The physician assistant experience in Scotland

Farmer J, Currie M, West C, et al. Evaluation of Physician Assistants to NHS Scotland - Final Report. Centre for Rural Health, UHI Millennium Institute, The Centre for Health Science, Inverness, UK. http://www.nes.scot.nhs.uk/documents/publications/classa/UHI_Final_Report_January09.pdf. Accessed March 3, 2009.

EXECUTIVE SUMMARY OF THE FINAL REPORT

BACKGROUND: Physician Assistants (PAs) are health professionals with generalist medical education that allows them to work in a variety of settings. They work under the supervision of a fully trained and experienced doctor. The profession emerged in the USA in the 1960s and is now being adopted by other countries, including England, in response to workforce gaps. A Scottish pilot of PAs ran from November 2006 to October 2008. Fifteen USA-educated PAs worked in Scotland at some period during those 24 months in the following settings: primary care; out of hours clinic; emergency medicine; intermediate care; orthopaedics; acute receiving unit. This is a summary of a two-year study of the Scottish PA pilot that aimed to evaluate the impact and contribution made by the appointed PAs to delivering effective healthcare in NHS Scotland.

METHODS: The evaluation used mixed data collection methods, including: individual and group interviews; monthly feedback forms; recording of scope of practice; work activity data collection and work shadowing. Data were collected longitudinally to assess changes. A case study approach was taken in selected settings to attain richness. For qualitative data management, nVivo was used. SPSS and Excel were used for quantitative data analysis.

FINDINGS

RESPONSE: Six group interviews were held with PAs; 63 interviews with team members; 20 interviews with patients; four with NHS senior managers and three with Partnership Forum representatives. Work activity data were collected for settings; 48% (92/190) of monthly PA/medical supervisor feedback forms were received.

SAFETY: Over 24 months, two minor patient safety issues were noted by supervising doctors: a mixup with patient notes and a PA advising a patient to change drug regimen without consulting the supervising GP. From this study, PAs appeared safe when working under medical supervision. All patients interviewed were satisfied with PAs, several noting that they appreciated PAs' communication skills.

EFFECTIVENESS: PAs' scope of practice tended to expand over time, but most thought they had not been able to work to the scope and level they would do in America. Inability to prescribe was a hindrance. PAs usually spent longer time with patients as patient education was reported to be a feature of PA training. PAs were reported to provide continuity in busy settings and to be an educational resource for other staff. Most interviewees reported PAs were working in a range from similar to a nurse practitioner to similar to a mid-level/generalist doctor. The valued distinctive features of PAs were: generalists with a background of medical training, confident and autonomous within their scope of practice, can do differential diagnosis, communication skills, confident in dealing with uncertainty. Medical supervision arrangements varied from close to formal/distant relationships. PAs reported working most effectively, and were most satisfied, where there was a distinct gap in a team that they could fill. NHS senior managers were mostly satisfied that PAs might be one of several new roles developed for the future NHS. Partnership Forum representatives suggested that team members became less anxious about PAs once they were informed and had worked with them.

COST-EFFECTIVENESS: Teams noted that PAs brought a level of skills and attitudes that overlapped with other roles. Thus PAs were described as complementing team skill-mix, rather than as a potential direct replacement for other staff members. When specifically asked to choose, interviewees suggested the types of existing job designations that PAs could be placed in. These included both nursing and medical roles and the costs of deploying a PA instead of these existing posts were calculated, based on gross salaries at the time of the study. (Toward the end of the study, the newly qualified PA post was evaluated under Agenda for Change at Band 7 [£29,091-£38,353]). It was found that PAs would cost approximately £15,000 more if they worked in the role of a practice nurse (as one PA was actually deployed in primary care) to saving £43,000 upwards if they worked ‘like' a generalist doctor (specialist trainee, staff grade or GP in training). Costs to the NHS would arise from setting up PA education courses, professional development, and related structures. The time spent by supervising doctors, with PAs, was also noted as a cost.

CONCLUSIONS

• During the study, PA's practice was found to be safe. 

• Patients who were interviewed were found to be satisfied with PAs.

• PAs were reported to be most valued, and expressed most satisfaction themselves, where they were working in a new role or where they could find a distinct space to fulfil their potential scope of practice. Findings suggest they were less able to do this in primary care, compared with other settings. This may be related to the settings and work arrangements in the pilot project.

• Findings suggest a ‘mid-level' practitioner space, that there are currently challenges filling, in some settings in NHS Scotland. There may be a range of types of practitioner (PA may be one of them) that could fill this generalist space, with appropriate education, training and experience. The skills and attitudes required to fill the space are: critical thinking, diagnostic skills (capacity for differential diagnosis), generalist/holistic medical approach, communication skills and confidence in dealing with uncertainty. Practitioners with these skills and attitudes can provide continuity and a training resource in settings. Given the suggestion that this space exists, it is up to NHS Scotland and its stakeholders to decide whether, and how, to fill it.

• The opinions of team members interviewed in this study concur with evidence from the USA suggesting that PAs add complementary skills and attitudes to teams and should not be regarded as a potential direct ‘substitute' for a nurse or a doctor. Findings suggest team members think PAs would be one of a range of roles that might be present in an ideal team. If PAs were to undertake some of the work that might ‘replace' existing roles, then cost savings might result. There would be costs in developing education, accreditation and support structures.

• A strong and trusting relationship is required between PAs and their supervising doctor. Although the NHS tends to be hierarchical, instances of these types of relationships emerged in the pilot showing that this is possible in NHS Scotland. With such a relationship in place, PAs were described as working like ‘physician extenders'; conducting a range of routine tasks in the manner that their supervising doctor required and freeing the doctor to concentrate on more complex work.

• PAs could not prescribe in the pilot. This was more of a hindrance in primary care and the out of hours clinic than in emergency medicine and other hospital settings. Piloting of PAs in other settings may be dependent on achieving prescribing rights.

• Findings of this study should be viewed in the light of caveats. PAs were piloted in a small number of settings. There were a small number of PAs, some departed and some arrived during the study, making evaluation complex. PAs could not prescribe and did not think they were given the scope to expand to their full potential. PAs in the Project were often highly experienced and were from the USA. The skills and attitudes of UK- or Scottish-trained PAs might be different. Sometimes personalities did not fit and this impacted on team members' and NHS Boards' experiences with PAs.

• The PA profession is spreading internationally in response to workforce gaps. This study suggests PAs may offer some promise in meeting Scottish policy goals. Scotland's choice is to become part of the world-wide development of the PA profession and/or to develop existing professional groups into the mid-level, generalist ‘space' identified.

DISCUSSION

Following the establishment of physician assistant programs in the United States, research was performed to document these early endeavors. This research concentrated on answering very basic questions, typically analyzing data that demonstrated the skills, physician acceptance, and patient satisfaction of early PA graduates. Throughout the 1970s and 1980s, studies were conducted to determine how physicians and patients accepted PAs, as well as describing what PAs did and where they practiced. Generally these studies were limited to small sample sizes such as a specific geographic region or the graduates of a specific program.

In early US studies, PAs first migrated to clinical practices and were then studied; thus, many variables pertaining to describing PA practice were uncontrollable. The Scotland pilot project, in contrast, was an experiment in which PAs were recruited to work in specific sites and clinical practices, and in which detailed observation as well as retrospective interview data were used to systematically evaluate their impact. The primary research question was whether US-trained PAs could be adapted to work effectively in Scotland's NHS and could contribute in a unique way. This report, while recommending that Scotland move forward in utilizing PAs, is richly detailed, describing subtle characteristics of PA practice not commonly seen in US research on PA practice. JAAPA

Rick Dehn is a clinical professor in the Department of Family and Community Medicine and program director of the FNP/PA program at the University of California at Davis School of Medicine in Sacramento. He is a member of the JAAPA editorial advisory board.