This chapter presents the findings from the perspectives of the operational managers. Eleven non-clinical operational managers from five NHS trusts participated. Ten spoke in interviews and one provided written information only. They ranged in their scope of responsibilities and titles, from divisional managers to service business managers and assistant service managers. They worked in medical, surgical and emergency services. All had worked in their posts for ≥ 18 months.
Many had come into their posts when PAs were already employed within the services and described not knowing about this type of professional previously. One had worked in the USA with established physician assistants and was able to contrast between an established model in the USA and one that was a more ‘dynamic’ model of testing and trying out in the UK.
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.
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.
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.
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.
I value our PAs and I think we need more of them . . .
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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:
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.
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.
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.
[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.
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.
[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.
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.
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.
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.
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.
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.
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.
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.