily basis, usually on weekdays and during daytime hours, they also knew the patients and their histories very well:

Because they’re there on a daily basis, so they will know the day-to-day goings on of the patients. So they’re there Monday to Friday, well, the consultant will be in theatre all the time, but the PAs are supposed to stay on the ward, so if there’s anybody unwell, they should know about it . . . if the patient’s had an X-ray, an ultrasound, they should be able to say ‘This is the X-ray, do you want it?’ and get the consultant to review it and say that they’re happy with it.

ID 121, senior nurse

Some of the nurses described forming close relationships with PAs who remained working in their specialty for a number of years and the trust that built up over time:

I’ve actually found them really good because with the junior doctor rotation, they have rotation every 6 months and with a PA they are, they’ve become like a you know member of the team in regard to that they’re long-standing . . . and you know you can build a more you know good relationship with them kind of thing . . . So, the last PA we had I think she was here for about 3 years before she left.

ID 142, senior nurse

As well as linking the nursing and medical teams, as described previously, PAs were frequently described as an intermediary between the two. The reasons offered for this included PAs being more approachable and less intimidating:

I quite like them in the sense that you always have this like nurse/doctor thing and they’re not really either if that makes sense so, it’s sort of, not a neutral party that’s not quite the right word, but they’re not a nurse or a doctor.

ID 112, senior nurse

And it’s quite nice to have them there to ask, ‘cause you wouldn’t, like, bleep the SHO to be like ‘Can you just give me your opinion?’. But if they’re [the PAs] on the ward it’s quite nice to have them there, like every problem you had kind of went through her so that was, like, quite nice.

ID 167, nurse

As well as bridging between the two professions, the PAs were viewed as a benefit in that they relieved some of the work of the nurses, particularly in relation to the induction of new doctors in training:

Before new doctors come in the nurse in charge would take that responsibility of going through, like inducting them . . . but here the responsibility, if there’s a PA around they will do that job and they will induct so that pressure was taken off us and I think we found it very, professionally very useful and we thought oh gosh, this is good.

ID 178, senior nurse

Many nurses commented that they felt that the PAs they worked with had a positive impact on patient experience. The nurses reported that the constant presence of the PAs on the wards meant that they were a familiar face within the medical team, someone whom patients and their families could easily approach:

[PA 1 first name] and [PA 2 first name] especially are so friendly, like they go over and they’re chatting, and, like, I think the patients feel more like they will discuss things with them more than maybe the consultant . . . Yeah, but I think definitely like they help the patients along.

ID 167, senior nurse

The nurses described the PAs as being very proactive, and appreciated by patients, in communicating the detail of the medical plans and updates of test results. Many nurses spoke positively of PAs’ communication styles, contrasting them with doctors, in explaining medical terminology:

I think PAs tend to have a different approach, a little bit more of a down-to-earth approach, explain things a little bit better and use terminology that people you know understand and things like that.

ID 112, senior nurse

Invaluable with relatives. If you’ve got one team leave and the next team starts, there’s somebody that’s always there constant, really great if we need a relative spoken to, she’s really willing to go and do that.

ID 66, nurse

Most of the nurses did not think that patients understood who and what PAs were:

I wouldn’t particularly say the patients would know that’s a PA. I think they very much I think call them doctors because they see them as part of the ward round and things like that.

ID 112, senior nurse

I think most of the patients, like, love them and I don’t they’re any, I don’t think they consider them any different to doctors either.

ID 167, nurse

Although nurses did not elaborate on the specifics of the cost of employing PAs, many of the senior nurses did speculate that from a trust point of view employing PAs must be cost-effective, as they saw them undertaking the work of the doctors:

And I suppose from a trust point of view it’s cost as well because they’re seeing . . . yeah the cost must be, because they see as much as doctors if not more.

ID 118, senior nurse

We turn now to consider the reported challenges in working with PAs.

Perceived challenges of working with physician associates

Although nurses described the positives that PAs contributed to the service, having PAs as part of the medical team also had some perceived limitations. These were the inability of the PAs to prescribe medicines, lack of clarity over the PA role and impact on nursing roles.

Impact on the nurses’ role

Two of the nurses described the way in which the introduction of the PA role affected their role as nurses. The first was in changing the interaction between the ward nurses and the medical team and the second was a more direct impact on a nurse practitioner role. The first nurse suggested that the ward nurses had less interaction with the medical team following the introduction of the PAs. The PAs, being ward based, provided information that nurses might have provided previously, for example on ward rounds, or followed the consultant-led ward round by communicating the decisions to the nurses subsequently. In one nurse’s view, previously a nurse would have been part of the ward round. The second example was from a clinic setting, in which a nurse practitioner reported that her work was changed by the presence of a PA. The following quotation reflects the ambiguity and overlap of roles there can be in patient care:

When the PAs come in, the doctors automatically gravitate towards letting them see the patient over me. And maybe because as a nurse practitioner, and especially because I’m new and my role is new in this clinic, I think too that, you know like, I don’t sort of blame them because I think they would . . . they do have that much more knowledge base. However, they wouldn’t have a nursing input but then the nursing input could be substituted with any other nurse.

ID 101, senior nurse

Summary

This section has provided an analysis of the views of nurses, which were predominantly positive, of the contribution of the PAs to the service and to care of patients. Nurses particularly commented on the stability the PAs brought to medical teams and their continual presence in ward settings. Nurses were able to describe the ways in PAs enhanced the communications between the medical team and the patients and relatives. From the ward nursing team perspective, they identified that the PAs enhanced their access to the medical team in situations when a patient’s condition was deteriorating and of concern. Although PAs were described in mainly positive terms, the limitations to their practice, particularly the inability to prescribe, restricted their utility in some settings – especially those with high-dependency inpatients, those needing frequent prescriptions or in urgent care settings in which many patients could usually be seen by someone working at clinical practitioner level. Many commented on a general lack of clarity as to the PAs’ role and that understanding it seemed to be dependent on working with them. Most of the nurses considered that patients also did not understand who this new addition to the medical team was.

Description of the consultation records

Process outcomes

The clinical process outcomes within the ED visit have been measured as follows: length of time in the ED, whether or not the patient had an X-ray investigation carried out, whether or not a prescription was issued, whether or not a discharge summary was completed and the destination from the ED (admission rate).

Emergency department process: length of stay

The length of stay in the ED was available for all cases in the sample. Table 16 shows the distribution of the times.

TABLE 16 - Length of stay in the ED

Distribution	Length of stay in the ED (hours: minutes)
	Case type
	PA (n = 305)	FY2 doctor (n = 308)
Mean	3:03	3:48
SD	1:55	2:46
Percentile
10	1:00	1:39
20	1:25	2:16
30	1:56	2:46
40	2:34	3:14
50	3:12	3:34
60	3:33	3:50
70	3:50	3:58
80	3:57	4:00
90	4:00	5:17
Median	3:12	3:34
Minimum	0:11	0:13
Maximum	15:29	19:31

A sharp peak at a length of stay of 3 to 4 hours is noted (Figure 5).

FIGURE 5.

Distribution of length of stay in the ED (all cases).

Unadjusted comparisons of the length of stay for patients seen by a PA and those seen by a FY2 doctor suggest that those seen by a PA have a statistically significantly shorter length of stay in the ED, with a mean difference of 45 minutes (t = –3.916, df 611; p = 0.000).

The difference in expected length of stay between PAs and FY2 doctors was also examined after adjustment of other factors using linear regression, including age, sex, MTS (as a measure of acuity), whether or not they were admitted, whether or not an X-ray was taken and whether or not a prescription was given. Overall, across all sites, those seen by a PA, given everything else being equal, can expect a reduction of 0.61 hours (36 minutes) in length of stay in the ED.

Rate of re-attendance at the same emergency department

Re-attendance within 7 days of the index ED visit was found following 8% (n = 48) of the 610 visits for which these data were available (Table 17). Logistic regression was used to model the likelihood of re-attendance. After adjustment for confounding, no statistically significant difference was found in the rate of re-attendance between PAs and FY2 doctors.

Clinical review of patient records

In the context of the above finding that the study’s primary outcome – the rate of re-attendance within 7 days – was seen not to differ for patient consultations attributed to PAs and FY2 doctors, a review was carried out of a subsample of 40 of the above ED consultation records (20 PA and 20 FY2). Each record was reviewed by four ED clinicians against pro forma questions. In the following sections, we describe the reviews of the consultation record as well as inter-rater reliability.

Economic analysis

The economic evaluation set out to compare the costs of using PAs and FY2 doctors in the ED, from the NHS perspective. The main variables of interest, to be extracted from patient records, were also to be analysed as part of the clinical study [these were consultation lengths in minutes, diagnostic tests (blood tests and X-rays) ordered, prescriptions provided, referrals and follow-on care recommended, whether or not the PA or FY2 doctor sought advice from a senior colleague during the consultation, unplanned re-attendance within 7 days (primary outcome) and adequacy/appropriateness of care (obtained through expert review)]. The a priori analysis plan called for calculation of cost differences when statistically significant differences were found in variables, after adjustment for case complexity and consideration of the relative costs to hospitals of employing PAs and junior doctors.

When data collection began, it was found that it was not possible to obtain information on some of the identified indicators. Although time between the first clinical contact and when the patient left the ED was recorded, the patient-facing time of the PA or the FY2 doctor could not be distinguished. Information on blood tests, referrals and follow-on recommendations (other than admissions for inpatient care) and whether or not the PA or FY2 doctor sought advice from a senior colleague during the consultation was not available from all sites.

Of the data that were available, and as reported previously, there were no statistically significant differences between PAs and FY2 doctors with respect to the primary outcome, re-attendance within 7 days, after adjustment for demographic features of patients seen by PAs and FY2 doctors, site and Manchester Triage Score87 (the best available measure of acuity). The patients seen by PAs were observed to receive a significantly higher number of X-rays than those seen by FY2 doctors, after adjustment, but adjustment did not include actual conditions. X-rays could be ordered by any member of the ED team, for example the triage nurse in advance of the patient seeing the PA, and, in any case, PAs are not permitted to independently refer for radiography and have to get requests signed off by authorised colleagues.

Conclusions

Available data for comparing PAs and FY2 doctors were limited. From the information that could be gathered, the evidence suggests that both PAs and FY2 doctors practice equally safely and appropriately in the ED, with no differences in re-attendance rates. Moreover, problems exist in attributing outcomes or processes to individual professional staff because ED care is delivered through consultant-led teams, and both PAs and FY2 doctors routinely take assessments and treatment plans to consultants for checking.

The costs of hiring PAs and FY2 doctors differ. Most PAs are paid at NHS Agenda for Change band 7, although some more-experienced PAs may be at band 8a, and those recently qualified may be hired at band 6. 140 In accordance with validated national unit costs, these hourly rates, inclusive of oncosts and overheads, but excluding qualifications, range from £45 (band 6) to £62 (band 8a). 89 The equivalent hourly rate of FY2 doctors is £30. 89 Note that this figure should be treated with a degree of caution as there is a discrepancy between the mean basic salary for FY2 doctors141 used in the unit cost calculation89 and the national contract basic salary for FY2 doctors. 142 With PAs appearing as a more expensive resource, a strictly financial perspective might suggest that FY2 doctors are better value for money. There are, however, other considerations. Junior doctors have training requirements that mean that they are not always available for direct patient care. There is a shortage of junior doctors, and they are insufficient in number to be the sole source of meso-level care in EDs. Where overall staffing ED shortfalls arise, and hospitals bring in locum FY2 doctors, the real costs are higher. Use of PAs can help to relieve staffing pressures in EDs and improve efficiency in the delivery of care. They are able to safely treat patients with a range of conditions, enabling FY2 doctors, and more-senior colleagues, to cover more complex cases, and for FY2 doctors to thereby gain experience that is consistent with the objectives of the junior doctor training programme. Moreover, the role of individual FY2 doctors in the ED is transient, whereas PAs remain long term and provide continuity.

The final chapter provides a discussion of the findings from across the study.

The extent of the adoption and deployment of physician associates in hospital services

We found that PAs were increasingly being adopted into hospital workforces in England. A small but growing number of hospitals in England were employing PAs to work within a widening range of medical and surgical specialties (see Chapter 3, Survey of medical directors and Survey of physician associates). The growth was evident in comparison with data published for the UK in 20121 and reflects the data captured since in the 2016 UK FPA census. 59 This pattern of small but steady growth in adoption reflects those reported in the USA, the Netherlands and Canada. 22,143,144 We report for the first time that when some PAs have vacated their posts in secondary care they have not been replaced owing to the shortage of PAs to employ. This situation is likely to change with the public-finance-supported growth in training (through HEE) resulting in an estimated 3200 PAs in the UK (mostly England) by 2019. 145

We found that PAs, with the exception of those employed in emergency medicine, were mainly deployed to undertake inpatient ward-based activities of the medical/surgical team during weekdays, mostly in the daytime between 07:00 and 19:00 (see Chapter 3, Survey of physician associates, and Chapter 5, The physician associates’ working patterns: times and places). We found only a small number of PAs spending any time in outpatient clinics and theatres, and when they did it was a minor proportion of their working hours. This finding has also been reported in the USA146 and the Netherlands. 147,148

It was evident that while there was a core role in inpatient care, many of the individual PA roles were ‘bespoke’ or ‘moulded’ in that they were developed/trained to meet the requirements of an individual medical/surgical team, but their activities also reflected the experience, capabilities and competencies of the individual PAs (see Chapter 5 and Chapter 7). The longer a PA stayed in a post, the more skilled and knowledgeable they were reported to become in the work of that specific medical team and specialty. This was contrasted with the greater breadth of knowledge and skills developed by early-career doctors through rotation to different specialties. We found that some PAs had been trained by their consultant(s) to undertake specific clinical procedures in support of faster patient access to these procedures. All grades of doctors described a process of building trust in individual PA’s competencies; this reflects the concept of ‘entrustable professional activities’, which is widely used in medical education literature. 149 Some PAs had additional roles, such as a leadership role for other PAs, mentoring student PAs and hospital-wide involvement in specific initiatives related to quality improvement and patient safety. In addition, some had part-time roles within universities as PA educators.

The factors that support or inhibit the inclusion of physician associates as part of hospital medical teams at the macro, meso and level of the English health-care system

At the macro and meso level of the English health-care system, we found government policy and regional health plans supporting more advanced clinical practice roles, including PAs, in order to address medical workforce shortages (particularly in general practice) and the growing demand for health-care services (see Chapter 3, The policy review). This identifiable policy support was in contrast to the situation at the beginning of 2014, when we noted that PAs were absent from all relevant English policy documents, although they did feature in Scottish policy documents, particularly in relation to rural and remote areas. 17 The policy support identified in this study was more than rhetoric, with public finance assigned to supporting training with a target number of PA graduates, albeit with particular reference to general practice rather than acute hospital service (see Chapter 3, The policy review). By 2017, there were 33 PA studies courses in the UK,150 compared with two in 2013. 17

Our national survey of MDs in England indicated that a growing number were open to more advanced clinical practice roles, including PAs, to address junior doctor workforce shortages and increased patient demand (see Chapter 3, Survey of medical directors). However, the small pool of PAs to recruit from was identified as an inhibiting factor and PAs were not necessarily perceived as the right workforce solution by all MDs or professional leaders. Another important inhibiting factor that was reported was the lack of regulation of the PA role and concomitant lack of authority to prescribe and order ionising radiation. A public consultation was led on this issue by the Department of Health in late 2017 providing further evidence of increased macro-level support in the system. The results of the consultation were finally published in February 2019 with the decision to include physician associates in state regulation. 151

We found that the macro- and meso-level factors enabling and inhibiting the inclusion of PAs in the workforce were amplified and expanded at the micro level of the hospitals (see Chapters 4–9).

At the micro level, it was reported that developing advanced clinical practice roles, such as PAs, was a necessity in the face of the shortages of junior doctors to cover the medical rotas; the need to release junior doctors to undertake their training; the increased workload created by increased patient demand and expansion of services and recognised quality issues in service delivery.

Many different types of stakeholders supported the recruitment of PAs as a new source of advanced clinical practitioners in preference to depleting other staff groups, in particular nursing, which was also experiencing severe shortages. In addition, the PAs’ training in a medical model was reported to be a good fit within the medical/surgical team for undertaking the required medical work. Evidence from North America suggests that similar factors have supported the inclusion of PAs in acute medical/surgical teams. 133,152,153

As part of an innovation and change process,154 many participants within the hospitals identified the benefit of having clinical leadership, ongoing clinical champions for PAs and visible executive-level support (see Chapters 4, 7 and 9). This has previously been described in relation to one acute hospital unit in England. 44 The successful contribution of PAs in one or more consultant teams was identified as leading to other teams creating posts for PAs (i.e. the spread of innovation through diffusion51 rather than a top down managerial-led change). We return to the contribution of PAs in the following section.

Against these supporting factors, inhibiting factors were also identified at the micro level. Foremost among these was the lack of role regulation with attendant lack of authority to prescribe or order ionising radiation. The lack of regulation raised concerns about governance, responsibilities and liabilities (see Chapters 4 and 7), issues that have been raised in other countries where PAs have been developed or piloted and as yet do not have regulation or licensing procedures. 155,156 The extent to which the lack of authority to prescribe or order ionising radiation was viewed as an inhibitory factor varied between specialties.

A few clinical leaders (medical and nursing) were reported to have views that PAs were not the right group to develop or employ, favouring nurses or others. Likewise, some consultants working in some specialties with high-dependency patients, having employed PAs, were not re-appointing when PAs left as they considered doctors to be a better fit to the particular needs of that team and patient group. The extent to which the lack of prescribing or ordering ionising radiation authority, rather than other expressed concerns, was a factor in this experience was not clear.

Overall, the view was that PAs would become much more useful and attractive to the medical/surgical team if they had prescribing authority and there was much puzzlement as to why they did not have these rights. The Netherlands, where the first PA programmes commenced in 2000, agreed the legislation to regulate PAs and give them prescribing authority in late 2017. 157

Finally, the lack of a pool of PAs to recruit from was considered a serious inhibition and this was linked to concerns as to how best to retain PAs in medical/surgical teams. Other evidence from surveying PAs in the UK has suggested that retention might be an issue in some places as some PAs did not consider that they were being effectively used within the clinical team. 158

The impact of including physician associates in hospital medical teams on the patients’ experiences and outcomes

From interviews with inpatients and family members in this study, we found that they perceived the PAs as important in keeping them informed about their medical care and management plan (see Chapter 5). PAs were reported to be caring, approachable and good at communicating. Patients were very pleased with the explanations of important information they received about key aspects of their care. There was an implication that they better understood the explanation from the PA than the more complex language used by some doctors. PAs were trusted within their teams to convey important information to patients. Patients were content, and felt that it was appropriate, to be physically examined and have basic medical procedures carried out by a PA. Overall, inpatients and relatives reported being very happy with the care they received from the PA and the hospital staff.

Patients and relatives did not understand the PA role as a concept, but placed more emphasis on receiving good care, rather than the job role or title of individuals in the team treating them. This contrasted with the patient and public voice representative groups, which considered that it was important that patients understood exactly who and what members of their clinical team were. All participants were happy to have a PA involved in their care in the future. Some additional caveats were added, such as they thought that PAs were a good idea (to assist with staffing pressures) as long as they were properly supervised. In addition, some participants wanted reassurances that this addition to the medical team did not result in fewer doctors. High levels of satisfaction with PA involvement in acute inpatient care for similar reasons has been reported from studies in North America and the Netherlands. 109,110

All types of staff (including in emergency medicine) interviewed across the case study sites reported that patients really appreciated the work of the PAs, as evidenced through positive comments, compliments, gifts and seeking them out to talk to (see Chapters 4 and 6–9). We discuss the patient outcomes in more detail in the following section.

The impact of including physician associates in hospital medical teams on the organisation of services, working practices and training of other professionals, relationships between professionals and the service costs

We consider first the impact on organisation, working practices and costs, before turning to the impact on relationships and on the training of other professionals.

Synthesis

This study is framed by the dimensions proposed by Donabedian49 and Maxwell50 for evaluating health-care services and is applied here to the innovation of PAs in secondary care. The dimensions are acceptability, effectiveness (including safety), equity (fairness) and efficiency (including costs).

Physician associates were an acceptable group of health professionals to contribute to secondary care at the macro, meso and micro levels of the health system. The macro and meso levels of support are in marked contrast to the situation when the primary care study was completed. PA training and employment is now supported at the government level by all countries in the UK.

Physician associates were found to be acceptable and appropriate by most, but not all, doctors, managers and nurses. Patients had little knowledge of the PA role itself but viewed the PAs very positively within the context of the medical/surgical team. Some consultants in specialties with high-dependency patients reported that doctors were more appropriate for the level and/or pace of work, particularly prescribing, required in that setting. Clinicians and managers were supporting the development of many types of mid-level advanced clinical practice roles, of which PAs were one. For many doctors, the training of the PAs in the medical model made the PAs particularly appropriate for the work they required. It should be noted that other hospitals in England have developed medical assistant roles (sometimes called doctors’ assistants or physician assistants) to support doctors. These are trained to the level of health-care assistants to undertake tasks such as phlebotomy and clerical work under the direction of the medical/surgical team. 170 The contribution of different types of roles supporting the medical/surgical team requires further investigation.

For junior doctors and some nurses, there was uncertainty as to the scope of the role, an uncertainty compounded in the eyes of many by their lack of inclusion in the regulatory process for health professionals. Inclusion of PAs in these processes for health professions was viewed as important in terms of their acceptability, their perceived effectiveness (particularly in relation to prescribing and ordering X-ray investigations) and governance.

Physician associates were deployed, within a medical or surgical team, to mainly work in the inpatient ward under the supervision of consultants and their registrars. In the EDs, they worked as part of the team, with early-career doctors and other advanced clinical practitioners, and under senior medical supervision. Their work was described as aiding patient flow and releasing doctor time for more complex, medically unstable patients, for outpatient consultations, for the operating theatre and for training activities. There was no indication that this was inequitable (unfair) to any group of patients.

As part of the medical/surgical team, PAs were reported to be clinically safe in the work they did and to add to patient safety through their knowledge of policy and the practices of the consultants and the organisation. These colleague reports were supported by the finding that the patient outcomes and consultation records of FY2 doctors and PAs in the ED were equally safe and appropriate.

There was difficulty of attributing patient outcomes and cost to an individual professional when the provision was team based and affected by multiple other factors, but, in general, the reported contribution of PAs was highly positive.

Planning and developing a medical and surgical workforce is recognised as internationally challenging. 145,169,171 Medical staffing shortages have continued to rise in England, with a government response during the study period to create an additional 1500 medical student places in England from 2018. 172 The General Medical Council, although welcoming this growth, noted that their presence will not be felt in the workforce as graduates until 2023 and raised questions as to the availability of sufficient capacity within the workplace to train increased numbers. 173 Cyclical shortages of different grades of doctors with attendant reports of increased pressures on the employed doctors has been a recurrent feature of the NHS. 174 Achieving a sustainable medical workforce with the right balance of consultants, GPs, specialty doctors (i.e. not in training posts) and junior doctors has to take account of (1) the service demands, (2) the training requirements for career advancement and (3) the creation of manageable jobs within interesting careers. Having a cadre of flexible, mid-level practitioners, trained in the medical model, who can support doctors, but are not doctors, or intending to replace doctors, may help address inherent tensions between service demands, training requirements and budgetary constraints, as well as mitigate cyclical shortages.

Strengths and limitations

This was a mixed-methodology study that had multiple elements. The major strengths are as follows:

• the use of multiple methods over a number of workstreams, allowing a macro-, meso- and micro-level view of the research questions

• undertaking micro-level investigation that included hospitals from a wide range of different sites (both major conurbations and smaller cities/towns, large tertiary referral and small ‘District General Hospital-type’ sites), from a wide range of specialties and with a considerable proportion of the known PA workforce in secondary care in England

• collection of extensive qualitative data from a wide range of stakeholders utilising individual interviews, allowing analysis of perspectives gathered from senior managers (MDs and trust board members); members of the medical team (senior and junior doctors) and other clinicians, such as nurses; patients; and relatives

• gathering of quantitative and qualitative data on PAs ‘in action’ in hospitals, using both observation and self-completed diaries

• carrying out a well-powered quantitative comparative analysis of the documented processes and outcomes of patient care by PAs and FY2 doctors in three EDs in different parts of the country.

The main limitations of the case study elements were largely a result of the difficult circumstances and constraints on research within a highly complex and dynamic system, which was simultaneously under great pressures. 175–179 The protocol was changed twice to try to accommodate real-world changes and priorities. For example, we had intended to compare activity of PAs and FY2 doctors while managing minor cases in EDs but found changes (between the time period we negotiated the research funding and when we commenced recruitment) in how many PAs worked in EDs and in what area of the ED PAs worked in, with most currently working in ‘majors’. This required a change to comparison of ‘majors’ cases instead. This change to ‘majors’ patients also introduced the potential for selection bias in the sample, in that patients in the minors section are attended by the next-available professional whereas patients in the majors section are attended by professionals based on a range of factors, such as severity/immediacy of the injury/illness, number of patients arriving at that time point and the availability of staff, as overseen by a senior doctor in charge. Although there might be the potential for selection bias by a senior doctor in charge in the majors section, three factors in the design mitigated this: (1) the use of three different ED departments rather than a single ED, (2) the overall sample was obtained from a 16-week period at all times of day and night in which there will have been the greatest variation in both the factors referred to above and also individual senior doctors in charge and (3) statistical adjustment for MTS,87 alongside other potential confounding factors, in modelling. The changes also resulted in a very limited economic analysis, unlike the analysis that was planned. There are still relatively few PAs working in secondary care and there is a smaller number within that group who are willing to volunteer to participate in this type of research. However, we successfully recruited six hospitals with PAs (and three with PAs in the EDs) and, within those, 41 PAs willing to participate.

We were unable to access quantitatively measurable data on the effect of the introduction of PA on patient outcomes (other than in the ED) or costs as the hospitals were unable to supply these type of data. In addition, the attribution of changes in quality of patient care, patient safety events or cost savings to the introduction of PAs is problematic when such an introduction commonly went alongside other changes or responses to other significant events, such as unprecedented surges in demand and workforce shortages. However, we were able to describe and scope the range of potential impacts, which could inform the design of future studies either through matched comparisons of medical/surgical teams with and without PAs, such as those used in the Dutch study,110 or in a ‘stepped-wedge’ design (in which the change is introduced sequentially in all sites so that all participants get the intervention, but not simultaneously). 180

Conclusions

Physician associates are a new group of health-care professionals being adopted in a minority but growing number of secondary care hospitals across the UK. The well-documented workforce shortages in the NHS meant that PAs were one of many solutions being followed to address, in particular, the shortage of doctors. PAs were deployed to undertake some of the work of junior doctors, releasing their time to focus on complex and new patients as well as training requirements. The work that PAs undertook was mainly the ward-based activities of the medical/surgical teams and included significant amounts of medical administration. This work was considered to significantly aid patient flow and patient experience. The stability of PAs in the work setting, in contrast to doctors in training, was reported to be valued in inducting new doctors and also contributing to patient and junior doctor experience, patient safety and throughput and the development of trust between PAs and the medical and multidisciplinary teams. Patients were very satisfied with PA care as part of their medical/surgical team but had little understanding of the role. The pragmatic comparative review of ED records of patients attended by PAs and Foundation Year doctors found that they provided equivalent, safe care, suggesting that PAs are another source of advanced clinical practitioners that can be employed in that setting. The main cost benefit identified, but not quantified, by managers and clinicians was thought to be the reduction in employing locum junior doctors. Even when this was discussed, patient safety and experience were the main considerations. Although some specialties with high-dependency patients reported that PAs were less appropriate than junior doctors, most specialties reported inefficiencies and problems in the workflow created by the lack of PA authority to prescribe and order ionising radiation. It is clear from our study that PAs could provide a flexible addition to the secondary care workforce without drawing from existing professions or reducing opportunities for doctors in training. However, their utility in this setting is unlikely to be fully realised without the appropriate level of regulation with attendant authority to prescribe medicines and order ionising radiation within their scope of practice.

Implications

Physician associates have the potential to be a competent and flexible addition to current and future medical and surgical teams. Patients, the public and secondary care professionals need more information to understand both the role and also its potential contribution to acute care medical and surgical teams. Individual employing NHS organisations need to consider their role in this alongside that of national NHS and professional bodies.

Physician associates are a workforce innovation that is not necessarily welcomed by all other professional groups. As an innovation, successful introduction and growth is likely to depend on a planned process with attendant senior levels of support, local champions and embedded governance and review processes. This requires employer organisations to both plan and identify appropriate people and resources. With the expected exponential increase in PAs in England in the next 2 years, this requires prompt consideration.

Findings from this study suggest that the efficiency and contribution that PAs could make to medical and surgical teams in secondary care will be increased by the legal authority to prescribe, which can be achieved only by including PAs in the regulatory framework for health-care professionals. This has implications for policy with regard to regulatory frameworks for health professionals in the UK.

In order for there to be a supply of PAs for secondary care, there needs to be cognisance of this group in health profession education commissioning at a local level. Education commissioners at local levels should consider the contribution PAs could make to a future flexible secondary care, and not just primary care, workforce.

Further investigation

This study has highlighted a number of questions that require further investigation in the context of increasing numbers of PAs and other mid-level practitioners available in the UK to join the NHS workforce. These include:

• What are the patient outcomes, experiences and service costs for same-specialty medical/surgical teams before and after the introduction of PAs using stepped-wedge quantitative research designs?

• How does the work of the medical and surgical teams in the same specialties vary between hospitals with different types of infrastructure, technology and patient flow systems and what workforce is required to meet the variation?

• What is the extent of the use and role of medical assistant roles in different medical and surgical specialties and how does that compare and contrast with the use of advanced clinical practitioners, including but not limited to PAs?

• What is the influence of sociodemographic and geographic factors, and types of hospitals, such district general or tertiary hospitals, on the demand for PAs and other advanced clinical practitioners, in a secondary care workforce?

• What factors influence clinician and manager decision-making as to staffing and skill mix in secondary care teams, with particular reference to beliefs, preference, evidence and use of financial data?

• Can workforce modelling of different permutations of skill-mix support to medical and surgical teams, in which supplementation and/or substitution are explicit, assist managers and clinicians in workforce decision-making?

• What opportunities are available to retain PAs (and other advanced clinical practitioners) longer term in an essentially flat career structure?

• What impact will the rapid growth in PA numbers in England over the next 3 years have on perceptions and development of the role?

Contributions of authors

Vari M Drennan (Professor of Health Care and Policy Research) conceived, obtained funding for and led the study. She contributed to all elements of the study, led the emerging-findings seminar and overall synthesis of findings, and drafted the final report.

Mary Halter (Associate Professor of Emergency Cardiovascular and Critical Care Research) conceived and obtained funding for the study. She was project manager and contributed to all elements of the study. She convened the London patient voice groups and led on the surveys, systematic review, data collection and analysis within the EDs. She wrote the initial draft chapters on the PA deployment (see Chapter 5) and the ED element (see Chapter 10). She also contributed important intellectual content to the revisions of the final report.

Carly Wheeler (Research Associate) undertook surveys, the systematic review, data collection and analysis in the case study sites. She helped convene the London patient voice group. She prepared the initial draft of the nurses’ view chapter (see Chapter 9). She also contributed important intellectual content to the revisions of the final report.

Laura Nice (Research Associate) undertook data collection and analysis in the case study sites. She contributed to the West Midlands patient voice group. She wrote the initial draft of the patient and family views chapter (see Chapter 6). She also contributed important intellectual content to the revisions of the final report.

Sally Brearley (Patient and Public Involvement) conceived and obtained funding for the study. She contributed to all elements of the study and chaired all research team meetings. She led on the patient and public involvement, including chairing of the emerging-findings seminar. She contributed important intellectual content to the revisions of the final report.

James Ennis (PA and Lecturer) was awarded the funding and contributed to all elements of the study. He provided PA expertise and knowledge. He contributed to the West Midlands patient voice group and undertook qualitative interviewing and analysis in the study sites. He also contributed important intellectual content to the revisions of the final report.

Jon Gabe (Professor of Sociology) conceived and obtained funding for the study. He contributed to all elements of the study, provided expert knowledge in sociology applied to health care and qualitative methods and undertook analysis of qualitative data. He contributed important intellectual content to the revisions of the final report.

Heather Gage (Professor of Health Economics) conceived and obtained funding for the study. She contributed to all elements of the study, provided expert knowledge in health economics, led on the economic analysis and prepared results for publication. She contributed important intellectual content to the revisions of the final report.

Ros Levenson (Independent Researcher) undertook the senior manager and clinician interviews, leading on the analysis and initial draft of that chapter. She contributed to all elements of the study, including contributing important intellectual content to the revisions of the final report.

Simon de Lusignan (GP and Professor of Primary Care and Clinical Informatics) conceived and obtained funding for the study. He provided expert clinical knowledge and expertise in the organisation of medicine and clinical informatics. He contributed to all elements of the study and contributed important intellectual content to the revisions of the final report.

Phil Begg (Executive Director of Strategy and Delivery in a NHS Trust and Professor) helped conceive the study and was awarded the funding. He provided expert NHS management knowledge of the acute sector organisation and workforce issues. He convened the West Midlands patient voice group. He contributed to all elements of the study and contributed important intellectual content to the revisions of the final report.

Jim Parle (GP and Professor of Primary Care) helped conceive the study and was awarded the funding. He provided expert clinical knowledge, expertise in the organisation of medicine and medical education as well as PA education. He contributed to all elements of the study and led the study elements in the West Midlands. He contributed important intellectual content to the revisions of the final report.

Publications

Halter M, Wheeler C, Drennan VM, de Lusignan S, Grant R, Gabe J, et al. Physician associates in England’s hospitals: a survey of medical directors exploring current usage and factors affecting recruitment. Clin Med (Lond) 2017;17:126–131.

Wheeler C, Halter M, Drennan VM, de Lusignan S, Grant R, Gabe J, et al. Physician associates working in secondary care teams in England: interprofessional implications from a national survey. J Interprof Care 2017;6:1–3.

Wheeler C, Halter M, Drennan MV, de Lusignan S, Grant R, Gabe J, et al. Physician associates working in secondary care teams in England: interprofessional implications from a national survey. J Interprof Care 2017;31:774–6.

Halter M, Wheeler C, Drennan VM, de Lusignan S, Grant R, Gabe J, et al. The contribution of physician assistants/associates to secondary care: a systematic review. BMJ Open 2018;8:e019573.

Drennan VM, Halter M, Wheeler C, Nice L, Brearley S, Ennis J, et al. What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study. BMJ Open 2019;9:e027012.

Data-sharing statement

All qualitative data generated that can be shared are contained within the report. All data queries and requests should be submitted to the corresponding author for consideration. Please note that exclusive use will be retained until the publication of major outputs. Access to anonymised data may be granted following review.

Patient data

This work uses data provided by patients and collected by the NHS as part of their care and support. Using patient data is vital to improve health and care for everyone. There is huge potential to make better use of information from people’s patient records, to understand more about disease, develop new treatments, monitor safety, and plan NHS services. Patient data should be kept safe and secure, to protect everyone’s privacy, and it’s important that there are safeguards to make sure that it is stored and used responsibly. Everyone should be able to find out about how patient data are used. #datasaveslives You can find out more about the background to this citation here: https://understandingpatientdata.org.uk/data-citation.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care.

Advisory group terms of reference

Public and patient involvement group information and terms of reference

Physician associates in secondary care research: physician associate survey

1. Which country are you currently practising in as a PA?

• England

• other.

If other – thank you for your interest in our research into PAs in secondary care; however, at the present time we are only able to survey PAs working in England. If you are interested in keeping up to date with the study’s progress, please contact [contact details].

2. As a PA, do you practise in a single job or multiple jobs?

• single

• multiple (please specify how many).

3. Which specialty are you working in for each job? Full list of specialties given as drop-down list (e.g. Accident & Emergency, General Acute, Paediatric Accident & Emergency, Acute Medicine, Acute Internal Medicine, Allergy, Cardiology Diabetes, Dermatology, Elderly Care Medicine, etc.)

4. Please select which setting(s) you currently work in (please answer for each job if you work in more than one):

• emergency department

• inpatient ward

• intensive care unit

• medical assessment unit

• operating theatre

• outpatients

• rehabilitation

• walk in/out of hours

• other (please specify).

5. Is the specialty you are currently working in part of a rotation?

• yes

• no.

6. If you are on a rotation programme, how long is the programme (in months)?

• less than 12

• 12–23

• 24–35

• 36 or more.

7. In addition to your current specialty, what other specialties does your rotation programme include? Free-text response

8. Which other health-care professionals make up the specialty consultant-led team in which you work?

• clinical nurse specialist(s)

• Foundation Year 1 doctor(s)

• Foundation Year 2 doctor(s)

• medical consultant(s)

• non-career grade doctor(s)

• physician associate(s)

• specialty training doctor(s)

• other(s) – please specify

• please provide further information if you selected ‘other’.

9. Which type of health-care professional is your line manager?

• a medical consultant

• another grade of doctor

• another type of clinical manager

• other (please specify).

10. Please can you describe your clinical supervision arrangements day to day/on each shift.

• e.g. I am supervised by the consultant in charge of the team on each shift.

• e.g. I am supervised by the registrar on the team when working on the ward and by the consultant when in clinic or theatre.

11. Please can you describe your ongoing clinical/educational supervision.

• e.g. None, I am only supervised day to day.

• e.g. I have a clinical supervisor who I go to for XYZ and an educational supervisor who I discuss XYZ with.

• e.g. I have a lead consultant who I meet with weekly/monthly.

12. Thinking back over the last 4 weeks, please indicate the number of day and night shifts you worked for weekdays and weekends (with week 4 being the most recent week). Drop-down menu.

13. Please describe in broad terms a typical work shift for you.

• e.g. all shift – working in A&E minors seeing next-in-turn patients

• e.g. morning – part of consultant ward round; follow-up items from the round such as ordering tests

• e.g. afternoon – outpatients clinic; meeting with consultant.

14. Are there any factors that change the type of work that you do? – e.g. sickness within the clinical team.

• yes (if yes please add details)

• no.

Please could you provide some information regarding the hospital that you work in.

15. Is your hospital acute or mental health?

• acute

• mental health.

16. Approximately how many beds does your hospital contain? Drop-down list of numbers.

17. What is the length of your experience post qualification (in years)?

18. In which country did you undertake your PA training?

• United Kingdom

• United States of America

• other (please specify).

19. If you have any additional comments relating to your work role or deployment as a PA, please leave them below.

END OF SURVEY

Thank you for your time and help.

We have a number of reasons why you might wish for us to have your contact details, as follows:

• You would like to be entered into the prize draw for a £40 book voucher.

• You may be interested in hearing more about case study work we are aiming to undertake with hospitals that employ PAs.

• You would like to be kept informed of the study’s progress via newsletters.

• You would like to see the report of this survey.

As this survey is anonymous please click the following link to provide us with your contact [click here].

Alternatively, you can e-mail us at any time: [contact details].

MEDLINE

Date searched: 24 November 2015.

Date range searched: 1 January 1995 to 1 January 2018.

Patient interviews

Physician associate interviews

Staff interviews

Senior manager and clinician interviews

Instructions to researchers for observations/shadowing