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 Lynn Tyrer, PA-C
The author works as a PA in Tipton, England, which is near Birmingham. She has indicated no relationships to disclose relating to the content of this article.
In September 2003, I started work as a PA at a family practice clinic in the United Kingdom (UK). This clinic—or general practice surgery, as they are called—is located in a low-income, high-need area, and the business partners had struggled to find a full-time physician to replace the one who had retired. Eventually, they turned to US-trained PAs for a solution. On a smaller scale, their situation was not unlike the one that launched the PA profession in the United States, and they sought out a profession that has long been committed to providing care in underserved areas. This was an exciting opportunity for me, because I would be able to promote the profession on an international level. Since becoming a PA, I have passionately believed that we can help meet medical needs worldwide—and I even found evidence supporting that belief when I wrote my research thesis as a student. I do believe that PAs will eventually have international representation and unification similar to other medical professions. I also wanted to practice in a country with a national health system so I could experience firsthand the pros and cons of such a system. And, I wanted to be able to travel.
I was hired on a 2-year work contract. As part of the contract, I am also part of a pilot research project commissioned by the Changing Workforce Programme of the UK Department of Health. My days include working in the clinic, doing home visits (a routine part of the primary care service here), attending meetings to assist in the promotion of the PA profession in the UK, and collecting and recording data as needed for the pilot study. I work on a team with two doctors, one nurse practitioner (who mainly sees patients with diabetes, COPD, and asthma), and a practice nurse who performs duties similar to that of a LPN. Nursing titles and nursing training differs from those in the States. 9:00 AM
I arrive at the clinic and finish any paperwork not completed from the previous day. This time is also reserved for answering any incoming phone queries from patients.
9:30 AM
Clinic starts. I typically see 15 patients in the morning. The appointment times are set 10 minutes apart, with approximately 12 slots booked and 3 left open for patients requesting appointments that day. One of the new mandates set out by the UK National Health Service (NHS) is the access target. These targets were established in response to patient demand. For primary care, the mandate stipulates that a patient should be offered an appointment with a health care practitioner within 24 hours and an appointment with the doctor within 48 hours. In addition, we have the new General Medical Service (GMS) II targets. These reflect clinical and administrative goals and reward good clinical practice. For example, points are given if 80% of diabetic patients on the practice register have an A1C less than 7.4% and if smoking status has been ascertained and cessation advice given for persons older than 16 years.
All goals set by the NHS ultimately are linked to reimbursement. Clinicians are encouraged to try to address the GMS II goals opportunistically when seeing patients. This is often difficult to manage in a 10-minute appointment with a patient who has two or more problems, however, so the practice makes the effort to schedule appointments specifically to address GMS II goals.
The range of patients and presenting problems that I see are similar to those of a PA working in the United States, with a few exceptions. These include people requesting OTC medications (certain people qualify for free medicine) and those requesting “sick notes” (forms issued by the doctor signing a patient off of work). Sick notes are issued for varied reasons, but they can be given for conditions as simple as the common cold. Patients who are off work for more than 7 days need a note from their doctor explaining why.
Another difference in the NHS is data recording. Health care is moving toward a “paper light” system, in which all information will be electronic and accessible via a national database. All patient information at our clinic, from administrative information to telephone conversations, is entered onto the computer. This includes all clinic appointments as well. In the States, the clinician typically knows why the patient is coming in; also, a nurse usually obtains needed equipment in advance and prepares the patient. In the UK system, however, a nurse does not see the patient first. Clinicians collect their own patient data (eg, vital signs, weight, peak flows) and must also prepare patients for examination and arrange for any necessary equipment. This process does affect the schedule, and patients must sometimes book new appointments for further data collection and management.
This morning in clinic, the presenting problems I saw were hyperemesis in pregnancy (I referred the patient to secondary care for inpatient treatment), a few coughs and sore throats, increased shortness of breath in a patient with COPD and CHF, low back pain (two patients), menorrhagia, a Pap smear and well woman check, BP management, breast lump, rectal bleeding, depression (two patients), and a few rashes.
12:30 to 3:30 PM
This time is reserved for administrative work but is usually an extension of clinical tasks. Initially, I complete any referrals to specialists or consultants that arose from the morning clinic. Then I go through laboratory and radiology results, both of which are again recorded on the computer. Following this, I respond to patient telephone inquiries and medication requests that reception staff recorded that morning, as well as question or approve any medication changes recommended in secondary care. If any home visit requests have come in for the morning, these are divided between the doctor and me. On average, we usually have about three requests a day. Much of the 3 hours between morning and afternoon clinic can be taken up with home visits. I try to take 30 minutes for lunch—and if there is time left over,
I spend it doing administrative tasks such as medication reviews.
Lynn Tyrer about to make a house call in Tipton, UK.
3:30 to 6:00 PM
This is evening clinic, where again I am booked for 10-minute appointments. Generally I have 11 appointments during evening clinic—most prebooked. I saw a similar range of patients this afternoon as I did this morning, with a few exceptions. One patient was specifically booked for a medication review (which helped to capture information for the GMS II targets), and one was booked for a double appointment to fill out an insurance claim form. Following my last patient, I complete any consultant referrals, review laboratory results, and respond to any patient inquiries.
Frustrations and rewards
I have encountered some frustrations practicing as a PA in the UK. Primarily, these include the waiting lists and the growing pains associated with starting up an old profession in a new country. Patients sometimes must wait for 6 months or more before they can see a specialist. The waiting lists for some radiology studies, such as ultrasonography, are also up to 6 months. More detailed imaging studies, such as CT and MRI, can be ordered only by specialists; even primary care physicians are not permitted to order these tests. On a professional level, the local radiology department has not approved PAs working in primary care to order radiographs, so we must obtain a signature from our supervising doctor. The same goes for prescribing medications. Despite these frustrations, the rewards have been worth the sacrifices.
About 18 US-trained PAs are currently working here in the UK, with a further 11 to start soon. Most are working in primary care, and some are working secondary care in emergency settings. Each PA may be utilized in different ways, depending on clinic setting and team decisions. My experience has been educational, rewarding, and challenging, and I am proud to have worked with other PAs, as well as with forward-thinking UK clinicians, to promote the PA profession “across the pond.”
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