Physician Associate Role (Secondary Care) Impact Case Study

Background

Physician Associates (PAs) are healthcare professionals with a generalist medical education who work under the supervision of a doctor to provide medical care. The PA role was first introduced in 2003 and, in 2022, there are approximately 1305 PAs working in NHS hospitals (NHS Electronic Staff Record, June, 2022). This case study provides insight into how the PA roles are typically used in secondary care, and the impact of the role on NHS patients, systems, and workforce. The case study data are based on a qualitative analysis of interview data collected from 12 research participants (4 PA leads and 8 PA employers) from 10 NHS secondary care organisations across 5 NHS England regions. The data indicate that the perspectives of the leads and the employers are mostly aligned, thus the viewpoints have been combined for the purpose of this case study.

How PA roles are utilised

PAs are a flexible workforce who are utilised in a wide range of clinical areas. The specific tasks performed are dependent upon the clinical area worked in and can vary between hospitals. Typical tasks include running clinics, clerking, undertaking post take ward rounds and facilitating patient discharge. In some NHS trusts, PAs work with outpatients or are employed to work in the community providing care to specific patient groups (e.g., people with learning disabilities). Others provide care within in-patient units.

PAs also work in specialist areas, for example, they might see patients with diabetes or gastric illnesses, with many having opportunity to pursue specialist interests. Some trusts offer preceptorships or rotational posts enabling PAs to work between departments or across hospital sites.

Most PAs undertake core 9 – 5 hours. However, in some hospitals, PAs have been moved into out-of-hours working to meet service needs. Emergency medicine, acute medicine, and paediatrics are typical areas where PAs can work evenings/weekends. There are some barriers to hospitals introducing out-of-hours working for PAs. These include lack of supervisory capacity, insufficient numbers of PAs to enable 7-day working, and because PAs are unable to prescribe. PAs are not permitted to request ionising radiation, which is a further limitation, although many PAs are able to work around this.

At Ashford and St Peter’s Hospitals NHS Foundation Trust, the PA role has helped to improve elderly patients’ access to clinical services whilst enabling the trust to meet national guidelines for frailty patients:

“ They’ve [PAs] massively increased our ability to see elderly patients and we're also able to increasingly follow national guidelines. So, for example, there's a guideline where patients who have had laparotomies and who are over the age of 65 should be seen within a timely fashion by the frailty team, so we're able to now meet these guidelines and expand upon them, which we weren't able to do before.”

Arvindan Lingeswaran, Consultant Physician Senior Adult Medicine Service and General Internal Medicine, Ashford and St Peter’s Hospitals NHS Foundation Trust

Impacts on patients and service provision

The data suggest that the PA role positively impacts patients and service provision in several important ways. A key theme is that the PAs provide continuity of care. This is because they are a constant presence during core hours and since many do not rotate through departments (with those that do rotate doing this at a different time from postgraduate doctors). This continuity positively impacts patients in terms of their patient experience, whilst also enabling increased service efficiency. For example, the data suggest that the continuity of care provided by PAs leads to faster patient discharge.

PAs are additional members of staff who help support service provision. They can see many new patients which enables more clinics to be offered and reduces waiting times and the likelihood of cancelled lists. They can also offer follow-up appointments which is useful as some consultants are unable to provide these appointments for many months. This helps to provide continuity of care and means that existing patients can be seen more quickly

A significant aspect of the PA role is supporting with ward rounds and reading and writing in patient notes. Because PAs can communicate with consultants during ward rounds, this provides an escalation path and saves senior staff looking through patient notes, which leads to increased departmental productivity.

Many PAs are trained in specialist procedures (e.g., ascitic drains and lumbar punctures), with the data suggesting that utilising skill mix in a medical team approach can reduce delays for patients.

Furthermore, PAs are increasingly being used in innovative ways in new services (e.g., in virtual wards) which supports patients to stay at home and positively impacts patient flow.

“ And one of the real benefits of the PA role is that they're there Monday to Friday, 9 to 5. So, they provide really good continuity to the patients and to rotating teams.”

Rosie Lockwood, Geriatric Lead and Physician Associate Lead, Sheffield Teaching Hospitals NHS Foundation Trust”

“ I think it's that continuity. So, continuity of care for the patients on the wards. So, if you've got someone who's been there for some time, the PA can help facilitate things because they understand the processes and what needs to happen to be able to facilitate discharge quickly.”

Amy Tullin, Chief Physician Associate, Epsom and St Helier University Hospitals NHS Trust

“ A couple of our PAs are trained and very competent in lumbar punctures and so it allows patients to have them done at a much earlier stage. We're not waiting around for a registrar to be free on call.”

Sally Davies, Consultant in Respiratory and General Medicine, Chesterfield Royal Hospitals NHS Foundation Trust

“ The PA [role] brings benefit because technically there’s more people on the shop floor… that's the greatest impact on a ward-based or assessment-based area…I know there are shorter waiting times for clinics because we're offering more clinics. So, I know that the wait time for my division has definitely come down.”

Natalie Daniels, Consulting Neurodevelopment and Safeguarding Paediatrician, Alder Hey Children’s NHS Foundation Trust

Impacts on workforce

The data suggest that PAs are a helpful part of the solution to addressing NHS workforce shortages because they are typically science graduates who are not already working within the NHS. They are trained to be a flexible workforce who can provide an appropriate skill mix across the service provision. This means that during staff absences, PAs can take on some of a clinicians’ workload (e.g., child protection medical assessments, fast-track cancer clinics, and theatre cover), reducing the need for expensive locum doctors.

Because many PAs tend to be permanent members of staff with a routine working pattern, they provide a level of stability to the workforce which benefits the whole multidisciplinary team. For example, PAs understand departmental processes and protocols which can help with inducting postgraduate doctors on rotation. Additionally, because they have capacity to see follow-up patients, PAs reduce the burden on consultants, freeing them up to work on more important tasks and to deliver training. PAs also free up consultants’ time by providing training to PA students and postgraduate doctors.

The data show that there is some hesitancy around utilising PAs because of the limitations of the role. The fact that PAs are not permitted to prescribe or order ionising radiation due to lack of statutory regulation are perceived by many as significant hurdles. However, departments often address these limitations by strategically utilising PAs in areas where the barriers cause less of an issue. There is also some resistance to the role amongst postgraduate doctors with the data suggesting that comparison is often drawn between salaries of qualified PAs and doctors in postgraduate training working at similar levels of competency. However, the data also suggest that this resistance appears to wane after doctors have gained experience working with PAs. Overall, the views regarding the role are mixed across professions but may change in time when the role becomes regulated, or with greater evidence regarding the benefits of the role.

“ …and the PAs provide a level of continuity of care for both the patients and more importantly for the team. So rather than having to train up a new clinician into the role every few months or so you've got somebody that is trained up and you can build on their competencies over time.”

Helen Crimlisk, Deputy Medical Director, Sheffield Health and Social Care NHS Foundation Trust

“ PAs are able to make services more efficient because they have that continuity into things like the induction of new team members, whether that's students or junior doctors… you're able to help them get on board more quickly and more efficiently...”

Dina Bateman, Co-lead Physician Associate, University Hospitals of Leicester NHS Trust

Achieving increased impact

To achieve greater impact of the PA role, the data suggest that the following are required:

• More PAs
• Increased funding for employing PAs in secondary care
• GMC regulation
• Ability to prescribe
• Ability to request ionising radiation
• Preceptorship/foundation year on a national scale
• More training in advanced skills
• Joined up approach to career development
• Increased awareness of the role