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PAs and the rocky road to regulation

By Catherine Reilly - 16th Apr 2023

regulation

As plans advance in the UK to introduce statutory regulation for physician associates, Catherine Reilly reports on the situation in this country

The Minister for Health Stephen Donnelly “wants to see” a grade for physician associates (PAs) introduced for Irish healthcare and has asked his officials to progress this, a Department spokesperson told the Medical Independent (MI) earlier this month. “Physician associates are not currently a recognised grade in the Irish health service, so the Department of Health is currently engaging with the HSE regarding an evaluation of the role with a view to progressing the matter.”

This is a change in tone from the Department, which last year stated that “the benefits of the introduction of a further wider pilot project” would “better inform future deliberations” about potentially recognising the PA grade.

There are currently 62 PAs working in the Republic of Ireland, according to the RCSI, which offers an MSc in PA Studies and has been advocating for recognition and regulation.

Director of the programme, Prof Lisa Mustone Alexander, told MI a further 16 students are due to graduate at the end of 2023. This could bring the number working in Irish healthcare to almost 80 next year. Most of the PAs are working in public and private hospitals, and a smaller number are based in primary care. It is understood the RCSI regards the deployment of PAs as beyond pilot stage.

Public employers include Beaumont Hospital, Dublin; Our Lady’s Hospital, Navan; Children’s Health Ireland at Temple Street; Connolly Hospital, Blanchardstown; National Orthopaedic Hospital, Cappagh; Our Lady of Lourdes, Drogheda; and the Mater Misericordiae University Hospital, Dublin.

Prof Alexander gave an online presentation on the Irish experience of PAs at the recent World Health Organisation Global Forum on Human Resources for Health.

According to a paper authored by Prof Alexander and colleagues and published in the Journal of the American Academy of PAs in March: “Our forecast for 2035, based on one programme at one university, is about 300 PA graduates. This is a cautious estimate as we await progress in advancing this role nationally via our Department of Health.”

Speaking after the Department’s recent statement, Prof Alexander told MI: “We are very happy with the Minister’s announcement and we welcome working with the Department of Health and HSE to expeditiously integrate current and future PAs into the health system.”

Remit

PAs are trained in the medical model and work under consultant or GP supervision. They support physicians and surgeons in the diagnosis and management of patients and are trained to perform several roles, including taking medical histories, performing examinations, making diagnoses, and analysing test results.

According to the Irish Society of Physician Associates (ISPA), PAs provide continuity of care and stability to healthcare systems. Research and data have reported the ongoing impact PAs have on improved patient flow, reduced waiting lists and increased patient access to healthcare services, it informed MI.

PAs are long established in US healthcare and growing in the UK, where approximately 3,000 are employed across hospital and primary care. While the NHS has a longer experience of employing PAs compared to Ireland, their proliferation is a more recent phenomenon in the context of rising patient needs and global healthcare workforce shortages.

In February, the UK Department of Health and Social Care opened a consultation on the legislative provisions to regulate PAs and anaesthesia associates (AAs). It stated that PAs and AAs were “already a valued and integral part of the multidisciplinary healthcare team, but they have the potential to make an even greater contribution”.

The aim of the consultation, which closes next month, is to seek views on the legislative provisions that will provide the General Medical Council with the powers and duties to regulate these professions.

On a practical level, the absence of regulation means that PAs cannot order ionising radiation or prescribe medications. More fundamentally, there is no statutory regulatory process in place if serious concerns were to be raised about a PA’s conduct or performance.

The ISPA manages a voluntary register that is open to graduates from PA programmes in Ireland, the UK, the US, and Canada. The register allows employers and potential employers to confirm whether an applicant or employee is fully qualified. Under this system, PA graduates must undertake a national certifying exam and a recertification exam every six years, as well as engage in continuing professional development.

The ISPA noted: “The PA profession is awaiting recognition as a grade within the Irish healthcare system and there has been no named statutory regulator to date. This is a limitation for PAs as without recognition and regulation, PAs are unable to work to the full scope of their practice, ie, prescribing and ordering of iodising radiation. To further progress the profession, alongside increasing awareness of the role, a grade must be introduced, and regulation is key.”

The Society added that it has engaged in positive meetings with the Department, HSE and NCHD Taskforce and is “waiting patiently on further progression of the profession”.

PAs in the public hospital system are included in the parameters of the Clinical Indemnity Scheme. A spokesperson for the State Claims Agency (SCA) said: “The question of regulation is a policy matter for the Department of Health. The SCA has not identified any adverse claim trend in relation to physician associates.”

Course

The PA role was first introduced in Irish healthcare in 2015 when RCSI commenced a small-scale two-year pilot at Beaumont Hospital’s surgical directorate involving four overseas-qualified PAs. In 2016 the College launched the first (and to date only) PA postgraduate course in the Republic of Ireland (Ulster University also offers a programme). Prospective candidates must have a science-related/health sciences degree to gain admission to the “fast-paced” two-year course at the RCSI.

A small number of private and public hospitals have offered scholarships in return for a service commitment, while the Irish American Partnership has also provided scholarship funding. Fees for the RCSI programme are €12,250 (including NUI fee) for year one and €12,000 for year two.

The College has also launched a hybrid programme for prospective students outside Dublin. Six students joined by this mechanism in January and Prof Alexander foresees this as “a growth area” for the programme. Currently, RCSI expects 15 to 20 PAs to qualify through the programme and enter the workforce annually. As the numbers steadily accumulate, the question of regulation is becoming more pressing.

Demand

Prof Alexander said the clinical demand for PAs is “very strong” and there are “more jobs than we have graduates”.

“The PAs that are in the clinical positions are doing great work, really helping to reduce the waiting lists, and increase access to care,” she said.

Based on a graduate survey conducted last year, the largest proportion of PAs were working in orthopaedics. Prof Alexander said this finding was not specific to Ireland and reflected the surgical needs of aging populations. Graduates have also entered other surgical specialties, as well as acute medicine, anaesthesiology, psychiatry/mental health, primary care, and fertility medicine, for example.

The lack of prescribing powers is a frustration for PAs who wish to operate “at the highest level” of their training.

Prof Alexander is also working with members of the programme’s external advisory board on a scope of practice document for PAs in GP settings that will be used to provide “needed guidance to the indemnity providers”.

She added: “I would say I am just really pleased with the receptivity that PAs have had here in the hospitals and by the patients and consultants. It has not been a difficult process to see them integrate into the system.”

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