Findings from the micro level: the deployment of physician associates

This chapter presents a description of the deployment of the PAs recruited into the study by way of an introduction to the participants in the six case study sites. This description comes from three sources of data: work diaries completed by PAs, interview data from the PAs and researcher observations of the PAs in practice. The views of the PAs on their impact, and the challenges associated with their role, are also briefly described.

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. (Figure not reproduced here; see the original article.)

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

Working hours

Work diary entries document 23 working weeks with 107 individual working days. Out of these 107 working days, 100 days were evenly distributed across the normal working week and seven were over weekends (four Saturdays and three Sundays). During these 107 working days, PAs worked a total of 1109 hours and 45 minutes (median 9.5 hours, interquartile range 8.38–12.13 hours). On average, PAs worked 48 hours and 15 minutes per week (median 47.25 hours, interquartile range 40.38–58.75 hours).

The PAs who were interviewed universally described themselves as belonging to the medical team, and their place in work rotas mostly reflected this, with descriptions given of the anticipated medical workforce for particular days or times. As we observed in the diaries, in most specialties, PAs described their main working hours as being daytime, weekday hours. When an extended-hours rota was worked by PAs, this either reflected the nature of the work in the setting (e.g. the ED where PAs worked at any time with consultant-level cover) or had come about over time, usually to address medical workforce gaps, as workload out of hours was described as being higher:

So the minimum we’d have would be one on each side [one 24- and one 28-bed ward] from 8 [a.m.] ‘til 4 [p.m.] but that sort of does vary as well. So, on a bank holiday there might be only one to cover 50 patients, on a weekend there might only be one to cover 50 patients, and on bank holidays and weekends there’s nobody coming at 2 o’clock [p.m.], there’s just that PA.

Although the caseload was high, this out-of-hours work was described positively as offering opportunities to expand and develop the PA role:

We realised when we first started working that the weekend and the evenings were the best time for us to get more experience . . . professionally it was really helpful because we could get more, we had more opportunities to practise our procedures because there were less trainees around . . . so, our lead consultant at the time . . . they wanted more cover on the weekends and some more cover out of hours, and then it kind of worked for us in terms of our own learning as well, so it’s kind of what we decided on.

For another PA, ‘on-call’ work was seen as desirable but unattainable owing to the limitations on PAs’ independence:

In line with this pattern, the majority of observations were carried out during the standard working week (between 08.00 and 18.00, Monday to Friday), but four observation sessions took place in the evening, night or daytime weekend shifts.

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.

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. (Figure not reproduced here; see the original article.)

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 ward round

In most settings, other than the ED, the ward round appeared to be a central feature of the PAs’ daily work, mostly taking place in the mornings, with PAs describing their work done in preparation for, during and after this daily activity. Ward rounds varied slightly by setting; they were seemingly dependent on whether patients were being reviewed on acute-assessment, high-turnover units where they were not known to the medical team or on a potentially longer stay (even if just for a few days) ward. The composition of the medical team also appeared influential, with rotational on-call consultant, the patient’s own consultant and registrar or junior doctor models all mentioned. In interviews, the tasks associated with ward rounds – for PAs – included preparing notes, offering information, particularly knowing the patient’s test results, answering questions about the patient, scribing into medical notes and getting hold of missing information.

In interview, although the tasks were articulated, it was difficult to accurately judge the level at which the PA was working. During observation, widely varying roles were seen, ranging from participating only in taking instruction and scribing in the notes, to being the main information source for the consultant, as seen in the following excerpt from the researcher’s notes on a 22-bed ward round carried out at the bedside in a surgical specialty, as shown in Box 1.

The PA was on the phone to radiology at the ward staff base as the consultant arrived on the ward. There was a flurry of activity as staff gathered around the consultant and a group of six people started to follow the consultant. The PA finished the phone call and rushed to join the round just as the consultant was moving to bed 2. The ward round moved at pace bed by bed, perhaps spending between one and three minutes at each bedside. When the PA joined at bed 2, the on-call consultant immediately asked the PA what the problem with the patient was and the PA answered ‘complaining of neck pain’. I could not hear the whole conversation as I was at the back of the group, but I could see that the PA and physiotherapist were the only team members the consultant was talking to, and that the PA was also scribing. At bed 3 the ward sister led the conversation, talking directly with the consultant. Here the PA (nor any other member of the team) had any input. At bed 4 the consultant talked first to the patient, then to PA, saying ‘Just remind me . . .’. The PA gave an update about radiology, then the clinical nurse specialist gave another update to the consultant. At bed 5 the consultant went ahead with the PA, talking (I couldn’t hear the content of this). At the bed the consultant asked the ward sister ‘what’s happening here?’, then said to the registrar ‘needs urgent CT’ [computerised tomography], at which the PA says ‘it’s been requested’. As the team left the bedside, the PA said to patient ‘I’ll come back and talk to you after.’ . . . The ward round continued similarly bed by bed with the PA note taking on every patient. At bed 8 I noted that the PA introduced a new patient to the consultant by name and clinical condition and the consultant said to the PA: ‘get him to the CT today’. The ward sister said to the PA ‘CT?’ and the PA said to the ward sister: ‘I’ve discussed with them already, he can go’ (I noted that this was the patient the PA had been on the phone to radiology about immediately prior to the ward round). At bed 10 I noted that the PA presented questions to consultant and the physiotherapist, and the consultant asked the PA if everything else was OK. The PA answers: ‘yes’ but then raised an issue about antibiotics. The patient asked the consultant a question about X-ray results, to which the PA answered.

This observation excerpt supported the description of ward rounds as pivotal points in the PA’s day, for which it was important to be well prepared and from which emerged ‘the jobs’ to be done, described in the following section.

‘The jobs’

Associated with the ward round in many cases, but ongoing throughout the day, were the activities that may be described as enabling patient care decisions – although these are described later in this study report as ‘clinical administration’ by others, no PAs used this term, but variously referred to these activities as ‘ward work’, ‘the jobs’ or ‘clinical jobs’. These activities did not involve direct patient contact, rather they took the form of ordering blood tests and investigational procedures – via a computer system, by telephone or occasionally in person; chasing the date for, or results of, such procedures; reviewing and acting on results; activities related to prescribing; and discharge summaries. In interviews, these ‘jobs’ were mentioned almost in passing by many, even though these were their core role, as if these did not require explanation or attention:

So just doing the preliminary kind of management investigations that needed to be done.

These parts of the PAs’ role, however, were clearly on show when observed, as, for many, they took up much of their day and appeared to be closely related to their value in the team in terms of having information ready for the ward round (as previously described), and in enabling medication reviews and readiness for surgery or discharge. There were many examples of these types of work during observation periods, usually interspersed with seeing patients face to face or reporting to seniors – this work took place in PA/doctor offices adjacent to wards or at the staff bases on wards. For example, one observation session included the notes of events in Box 2, which were not continuous.

While the PA was writing on patient history sheet a SHO [senior house officer] asked the PA how to book a CT [computerised tomography] cystogram. The PA said: ‘just do [specialty-specific investigation]’ and the SHO said: ‘they want [specialty-specific investigation], that was the outcome of this morning’. The PA looked on the computer and said: ‘you mean X patient?’. Later in the observation the SHO asked the PA: ‘can you get renal to look at X patient’? The PA replied: ‘CT showed no leak?’. SHO: ‘no’. PA: ‘will do’. The PA went to see a patient at their bed and then returned to the computer. Later again, the PA was looking at the patient list being looked after that day and told me: ‘I can go here, look at the pathology results on screen, need to halve the warfarin.’. The PA went to see another patient at the bed. Back at the staff base the nurse asked about warfarin and the INR [international normalised ratio]. The PA said: ‘hold, no warfarin today’ and then went directly to the patient at the bed and explained this. The PA filled out the warfarin chart and told me [the researcher] not to worry, the PA was not prescribing, but recording the INR. Later the PA went to the outpatient clinic. Here the consultant asked the PA to get bloods done for a patient and the PA directed the patient to as no one was waiting. The PA explained to the patient that they were ‘booked in for Friday’. Back at the computer the PA looked up this patient’s ultrasound results, then the PA’s bleep went off. This was a call from radiology and I heard one half of a discussion about putting in a request for an investigation. After this the PA collected the urgent bloods from phlebotomy and took them directly to the lab. After this the PA bumped into the consultant, who agreed the patient’s booking day of Friday, patted the PA on the arm and thanked them for sorting the bloods. Next, microbiology bleeped the PA. The PA . . . came back with some patient records and said they were going to do two discharge summaries for patients and book [specialty-specific investigation]. Later the PA was on a mobile phone saying: ‘you on call tonight? [first name] clearly handed over, all you need to know is patient has [clinical condition].’. The phone call continued with the PA spelling the patient’s name, and giving the hospital number and patient age, stating that the patient had had surgery, with some problems, had spoken to [other specialty] and looked up the renal function which was ‘fine’.

As noted briefly in the excerpt in Box 2, writing discharge summaries was also observed to be part of the core PA role in all settings. Many PAs listed writing discharge summaries in interviews and, for some, this was described as a fairly independent process following discussion with a senior colleague, but the process was also described as problematic; PAs referred to the process of ‘signing off’ as being hampered by the relationship of discharge summaries to the prescribing of medicines to take home [to take outs (TTOs)]. For example:

In observation, the to and fro process was clearly observed as inefficient double-handling of the work, with junior doctors preferring to check the patients’ notes before signing off a summary. Completion of the summaries was also observed as a process that ran parallel to numerous other tasks being carried out, the summary being kept open on a computer while interruptions from staff, patients or relatives occurred or other ‘jobs’ were carried out.

Patient assessment

Patient assessment, as described and observed, took three main forms: with an acutely presenting patient who was not known to the PA (or the medical team), with an outpatient attender and review of an unwell inpatient.

In the ED, medical assessment units and specialty-associated GP referral/assessment beds, PAs were observed doing what they described in interviews as assessing the unwell patient, with a view to presenting their assessment to a senior member of the medical team:

Then as the day goes on, look after the patients that are ward based pre and post op [operative] and take referrals. We do our own clerking on this ward, so they don’t go through the [emergency or acute assessment units], they come straight to us . . . from GP; from other trusts that don’t do a [specialty] service; from our [ED]. We have an on-call registrar and an on-call consultant that accepts referrals each day. Commonly we’ll get a call, or I’ll get a bleep on the ward, saying X is coming up, it’s a 77-year-old man and he’s really unstable, so then I’ll quickly ring the consultant or reg [registrar], just to check they’ve accepted him and they know about this patient. Because there are times when we get [clinical condition] that come over . . . and they often don’t go through our resus [resuscitation section of the ED] unless they’ve been in another hospital resus. They come straight to our assessment bay because on the ward we’ve got an assigned assessment bay. So, they are all quite unstable when they come in. So, this is a ward-based job and also an assessment-service-based job because we don’t admit everyone that comes. So, we could get someone who comes up from a GP and we’ll do an assessment and send them on their way. I’ll be taking an active role in clerking and then referring to a senior.

In the excerpt in Box 3, a PA in an ED was observed carrying out face-to-face patient assessment.

The PA was observed at the beginning of their shift, starting work by logging onto a computer, looking at the list of patients waiting and selecting which patient to see. I did not observe this decision being checked by anyone and the PA walked through the ‘majors’ bay, said hello to the nursing staff, picked up the patient’s notes from the nurse’s base desk, read the ambulance and nurse triage notes and blood results and went to a cubicle where the patient was laying on a trolley. The PA spoke directly to the patient and introduced themselves by first name and being a physician associate. The PA asked the patient a large number of medical assessment questions from the general opening: ‘what’s been going on?’ before moving on to the history of the condition and its symptoms, the patient’s past medical history and medications. Throughout this the PA crouched at the trolley, at eye level with the patient, listened to the patient and relative, and made a few notes on a piece of paper. The PA went onto examine the patient and then presented a plan: ‘I suspect we want to involve surgeons for an opinion, you look dehydrated, you’re very warm, I wonder if you need some i.v. [intravenous] antibiotics . . . I’ll chat with the boss, get a chest X-ray and tummy X-ray and fluids and pain relief and go from there’. I noted that the PA did not explain who ‘the boss’ was, nor did the patient ask. The PA went back to the medical office where several doctors were on computers. The PA presented a brief summary of the case to the consultant; the consultant asked further questions and looked at the blood results. I could not hear everything said but it appears that there was agreement to order an X-ray but not yet refer to the surgical team. The PA suggested giving more morphine; the consultant agreed and signed the script the PA had written. The PA then asked a nurse to give morphine and fluids, and to do a screening urine. The PA went back to the office and typed up the patient notes, then asked the consultant ‘Next on the list?’ referring to who should be assessed next. The PA went on to assess the next patient and, after presenting this second case, the consultant pointed out that the X-rays for the first patient were back. The consultant gave the diagnosis, which was less serious than the patient’s earlier presentation had suggested to the PA and consultant and the consultant advised the patient could go home. The PA asked, and the consultant agreed that pain relief was required. The same pattern of initial assessment, discussed with the consultant, continued throughout the shift.

A small number of PAs were observed in the outpatient setting, either seeing routinely booked inpatients, or, as in the excerpt in Box 4, in a clinic assessing acute injuries.

The PA was in clinic with an advanced nurse practitioner and another nurse who was new to the specialty, with the cases being divided between them, selected one at a time from a computer list. They explained to me that there was usually a SHO [senior house officer] or registrar ‘next door’ but not on the day observed. The PA worked in a clinic room assisted by a nurse, for example clerking the patient while the nurse cut off bandage, explaining the type of injury to the patient, examining the injury site and site, showing the patient their X-ray. The PA told me [researcher] that they were following a treatment pro forma for the particular injury site. The PA told the patient: ‘I don’t see anything significant but I’m just going to run past my senior.’. The PA went into theatre [where the senior doctor was], gained an opinion [I did not observe this interaction in theatre] and returned to the patient and explained that the injury would be strapped, but the site would be weak for six months. The PA applied the strapping whilst joking with the patient. After writing the patient notes on a computer, the PA went onto the next patient, following the same pattern of assessing and checking with the senior doctor, whilst also discussing cases and treatments with the nurses the PA was working alongside.

Both of these excerpts (see Boxes 3 and 4) described the PA working without direct supervision at the side of the patient but using the consultant to check each patient plan with after assessment, with patient throughput in the ED or clinic maintained. In another outpatient clinic example, what appeared to be delays were observed with junior medical team members, including the PA, queuing to see the consultant, who was also seeing other patients, to present their initial assessments and questions. The consultant repeated the questions the PA had asked and added more information. Some frustration with waiting time was observed from the patients.

Procedures

Many, but not all, PAs listed specific patient contact procedures they carried out either often or less frequently. Common procedures listed by the majority of PAs, almost in passing, were cannulation and phlebotomy, although many acknowledged the role of the nursing staff in blood taking.

Other practices were described or observed, including urinary catheterisation, arterial blood gases, electrocardiograms, the placement of long intravenous lines, chest drain, extubation, surgical assist roles such as closure, ultrasound for cannulation, lumbar puncture and other specialty-specific procedures. Few of these were observed in practice: only the surgical assist role in holding surgical retractors and testing tissue biopsies using in-theatre equipment and ultrasound-guided cannulation in the ED were observed.

Conducting more procedures appeared to be associated with time since qualification, or personal development over time within a particular specialty. Competence to carry out a procedure was clearly important, with a system and sign-off documents being mentioned by PAs at more than one case study site. Procedures were also, in some cases, a contested area of PA work, with trainee doctors described as ‘competing’ for procedures; views on this varied from a sense that there was plenty work to go round, to a feeling that rotating junior doctors should be allowed the opportunities as they would not be staying in the specialty, to noting the limitations of allowing the junior doctors first refusal on the career development of PAs. All of the views suggested that the PA role was there to fill medical staffing gaps, whichever part of the medical work that entailed.

In one PA’s case, they were also the staff member supervising opportunities for other juniors:

I’m quite good in doing procedure lumbar punctures so my colleagues, doctors came to me and say, could you please supervise me to do this lumbar puncture, I need my clinical placements to be signed off so they were supportive.

Limitations on procedures also varied by specialty, with PAs in one specialty reporting that the ward was so short of medical staff that PAs were never released to do what the junior doctors were doing in the first week of their rotations. The reverse was described in another case, in which surgical team shortages were described as being responsible for the PA being pulled off ward work to cover theatre.

Other associated patient-facing activities that were reported or observed included, but were not limited to, giving information to patients and relatives, discussion of DNAR (do not attempt resuscitation) or end-of-life issues and surgical consent.

The degree of PA activity on ward rounds, the ‘jobs’, patient assessment, procedures and the other specific patient-facing tasks varied in PA self-report and observation by setting and by specialty, rather than by PA per se, although there were mentions in interviews of the degree of trust of the senior medical team for the PA to carry out these activities being related to length of experience of the PA in the particular setting and contemporaneous knowledge of the PA’s competence. This is discussed in the following section in terms of the role of the PA in the medical team.

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.

A ‘supervised’ but trusted member of the medical team

The PAs told a consistent story about supervision, mentioning consultant- or senior-registrar-level support, which was usually directly available at the point of care or otherwise indirectly by telephone. This supervision was not tied to one particular person, but to whichever senior doctor was on cover for the ward or unit at that point in time.

These descriptions of supervision were supported by the concept of scope of practice being based on trust among the supervising team, as one PA described here:

This move within levels of supervision was also articulated by a PA with less experience whose role, nevertheless, was already expanding:

On this ward, I am supervised. However, I’m given what I would consider, for the amount of time that I’ve been here, quite a lot of autonomy. I see my own patients. I don’t need anybody to hover over me to see anything. If I am needing any assistance, I can always ask. There is always somebody about who I can always ask. In terms of supervision, only really when taking consent am I really supervised; just to see that I’m striking home the main points because I’m actually in the process of learning to be able to consent a patient for procedure.

This last point related to discussion about PA career structure in the interviews. The interview content here focused on change over time even within one specialty, about moving around specialties and about taking more responsibility. In some settings, this was about new procedures, in others about having one’s ‘own patients’, and in others about opportunities for being part of wider continuing professional development or taking on related roles outside the clinical setting, such as teaching, audit and staff management. These comments were set in the context of – mostly – acceptance of the flat career structure of the PA role, although some concerns about this were also raised:

At the moment, and I think it probably will always be this way, I don’t think we’re ever going to have a set progression like the doctors do is it’s your career will be what you make of it and what you want to do, you will have to push to do that and get it off the ground yourself, essentially, if you like. So, having a consultant who is willing to entertain your silly ideas about what you want to do and enable them is really important and we have that here. I know that if I wanted to do anything, essentially, I know that I’d probably be supported.

Supporting and challenging the medical hierarchy

The PAs were clear that they sat in a team, and that was the medical team. Although the setting influenced variations in team members, in general the team was composed of medical strata from consultant to registrars and more junior doctors in training. Most PAs described themselves as being similar in level to Foundation Year doctors (first or second year), with a smaller number considering themselves more akin to registrars. Some of this variation appeared to be related to length of experience in a setting, particularly in having built professional and personal relationships with consultants simply through being a long-term member of the team, and examples of the PA cutting across the medical hierarchy were apparent in interviews and observations, particularly in the PA having direct contact with the consultant:

If it was something sort of out of hours and there were some concerns, I’d phone up the consultants and, you know, we’ve had a really good working relationship, being . . . I’ve worked here for 3 years now so they understand how it will work and I get how they work, so you know, I’d only pester them if it’s necessary.

Some PAs could recount instances of being questioned or not being accepted by medical colleagues; most said that these occasions were now much rarer and, in general, they reported acceptance alongside continuing curiosity and requests for role clarification from those who had not previously worked alongside PAs.

Continuity and accessibility

Without exception, PAs mentioned aspects of their role that delivered continuity, on a day-to-day and longer-term basis, on the ward or unit where they were based. In some settings, patient throughput was such that individual continuity of care was not an issue day to day; in other settings, knowledge of the patient was considered to be held only by the PA:

So from Monday to Friday and junior doctors they rotate, they go on nights, go on days, there is also training development and they go on a course and things like so for the patients here was better because this time they know there is more continuous, they know this face and . . . so when the consultant comes he give the consultant handover which is progressive so they don’t repeat every time but they can add on whatever they want to add but there is a bit of continuity of the patient yeah . . .

Longer-term team continuity was also described by the PAs, in having a good knowledge of consultants and what they wanted for their patients, and in being a source of knowledge about hospital processes. This was presented by most as a source of knowledge for inducting rotating junior doctors, and direct patient care benefit was also mentioned in a couple of examples of perceived benefit to patients through enacting local clinical care pathways efficiently:

I think generally we probably make things better just because it means that there’s staff in to see patients so they’re not having to wait for a long, long time . . . Also, probably patient safety in some respects because I know in [specialty] there’s, for a lot of the operations you need to do like follow-up like [specialty-specific investigation], things like that and I think previously things were getting missed, you know, so people weren’t getting the follow-ups they might need so . . . And just because we know that kind of how it’s organised just means that things like that aren’t missed.

Accessibility for the nursing staff was also mentioned by several PAs in interview and noted widely on observation. For some, this was described as simply being on the ward; for others, it involved more than simply physical accessibility but being approachable and in having long-term relationships with nursing staff, as described by one PA:

But you win hearts and minds very quickly just by being there because ward staff often are frustrated because there isn’t something [in the patient’s medical records] to say ‘What exactly does this say here?’. Or, ‘Can Mr so and so have a drink now?’. And to actually have a PA that even if they’re not physically there they can pick up a phone and bleep and say ‘Mr so and so, can he be drinking no?’. Or, you know, ‘What is, can you come and sort this out for me?’. Once they realise that you are reliable, that you’re going to be there, that you will answer their problems and to be honest you could be a dustbin man and they’d be happy with you.

Accessibility to all staff on the ward was also widely observed and, in the vast majority of the interactions observed between PAs and nursing staff, this ‘open access’ appeared unproblematic, friendly and mutually helpful, and implicit to the contribution PAs considered themselves to be making.

Views of the impact of the physician associate contribution

The PAs reported their perceived impact in several ways while commonly being aware that these were anecdotal accounts. PAs described a number of potential areas in which they may have an impact, predominantly in filling gaps in the medical rota, providing direct patient benefit and providing system benefit.

One PA clearly articulated that they were additional, not substitute, members of the team, with benefits:

I think the doctors see that their workload is actually less [OK], that patient care is actually improved in the fact that we’ve got more hands on deck.

Some PAs reported junior doctors being able to go off the wards for training as a result of PA presence and in some cases they reported – and were observed – in clinics, assisting in theatre and in medical assessment settings, apparently taking the same role as the junior doctor, for example in settings where patients were allocated – with consultant supervision – to a junior doctor or PA to cover.

When asked directly about the patient’s experience, PAs were clear that this was difficult to judge in team-based settings, but that they had mostly positive experiences with patients who, they considered, were more interested in being well cared for and seen promptly than whether they were seen by a PA or a doctor.

Most PAs said that they did not know about costs but those who were prompted by the interviewer suggested that they must be cheaper than junior doctors, particularly if the PA presence had reduced the locum hours required.

The following quotation highlights that PA deployment has not been without its questions and its doubters, but that PA themselves see it as making an impact:

I think seeing us work is the most important thing. Initially, where would you fit in? Are you a doctor? How would you be able to fit in? But I think by seeing it first hand, it’s worked. A PA on the ward has been able to bring [to] birth a new role, and seeing it work and being effective makes people welcome it more and accept it. I think that because it’s working people are beginning to accept it.

Several PAs noted that the researchers would need to ask others on the team to consider their impact, and it is the views of managers, nurses, doctors and patients that we now move onto in Chapters 6–9.