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NIHR Signal Physician associates appear to make a positive contribution to inpatient care

Published on 15 August 2019

doi: 10.3310/signal-000807

Physician associates improve continuity of care and patient experience within the hospital setting. This first evaluation of the new role in the NHS suggests they could provide safe and equivalent care on defined tasks, freeing up time for doctors, and help with patient flow. However, some say that the actual and perceived potential is being held back by a lack of professional statutory regulation and the ability to prescribe.

The number of physician associates trained in some of the tasks done by doctors is growing. This can help ease staffing pressures and enable doctors to attend to more complex cases. Yet, despite the profession’s potential utility and increasing popularity, there is little evidence on the advantages or disadvantages of employing them in secondary care.

This NIHR funded study considers the way that associates are deployed and the appropriateness as well as the effectiveness of their work in relation to other team members.

A national survey shows that a small but growing number of hospitals are now using physician associates. It concludes that the profession is being restrained by a lack of autonomy, preventing the role from fulfilling its potential. Statutory regulation and prescribing or X-ray ordering rights may help ease the pressure on doctors and strengthen physician associate roles within the team. Evaluation of the impact of these positions as they become more common will be useful.

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Why was this study needed?

The physician associate is a relatively new profession in the UK. Numbers are growing – with over 3,000 students expected to qualify by 2020. Physician associates have to undergo two years’ intensive postgraduate training based upon a medical, rather than nursing, model. They work to a supervising doctor. Consequently, upon qualification, they can undertake a range of diagnostic and clinical duties that would otherwise be done by doctors.

Pressures on the medical workforce, including the EU working time directive limiting junior doctors working hours, have meant that this role is being championed by some medical directors and policymakers as a way to maintain service quality and safety.

So far, research evaluating their effectiveness has focused on primary care, and there is a dearth of evidence examining their role within inpatient settings. This study covered a range of uncertainties, including the number currently employed in the acute hospital sector as well as any impact on patient flow.

What did this study do?

The PA-SCER mixed methods, multiphase study investigated the contribution of physician associates to patient care in acute hospital medical services. It considered the way they are deployed and the appropriateness as well as effectiveness in relation to other team members.

The research included a systematic review. It took the mixed methods approach first to a high level with a policy review and a national survey of medical directors and physician associates. It then looked at the organisational level with case-studies from six English hospitals utilising physician associates. Finally, using a retrospective review of patient records in emergency departments, it compared the activity and views of physician associates and Foundation Year 2 (FY2) doctors alongside patient views.

Difficulty attributing patient outcomes and cost to individuals within a team means that there may be uncertainty surrounding some results.

What did it find?

  • One-third of medical directors of acute and mental health trusts (71 out of 214) replied to the survey. The results suggest that 20 trusts were currently employing physician associates with more looking to do so. Reasons for employment included junior doctor shortages and patient demand.
  • In-depth case note reviews at six hospitals showed that the patient outcomes and consultation records of junior doctors and physician associates in the emergency department were comparable. A random sample of 613 patient records was analysed. The re-attendance rate within seven days was 9% for physician associates and 7% for FY2 doctors (odds ratio 1.33, 95% confidence interval 0.69 to 2.57).
  • The lack of qualified physician associates was reported as a constraint in the survey by some medical directors, although not all were convinced by the usefulness of the role in the first place. Lack of professional regulation and authority to prescribe medicines and order X-rays or CT scans were the main reasons given, and hospital administrators wanted these limitations removed. Others felt that the role was simply not a good fit for their team, preferring to employ other staff groups such as nurses.
  • From organisational case study research in six hospitals, the team found that physician associates were often credited as providing stability in the medical/surgical team. This benefited patients through continuity of presence on the inpatient wards, increasing the medical/surgical teams’ accessibility for patients and nurses. Patients themselves, while often unaware of the differences from doctors, were generally supportive of the new role.
  • Physician associates were often in the position to build up a solid knowledge of their working environment as their roles were frequently static and developed to fulfil specific functions within the team. This knowledge revolved around departmental policies and practices, individual consultants, as well as the hospital itself and was particularly valued by junior doctors who frequently moved hospitals.

What does current guidance say on this issue?

The Faculty of Physician Associates at the Royal College of Physicians has produced several documents helping guide physician associates and their employers. The Code of conduct for physician associates, in particular, sets out guiding principles for the role.

While it notes that there is no statutory regulation for physician associates, there is a Managed Voluntary Register (held by the Faculty of Physician Associates at the Royal College of Physicians). Ultimately physician associates are responsible for their own practice, and while they should always be under direct supervision from a designated medical practitioner, the level of supervision should lessen over time.

What are the implications?

This national evaluation found that physician associates under medical supervision can provide safe and appropriate care in hospitals. This is the first major assessment of the new role in the UK. Physician associates have the potential to be a flexible member of the inpatient team with the ability to complete a wide range of tasks and provide some continuity on the wards, relieving pressure on junior doctors and others. Yet this flexibility, compounded by a lack of statutory regulation and prescribing authority, means that there is a lack of agreement as to their place and potential in improving care.

For this potential to be fulfilled, medical directors and others involved in staffing decisions could benefit from access to more information about the role, such as case studies, helping to illustrate just how a physician associate could be a good fit for their team.

Citation and Funding

Drennan VM, Halter M, Wheeler C et al. The role of physician associates in secondary care: the PA-SCER mixed-methods study. Health Serv Deliv Res. 2019;7(19).

This project was funded by the NIHR Health Services and Delivery Research Programme (project number 14/19/26).

Bibliography

Faculty of Physician Associates. Guidance for employers and supervisors. London: Royal College of Physicians; updated 2019.

Faculty of Physician Associates. Who are physician associates?  London: Royal College of Physicians; updated 2019.

Why was this study needed?

The physician associate is a relatively new profession in the UK. Numbers are growing – with over 3,000 students expected to qualify by 2020. Physician associates have to undergo two years’ intensive postgraduate training based upon a medical, rather than nursing, model. They work to a supervising doctor. Consequently, upon qualification, they can undertake a range of diagnostic and clinical duties that would otherwise be done by doctors.

Pressures on the medical workforce, including the EU working time directive limiting junior doctors working hours, have meant that this role is being championed by some medical directors and policymakers as a way to maintain service quality and safety.

So far, research evaluating their effectiveness has focused on primary care, and there is a dearth of evidence examining their role within inpatient settings. This study covered a range of uncertainties, including the number currently employed in the acute hospital sector as well as any impact on patient flow.

What did this study do?

The PA-SCER mixed methods, multiphase study investigated the contribution of physician associates to patient care in acute hospital medical services. It considered the way they are deployed and the appropriateness as well as effectiveness in relation to other team members.

The research included a systematic review. It took the mixed methods approach first to a high level with a policy review and a national survey of medical directors and physician associates. It then looked at the organisational level with case-studies from six English hospitals utilising physician associates. Finally, using a retrospective review of patient records in emergency departments, it compared the activity and views of physician associates and Foundation Year 2 (FY2) doctors alongside patient views.

Difficulty attributing patient outcomes and cost to individuals within a team means that there may be uncertainty surrounding some results.

What did it find?

  • One-third of medical directors of acute and mental health trusts (71 out of 214) replied to the survey. The results suggest that 20 trusts were currently employing physician associates with more looking to do so. Reasons for employment included junior doctor shortages and patient demand.
  • In-depth case note reviews at six hospitals showed that the patient outcomes and consultation records of junior doctors and physician associates in the emergency department were comparable. A random sample of 613 patient records was analysed. The re-attendance rate within seven days was 9% for physician associates and 7% for FY2 doctors (odds ratio 1.33, 95% confidence interval 0.69 to 2.57).
  • The lack of qualified physician associates was reported as a constraint in the survey by some medical directors, although not all were convinced by the usefulness of the role in the first place. Lack of professional regulation and authority to prescribe medicines and order X-rays or CT scans were the main reasons given, and hospital administrators wanted these limitations removed. Others felt that the role was simply not a good fit for their team, preferring to employ other staff groups such as nurses.
  • From organisational case study research in six hospitals, the team found that physician associates were often credited as providing stability in the medical/surgical team. This benefited patients through continuity of presence on the inpatient wards, increasing the medical/surgical teams’ accessibility for patients and nurses. Patients themselves, while often unaware of the differences from doctors, were generally supportive of the new role.
  • Physician associates were often in the position to build up a solid knowledge of their working environment as their roles were frequently static and developed to fulfil specific functions within the team. This knowledge revolved around departmental policies and practices, individual consultants, as well as the hospital itself and was particularly valued by junior doctors who frequently moved hospitals.

What does current guidance say on this issue?

The Faculty of Physician Associates at the Royal College of Physicians has produced several documents helping guide physician associates and their employers. The Code of conduct for physician associates, in particular, sets out guiding principles for the role.

While it notes that there is no statutory regulation for physician associates, there is a Managed Voluntary Register (held by the Faculty of Physician Associates at the Royal College of Physicians). Ultimately physician associates are responsible for their own practice, and while they should always be under direct supervision from a designated medical practitioner, the level of supervision should lessen over time.

What are the implications?

This national evaluation found that physician associates under medical supervision can provide safe and appropriate care in hospitals. This is the first major assessment of the new role in the UK. Physician associates have the potential to be a flexible member of the inpatient team with the ability to complete a wide range of tasks and provide some continuity on the wards, relieving pressure on junior doctors and others. Yet this flexibility, compounded by a lack of statutory regulation and prescribing authority, means that there is a lack of agreement as to their place and potential in improving care.

For this potential to be fulfilled, medical directors and others involved in staffing decisions could benefit from access to more information about the role, such as case studies, helping to illustrate just how a physician associate could be a good fit for their team.

Citation and Funding

Drennan VM, Halter M, Wheeler C et al. The role of physician associates in secondary care: the PA-SCER mixed-methods study. Health Serv Deliv Res. 2019;7(19).

This project was funded by the NIHR Health Services and Delivery Research Programme (project number 14/19/26).

Bibliography

Faculty of Physician Associates. Guidance for employers and supervisors. London: Royal College of Physicians; updated 2019.

Faculty of Physician Associates. Who are physician associates?  London: Royal College of Physicians; updated 2019.

The role of physician associates in secondary care: the PA-SCER mixed-methods study

Published on 5 June 2019

Drennan V M, Halter M, Wheeler C, Nice L, Brearley S, Ennis J, Gabe J, Gage H, Levenson R, de Lusignan S, Begg P & Parle J.

Health Services and Delivery Research Volume 7 Issue 19 , 2019

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. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

This report on the role of physician associates in secondary care has evidence on the ward level activities of physician associates and the response of doctors, nurses and patients to their presence.

It is prime new evidence on what has happened so far with 300 physician associates in post. Most physician associates were giving continuity to inpatient teams and were well received by patients and colleagues. They did best when specialised.

So far so good - but review is surely needed on whether the evidence really supports the big jump in scale to 3,200 physician associates by 2019. Could the programme be a bridge between hospital and out of hospital care - which is now the key development area?

Nick Bosanquet, Professor of Health Policy, Imperial College London

The commentator declares no conflicting interests