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