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Headline
Physician associates positively contributed to the medical and surgical team, patient experience and flow, to supporting the clinical teams’ workload and have potential to add further with expansion of their role.
Abstract
Background:
Increasing demand for hospital services and staff shortages has led NHS organisations to review workforce configurations. One solution has been to employ physician associates (PAs). PAs are trained over 2 years at postgraduate level to work to a supervising doctor. Little is currently known about the roles and impact of PAs working in hospitals in England.
Objectives:
(1) To investigate the factors influencing the adoption and deployment of PAs within medical and surgical teams in secondary care and (2) to explore the contribution of PAs, including their impact on patient experiences, organisation of services, working practices, professional relationships and service costs, in acute hospital care.
Methods:
This was a mixed-methods, multiphase study. It comprised a systematic review, a policy review, national surveys of medical directors and PAs, case studies within six hospitals utilising PAs in England and a pragmatic retrospective record review of patients in emergency departments (EDs) attended by PAs and Foundation Year 2 (FY2) doctors.
Results:
The surveys found that a small but growing number of hospitals employed PAs. From the case study element, it was found that medical and surgical teams mainly used PAs to provide continuity to the inpatient wards. Their continuous presence contributed to smoothing patient flow, accessibility for patients and nurses in communicating with doctors and releasing doctors’ (of all grades) time for more complex patients and for attending to patients in clinic and theatre settings. PAs undertook significant amounts of ward-based clinical administration related to patients’ care. The lack of authority to prescribe or order ionising radiation restricted the extent to which PAs assisted with the doctors’ workloads, although the extent of limitation varied between teams. A few consultants in high-dependency specialties considered that junior doctors fitted their team better. PAs were reported to be safe, as was also identified from the review of ED patient records. A comparison of a random sample of patient records in the ED found no difference in the rate of unplanned return for the same problem between those seen by PAs and those seen by FY2 doctors (odds ratio 1.33, 95% confidence interval 0.69 to 2.57; p = 0.40). In the ED, PAs were also valued for the continuity they brought and, as elsewhere, their input in inducting doctors in training into local clinical and hospital processes. Patients were positive about the care PAs provided, although they were not able to identify what or who a PA was; they simply saw them as part of the medical or surgical team looking after them. Although the inclusion of PAs was thought to reduce the need for more expensive locum junior doctors, the use of PAs was primarily discussed in terms of their contribution to patient safety and patient experience in contrast to utilising temporary staff.
Limitations:
PAs work within medical and surgical teams, such that their specific impact cannot be distinguished from that of the whole team.
Conclusions:
PAs can provide a flexible advanced clinical practitioner addition to the secondary care workforce without drawing from existing professions. However, their utility in the hospital setting is unlikely to be fully realised without the appropriate level of regulation and attendant authority to prescribe medicines and order ionising radiation within their scope of practice.
Future research:
Comparative investigation is required of patient experience, outcomes and service costs in single, secondary care specialties with and without PAs and in comparison with other types of advanced clinical practitioners.
Study registration:
The systematic review component of this study is registered as PROSPERO CRD42016032895.
Funding:
The National Institute for Health Research Health Services and Delivery Research programme.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Background
- Chapter 2. Methods
- Patient and public involvement
- Workstream 1: investigating the extent of the adoption, deployment and role of physician associates in hospital medical teams
- Workstream 2: investigating evidence of the impact and factors supporting or inhibiting the adoption of physician associates in the literature and policy
- Workstream 3: investigating the deployment and contribution of physician associates at the micro level of the health system
- Workstream 4: synthesis of evidence
- Chapter 3. Findings: evidence from the reviews and surveys
- Chapter 4. Findings at the micro level: perspectives from hospital senior managers and clinicians
- Chapter 5. Findings from the micro level: the deployment of physician associates
- Chapter 6. Findings at the micro level: patient and relative perspectives
- Chapter 7. Findings at the micro level: perspectives from the doctors
- Factors influencing the employment of physician associates
- The work and role of the physician associates
- Overall view of the contribution physician associates made
- Patient responses to physician associates in the medical team
- Factors inhibiting working with and employing physician associates
- Measurement of the impact and costs
- Summary
- Chapter 8. Findings at the micro level: perspectives from the operational managers
- Chapter 9. Findings at the micro level: perspectives from the nurses
- Chapter 10. Findings from the micro level: pragmatic comparison of patient consultations by physician associates and Foundation Year doctors in the emergency department
- Chapter 11. Discussion and conclusions
- The extent of the adoption and deployment of physician associates in hospital services
- 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
- The impact of including physician associates in hospital medical teams on the patients’ experiences and outcomes
- 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
- Synthesis
- Strengths and limitations
- Conclusions
- Implications
- Further investigation
- Acknowledgements
- References
- Appendix 1. Terms of reference for the advisory group and the public and patient involvement group
- Appendix 2. Electronic survey of medical directors
- Appendix 3. The physician associate survey
- Appendix 4. Systematic review: example of full search strategy
- Appendix 5. Topic guides for semistructured interviews
- Appendix 6. Work diary
- Appendix 7. Observation guide
- Appendix 8. Clinical review of emergency department records
- Appendix 9. Emerging-findings seminar
- Appendix 10. Characteristics of the included studies in the systematic review
- Glossary
- List of abbreviations
About the Series
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.
Last reviewed: April 2018; Accepted: October 2018.
- NLM CatalogRelated NLM Catalog Entries
- The role of physician associates in secondary care: the PA-SCER mixed-methods st...The role of physician associates in secondary care: the PA-SCER mixed-methods study
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