This study addresses questions about the introduction of a new role, the physician associate (PA), within the hospital medical workforce. It is focused, in the first instance, on providing information that addresses the questions of clinicians, managers and those involved in commissioning services and education programmes in the UK. This chapter provides the background and rationale of the study by presenting contextual information and the evidence at the time the study was commissioned (September 2015). The aims and objectives of the study are presented, followed by brief detail of the advisory process and the public’s role in advising the study team. The chapter concludes with an outline of the rest of the report.
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. (Figure not reproduced here; see the original article.)
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:
- What is the extent of the adoption and deployment of PAs employed in acute hospital medical services?
- 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?
- What is the impact of including PAs in hospital medical teams on patients’ experiences and outcomes?
- 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.