The world of healthcare is changing, and patient needs are changing with it. Traditional doctor-driven models of workforce planning are no longer sustainable in the United Kingdom (UK) healthcare economy, and newer models are needed. In the multiprofessional, multiskilled clinical workforce of the future, the physician associate (PA) has a fundamental role to play as an integrated, frontline, generalist clinician. As of 2016, about 350 PAs were practicing in the UK, with 550 PAs in training and plans to expand rapidly. This report describes the development of the PA profession in the UK from 2002, with projections through 2020, and includes governance, training, and the path to regulation. With rising demands on the healthcare workforce, the PA profession is predicted to positively influence clinical workforce challenges across the UK healthcare economy.
Background It has been argued that UK general practice specialist training should be extended, to better prepare GPs for challenges facing 21st-century health care. Evidence is needed to inform how this should occur. Aim To investigate the experience of recently trained GPs undertaking a 1-year full-time fellowship programme; in particular, workforce impact and career development potential. The fellowship was designed to provide advanced skills training in urgent care, integrated care, leadership, and academic practice. Method Semi-structured interviews conducted longitudinally over 2 years, augmented by observational data in West Midlands, England. Participants were interviewed on at least three occasions: twice while undertaking the fellowship, and at least once post-completion. Participants’ clinical and academic activities were observed. Data were analysed using a framework approach. Results Seven GPs participated in the pilot scheme. The fellowship was highly rated and felt to be balanced in terms of the opportunities for skill development, academic advancement, and confidence building. GPs experienced enhanced employability on completing the scheme, and at follow-up were working in a variety of primary care/urgent care interface clinical and leadership roles. Participants believed the fellowship made general practice a more attractive career option for newly qualified doctors. Conclusion The fellowship provides a defined framework for training GPs to work in an enhanced manner across organisational interfaces, with the skills to support service improvement and integration. The fellowship model appears appropriate to prepare GPs for portfolio roles. Its impact on NHS service delivery continues to be investigated by Health Education England.
Abstract Background Following evidence published in the Pharmacists in Emergency Departments (PIED 2016) study Health Education England funded novel advanced clinical practitioner training for pharmacists (ACP-p), to support service delivery. Objective To explore experiences and clinical activity of trainee ACP-p, and opinions and recommendations of both trainees and clinical supervisors. Setting Five Urgent/Emergency Care Departments in London UK. Method Longitudinal mixed-methods study in three phases of registered UK pharmacists appointed as trainee ACP-p. Phase 1 (May-July 2019) – early semi-structured interviews and focus group using an experiences, opinions and recommendations (EOR) framework, Phase 2 (January-December 2019) – prospective recording of trainee clinical activity, standardised using bespoke spreadsheet, Phase 3 (November-December 2019) – as Phase 1 but at conclusion of training. Main outcome measure Experiences, clinical activity, opinions and recommendations of study participants. Results Twelve (92 %) eligible trainee ACP-p and five supervisors were recruited. Identified themes were: trainee personality, educational components, length of programme, support/supervision, career transition, university and placement training alignment, recommendations. Success was dependent on effective support and supervision. Clinical supervisors should be allocated adequate supervision time. Trainees, their supervisors and emergency department staff should be given a clear brief. Study participants agreed that the programme could be successful. Trainee ACP-p reported that they could manage 82 % of 713 pre-selected clinical presentations. Additional training needs include: ECGs, X-rays and CT scans. Conclusions Pharmacists can successfully train as ACP-p in this setting over a two-year period. This career transition needs careful management and clear structures. Training ACP-p is a useful way of enhancing skills and supporting clinical services to large numbers of patients.
Aims/Objectives/Background In England, the demand for emergency care is increasing, confounded by challenges with recruitment and retention of multi-professional teams in Emergency Departments (ED). The intense working environment that clinical ED staff face is recognised as a cause of staff dissatisfaction, attrition and premature career ‘burnout.’ A new ‘shop floor’ Clinical Educator (CE) role may improve the retention and wellbeing of multi-professional ED teams. A Health Education England pilot developed and recruited CEs across 54 acute trust EDs in England, from 2017. Aston University and the Royal College of Emergency Medicine were jointly commissioned to undertake a service benefit evaluation. Methods/Design An online survey was circulated to CEs, learners and managers across the 54 study sites. Each group answered questions relating to experiences, opinions and reflections. Topics included impact of a CE on patient flow, confidence and competence of staff, as well as sustainability and any impact on staff wellbeing. Results/Conclusions Results 314 individuals accessed the survey and 291 eligible respondents completed it, including: 187 learners, 65 CEs and 39 ED Clinical Directors/Managers. Learners (169/187), CE (63/65) and managers (39/39) saw no change/an improvement in patient flow. 100% of CEs felt that a CE in the ED improved competence and confidence of staff (88.2% of learners, 89.7% of managers). 7% (61/65) of CEs and 87.2% (34/39) managers agree that CEs have improved wellbeing of staff. 8% of managers (26/39) were unsure whether the CE role would be funded beyond the pilot, but 66.7% (26/39) strongly supported continuation of the CE role. Conclusion Interim evidence suggests that CEs positively impact the multi-professional ED workforce.
This volume emerges from the stimulating Oxford conference on ‘Conquest: 1016, 1066’ commemorating the thousandth anniversary of Cnut’s accession to the English throne. The editors, Laura Ashe and Emily Joan Ward, seek to put the first conquest of the eleventh century in conversation with the much better-known process of 1066, through three overlapping sections: ‘Conquests, King and Government’; ‘Conquests, Society and Culture’; and ‘Conquests: Perspectives from Beyond England’. They achieve their desired conversation though a guiding Introduction would have been helpful. Most of the essays could have incorporated recent scholarship more convincingly, particularly that which addresses trauma and postcolonial theories, multilingualism and materiality. It is clear, then, that additional research, perhaps carried out by a more diverse and interdisciplinary group of scholars, is still needed to understand critical issues, such as continuity and rupture, the form and function of the extant record, and eleventh-century propaganda and politics. Questions generated here...
Background It has been argued that UK general practice specialist training should be extended to better prepare GPs for the challenges facing 21st-century health care. Evidence is needed to inform how this should occur. Aim To investigate the experience of recently trained GPs undertaking a 1-year full-time fellowship programme designed to provide advanced skills training in urgent care, integrated care, leadership, and academic practice; and its impact on subsequent career development. Design and setting Semi-structured interviews conducted longitudinally over 2 years augmented by observational data in the West Midlands, England. Method Participants were interviewed on at least three occasions: twice while undertaking the fellowship, and at least once post-completion. Participants’ clinical and academic activities were observed. Data were analysed using a framework approach. Results Seven GPs participated in the pilot scheme. The fellowship was highly rated and felt to be balanced in terms of the opportunities for skill development, academic advancement, and confidence building. GPs experienced enhanced employability on completing the scheme, and at follow-up were working in a variety of primary care/urgent care interface clinical and leadership roles. Participants believed it was making general practice a more attractive career option for newly qualified doctors. Conclusion The 1-year fellowship provides a defined framework for training GPs to work in an enhanced manner across organisational interfaces with the skills to support service improvement and integration. It appears to be well suited to preparing GPs for portfolio roles, but its wider applicability and impact on NHS service delivery needs further investigation.
Trends in primary care Medicare provision ABSTRACT This study documented trends in alternative primary care models in which physicians, PAs, or NPs provided care to older adults. The study also examined the role of these models in serving older adults with multiple chronic conditions and those residing in rural and healthcare professional shortage areas. The design was a serial cross-sectional analysis of Medicare claims data for years 2008, 2011, and 2014. Its 2,471,498 participants included Medicare fee-for-service beneficiaries who had at least one primary care office visit in each study year. For the physician model, Medicare beneficiaries' primary care office visits in a year were conducted exclusively by physicians; for the shared care model, the visits were conducted by a group of professionals that included physicians and either PAs or NPs or both; for the PA-NP model, visits were conducted by PAs or NPs or both. There was a decrease in the physician model (85.5% to 70.9%) and an increase in the shared care model (11.9% to 23.3%) and PA-NP model (2.7% to 5.9%) from 2008 to 2014. Compared with the physician model, the adjusted odds ratio of receiving PA or NP care was 3.97 in rural and 1.26 in healthcare professional shortage areas; and the adjusted odds ratio of receiving shared care was 1.66 and 1.14, respectively. Patients with three or more chronic conditions were most likely to receive shared care (adjusted odds ratio, 1.67). The increase in shared care practice signifies a shift toward bolstering capacity of the primary care delivery system to serve older adults with growing chronic disease burden and to improve access to care in rural and underserved areas.1 Commentary by Clese Erickson: Although whether the United States has enough physicians is intensely debated, everyone agrees that physicians are maldistributed. This study comes at a time when the number of PAs and NPs is steadily growing and filling important care gaps for Medicare patients with multiple chronic diseases and those living in rural and underserved communities.1 The authors likely significantly underestimate PA and NP contributions overall because fewer than half of NPs and only one-third of PAs practice primary care—the focus of this study.2,3 Patients welcome the idea of seeing PAs and NPs, particularly if they have seen one before, and numerous studies have demonstrated that PAs and NPs provide high-quality care.4 The question now is how much of shared care between physicians, PAs, and NPs is taking place in a team-based, patient-centered environment. Supporting policies that enable interprofessional education efforts, advance scope-of-practice laws, reward value-based care, and foster care coordination and task delegation where everyone practices at the top of their license are key to making the most of this valuable and growing workforce. REFERENCES Is there a societal benefit to restrictive scope-of-practice policies? ABSTRACT Providing healthcare to low-income patients in the United States remains an ongoing policy challenge. This study examined how important changes to occupational licensing laws for PAs and NPs have affected cost and intensity of healthcare for Medicaid patients. The results suggest that letting PAs prescribe controlled substances is associated with a substantial (more than 11%) reduction in the dollar amount of outpatient claims per Medicaid recipient. There appears little evidence that expanded scope of practice has affected proxies for care intensity such as total claims and total care days. Relaxing occupational licensing requirements by broadening the scope of practice for healthcare providers may represent a low-cost alternative to providing quality healthcare to the poor in the United States.1 Commentary by Stephanie Radix: As each state assesses how to improve patient access to healthcare, the nation faces an imminent deficit of primary care providers. Timmons innovatively explores the influence of malpractice reforms and occupational licensing laws on the supply of practicing PAs and NPs. Enacting tort reform and diminishing the barriers to full practice that inherently exist within restrictive licensing laws are essential to the ability of PAs and NPs to provide and increase access to healthcare in underserved areas. As to occupational licensing, the study notably mentions the anticompetitive nature of many of these laws, which serve no public safety or protection role but simply exacerbate workforce problems, subvert PA and NP flexibility, and limit patient access to healthcare. REFERENCE The PA business model: A disruptive innovation ABSTRACT The authors propose that a new disruptive innovation in healthcare has occurred through the development of a PA business model, which can be most readily applied in vulnerable rural healthcare settings. This study begins with a review of the state of the healthcare system in terms of PA use and primary care shortages in rural communities, then proposes that the PA-owned and -operated primary care business represents a disruptive innovation, via the application of the five principles of Clayton Christensen's 1997 thesis on disruptive innovation. Considering the state of the healthcare industry, the study logically defends the proposed model as a disruptive innovation in that it focuses on an underserved market, has lower costs, has few competitors, offers high quality, and provides a sustainable competitive advantage. For practical implications, the PA business model is a viable solution for providing primary care for rural communities with educational, financial, transportation, and other resource limitations. This is an original and unique application of the theory of disruptive innovation, which illustrates how a new business model can solve a chronic shortage in primary care, especially in underserved populations.1 Commentary by Matthew Aiello: Developing PA-led services in underserved and rural primary care is proposed as a way to manage workforce and patient access challenges in these settings and as an example of disruptive innovation in healthcare. The authors presented a theoretical study, with a well-developed background and clearly articulated workforce challenges, scope of the problem, patient need, and the suggested fix. The connection between the proposed strategy and the various principles of disruptive innovation was compelling as an argument, as was the idea of using a new business model to tap into and support the needs of a missing market. The issue comes with the need for the proposed innovation to be supported by systemwide change to the regulation, licensing, training, and indemnity cover for PAs. Herein lies the problem with applying disruptive innovation in the context of healthcare workforce. The reality of the situation is that healthcare cannot simply close for renovation. For this reason, the best that can be done is seek to improve what is there, rather than start again on a blank canvas. This would integrate the novel with the traditional in a way that would not truly be defined as disruptive innovation. If full system redesign is practically unrealistic as an option, are we trying to fit a round peg in a square hole by applying disruptive innovation to healthcare? Just because we can make a methodology fit does not necessarily mean that we should. The author's proposal and argument should be taken as a compelling opinion to inform further research. REFERENCE
The four nations of the United Kingdom (UK) have endorsed a new curriculum and credentialing process for consultant pharmacists. This study aimed to measure the self-reported consultant-level practice development needs of pharmacists across the UK.The study was a cross-sectional electronic survey. Inclusion criteria were: pharmacists registered to practice with the General Pharmaceutical Council; working in any professional sector across the UK; and self-identifying as already working at an advanced level of practice or in an advanced pharmacist role. Participants were asked to rate their confidence that their current practice aligns to the level described in the Royal Pharmaceutical Society Consultant Pharmacist curriculum on a 5-point Likert scale. Predictors of overall confidence with the whole curriculum were analysed using binomial regression.Nine hundred and forty-four pharmacists participated. Median age was 42 years; 72.6% were female. Research skills and strategic leadership skills had low self-reported confidence. Patient-Centred Care and Collaboration was the domain with the highest reported confidence. 10.2% (96/944) of participants self-reported confidence across the whole curriculum. The strongest predictors of overall confidence across the curriculum were advanced clinical practitioner qualification, research qualifications and self-identifying as a specialist. Increasing age and male gender also predicted confidence. White ethnicity and having an independent prescribing qualification negatively predicted confidence.A small minority of pharmacists self-reported confidence across the whole curriculum. A planned approach to develop research skills across the career spectrum, coupled with better identification of workplace-based experiential strategic leadership opportunities, may help deliver a larger cohort of 'consultant-ready' pharmacists.
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