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Integrating physician associates into the healthcare system

When news emerged in 2015 of the sanctioning of a physician associate (PA) pilot at Beaumont Hospital in Dublin, one headline warned of “assistants for doctors with no medical degree” being hired.

The pilot at Beaumont was a first for Irish public healthcare, where the role remains undeployed nationally and little understood. It is viewed sceptically by some doctors and, in particular, nurses.

Charges of ‘substitution’ and ‘yellow-pack doctors’ will need to be countered by advocates to ensure optimum team-working and public confidence if it does roll-out. But advocates have good reference points: The grade is firmly and successfully established in US healthcare and is continuing to develop in the UK, where there is a commitment to recruit 1,000 PAs to general practice in England by 2020, as part of efforts to address the GP workforce crisis (which also involves recruiting more doctors).

PAs are dependent healthcare professionals trained in the medical model and who work under consultant or GP supervision. They undertake medical histories, physical exams, interpret tests, diagnose and treat illnesses and give preventive health advice, and in the US, they have prescriptive authority. Typically, they have prior healthcare experience before undergoing postgraduate training to qualify as PAs.

The pilot at Beaumont concluded in October 2017, having commenced with four PAs recruited from abroad. The Department of Health is currently examining a report on the RCSI-spearheaded pilot. 

In 2016, the RCSI launched Ireland’s first postgraduate course to qualify PAs. It received seven students into the first cohort, which graduated from the two-year MSc programme in December 2017.

Last year, 14 students commenced the PA course and 11 this year. The tuition fees are €12,000 per year.

In an RCSI promotional video, Head of the School of Medicine Prof Arnold Hill described the role as “proven in the United States and the United Kingdom, and we think it’s timely to introduce this now because of the workforce challenges that exist in the Irish healthcare system”. Prof Hill said PAs offered “continuity of care” and complemented existing healthcare professionals.

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Prof Arnold Hill, RCSI

The HSE’s National Doctors Training and Planning (NDTP) unit has previously identified PAs as a potential replacement for surgical SHO service posts, which have a high turnover. The HSE National HR Director Ms Rosarii Mannion visited the RCSI programme in 2017. 

Beginnings

In autumn 2015, four PAs from the US and Canada commenced work in the surgical directorate of Beaumont. At the time, the Department of Health confirmed to the Medical Independent (MI) that the PAs would not be under the jurisdiction of any Irish regulatory body for healthcare professionals during the pilot. They were to retain their professional registration “with their [home state] US/Canadian regulatory bodies”, have performance reviews twice a year with their supervisory consultant surgeon, and maintain continuing medical education credits and up-skilling of competence. The State Claims Agency’s Clinical Indemnity Scheme agreed to indemnify the PAs for the pilot project.

But the proposed pilot appeared in doubt prior to these arrangements being agreed. Documents obtained by MI from the Department of Health under Freedom of Information legislation showed that the HSE Acute Hospitals Division sanctioned the Beaumont pilot in the early part of 2015 without obtaining official approval from the Department. 

In internal Department correspondence that discussed news of the proposed pilot, Chief Medical Officer Dr Tony Holohan said developing this role and “dropping it into services” without clear regulatory, scope of practice and accountability arrangements would be “unsafe and unwise”. However, Dr Holohan added: “The concept of a PA is a good one and can work, but requires to be developed and implemented in the appropriate manner.”

Eventually, the pilot commenced in autumn 2015 under the terms previously described.

Last month, the Department informed MI that the PA role was introduced on a “pilot basis only” in four specific areas at Beaumont Hospital for the two-year period. “This period expired in October 2017. The RCSI have submitted a report evaluating the PA pilot.  This report is currently being considered by the Department. As the PA role does not currently exist in the Irish public healthcare system, the Department does not hold any PA statistics, nor has it considered the role for regulation.” The Medical Council says “informal discussions” have taken place with the Department on regulation of PAs.

Private healthcare is showing a demonstrable interest in the PA role. Last year, Bon Secours Health System announced that it would part-fund two candidates for the RCSI programme commencing January 2018. Successful applicants must be willing to work as a PA graduate with the private healthcare group.

In May 2017, the RCSI further reported that Blackrock Clinic and the Galway Clinic would each fully sponsor one candidate’s fees for the duration of the two-year programme, with scholarships commencing in 2018. “On graduation, successful applicants must be willing to work as a physician associate in any of the clinical locations operated by the scholarship sponsors,” stated the RCSI’s website.

According to the Department of Health, “if a private hospital decides to employ a PA, it is a matter for that hospital” to ensure they are working “within an appropriate clinical governance structure”.

Currently, the RCSI’s course is one of two PA programmes on the island of Ireland. Ulster University launched its two-year Physician Associate Postgraduate Diploma/MSc, with 14 students admitted for the 2017 intake. A further 17 students commenced the course in 2018.

The prospect of the role embedding in the North has taken a significant step forward due to support from the Northern Ireland (NI) Department of Health.

A spokesperson for the NI Department of Health told MI: “The two-year PgDip/MSc in Physician Associate studies was introduced by Ulster University in January 2017. Although primarily a university initiative, the Department of Health (for Northern Ireland) has welcomed this step to generate a local supply of PAs, given that this role was identified within Health and Wellbeing 2026: Delivering Together (the response, published in October 2016, to the report produced by an Expert Panel led by Prof Bengoa tasked with considering the transformation of Health and Social Care Services in Northern Ireland) as a contributor to multidisciplinary teams for the future delivery of healthcare.

“The first cohort of students are currently being sponsored by Health and Social Care (HSC) Trusts, with Trusts paying university tuition fees for the students.

“The Department of Health for Northern Ireland has since undertaken to commission 20 places for PA students from Ulster University on an annual basis, and will pay tuition fees for these [EU] students directly to the university. The tuition fee is currently £9,545 p/a per student. The Department is also providing funding to HSC Trusts and to general practitioners to facilitate clinical placements in hospital [and healthcare] settings in accordance with curriculum requirements.

“The Department has initially agreed to support three cohorts of students and will evaluate the impact of this investment on the HSC workforce in 2021. Following this evaluation, a decision will be taken as to whether this funding arrangement will continue for a further period. The level of funding to be provided in 2019/20 (when the Department will be supporting two cohorts of students) will be in the region of £750,000.”

There are presently no conditions placed on students graduating under the Department-commissioned programme regarding their future employment. “The Department is aware of emerging interest in utilising PAs among secondary care Trusts and will be using this initial period of support to promote the role actively among Trusts and general practitioners. The conditions for any ongoing Departmental [support] will be reviewed as part of the revaluation in 2021.”

Prof Tara Moore is Professor of Personalised Medicine at Ulster University and founder of the university’s PgDip/MSc in Physician Associate studies. She says the prospect of taking on PA trainees was greeted enthusiastically by senior healthcare managers and clinicians who had prior experience of working with PAs.

But, as Prof Moore suggests, the most important stakeholders in integrating PAs into Northern Ireland’s healthcare system are the doctors who are undertaking to train PAs on the job in GP practices and hospitals. 

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Prof Tara Moore, Ulster University

In this respect, colleagues in the university and Department of Health workforce team have initiated an ongoing “hearts and minds” project for the multidisciplinary team of healthcare providers that PAs will work alongside and for patients and the wider public.

Currently, there are three PAs employed within the HSC, two in the Northern Trust area and one in Belfast. The Southern Trust has also recently advertised two posts and is due to hold interviews in the next few weeks.

MI asked Prof Moore what challenges have emerged in the clinical environment in terms of integrating their role: “Ensuring all stakeholders are fully informed about physician associates, their role and the training needs and how they can complement a multidisciplinary team is critical.

“Physician associates are trained on a medical model but are not doctors. They are trained to deliver healthcare to patients but always under the supervision and alongside a consultant, who takes ownership of them and supervises them, therefore ‘buy-in’ from doctors as trainers is essential.”

The NI Department of Health has been “very proactive and supportive” in working with the university. The first cohort began their course prior to the funding for fees being in place, while the second were fully recruited just before an agreement was reached. The 2019 recruitment will be the first where applicants know their course fees are covered.

The aim of the university’s PA course is to “enhance the Northern Irish workforce”, underlines Prof Moore. She adds: “There is existing evidence to show this can be a successful approach to deriving new workforce and manpower here to deliver care for the patients here in Northern Ireland — that is the drive and that is why the Department of Health wants to fund it.”

The UK is proposing to regulate PAs and conducted a public consultation exercise in late 2017. The General Medical Council (GMC) says it is best placed to assume this regulatory remit (but has underlined that doctors must not have to subsidise the establishment of this process or its ongoing operation).

Meanwhile, the Faculty of Physician Associates at the Royal College of Physicians in London provides professional support to PAs across the UK. The Faculty also oversees and administers the running of the Physician Associate Managed Voluntary Register (PAMVR) and has been campaigning to achieve statutory registration.

Integration

In the North, the Department of Health has appointed Northern Trust CEO Dr Tony Stevens as Academy Lead for Physician Associates. He is leading the development of plans to ensure PAs’ integration into healthcare services.

Dr Stevens offers a fascinating insight into the types of infrastructure required to support optimum deployment of this new healthcare profession in the Northern Irish context.

He says it is vital to have a pathway in place for PA graduates.

“Nobody in Northern Ireland really knows what a physician associate is, so they appear on the wards for training and people are saying, ‘who are they, what are they, how do they relate to nurses, what is the difference between a physician associate and an AHP [allied health professional], can they do this, can they do that’ — and even, ‘will they take our jobs?’

“So there is a whole range of issues that I think needs to be addressed. I am a doctor by background but as a Trust Chief Executive, I see my role as trying to facilitate the integration of physician associates into the healthcare system here, by just bridging the gap between the university and the service.”

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Dr Tony Stevens, Northern Trust CEO

A key aspect is ensuring PA trainees have similar training experiences and outcomes in specialty training across healthcare — in other words, “the quality assurance of undergraduate clinical training and to make sure there is consistency in the delivery of training”.

A “logical and consistent approach” to recruitment is required, and when employed, PAs must be safely integrated into existing multidisciplinary teams.

Dr Stevens is particularly interested in the prospect of commencing an internship scheme.

“So rather than just say that, at the end of two years, they are qualified and can apply for a job, can we, across all the Trusts in Northern Ireland, create an internship scheme, kind of like with junior doctors in the UK you have a foundation training programme, I think there is something similar in the South.

“Because it seems to me as quite high risk, when we have very little experience of physician associates, that we would just launch them into jobs, in ones and twos, without some supervised year or two years where they develop their skills and knowledge and we almost ‘socialise’ them into existing teams.”

He also views regulation of PAs as “absolutely crucial”.

As to feedback from established healthcare professions, Dr Stevens says doctors who understand the role are “quite positive” and even “enthusiastic”.

“I think some of the other professions like nursing are more cautious and unclear what they bring to the table that, say, nurses or AHPs don’t already offer. The jury is out on that [for them]. But the doctors are keener. We need to see what the true potential is and again, one of the challenges for us in the North, and I suspect in the South too, is when you are dealing with such small numbers, it is very hard to create momentum and there is a real danger they’ll end up working in ones and twos and without a lot of peer support… and that might lead to a very cautious approach, which would undermine their value.

“To my mind, to make it worthwhile having them, we really have to be quite adventurous in what they can do but without the experience and without the numbers, I suspect we might end up being quite conservative and if we are very conservative about what we let them do, they are not going to add very much value and we are going to turn around and say, ‘is it worth it?’ So I think we are kind of caught; we need to see what is happening internationally — the States, Canada, in England in fact, and fully understand the potential.”

There are two acute hospitals in the Northern Trust — Antrim Area Hospital and Causeway Hospital, Coleraine. The latter is a smaller hospital that struggles to recruit junior doctors. Dr Stevens considers that alternatives to doctors are needed to maintain essential acute services into the future.

He feels that the potential of this new profession to carry out tasks of junior doctors — particularly early-stage junior doctors — could be hugely valuable and “may mark out the way in which some of our smaller hospitals can survive and thrive”.

“The UK does not have, in my view, a workable medical model,” continues Dr Stevens. “We are over-dependent on trainee doctors and short of them… We have a consultant-led service — a consultant-delivered service is incredibly expensive — so we don’t have enough people to deliver services; same as the South. I don’t think we have recognised that…Nobody is working on a model to change the medical profession to fit with what is currently required, so physician associates in my view offer an opportunity to plug a gap, and it is a service gap, obviously.

“I am still not convinced that the solution to the medical profession [shortages] is to have more medical schools and to produce more and more doctors. One, because I think by doing that you actually change the medical profession, and ultimately then you will be spending a fortune training doctors to a very high level and the jobs you actually want [many of] them to do will be fairly mundane and routine. Wouldn’t it be better to train a different cadre of people to do a lot of that work? I remain to be convinced that the solution to the current workforce problem is more and more doctors, because actually the really high-value, high added-value work you need your doctors to do is relatively limited. What you really need is people who can carry out processes for you. In other words, if your doctors are the ultimate decision-makers, how many do we need?”

Dr Stevens is very positive about the role of the two PAs employed in his Trust — but he believes an established national infrastructure would enhance the role.

The Northern Trust’s PAs, who are working in emergency medicine, are “facilitating our decision-makers, which are our consultants, by preparing everything for them, so all they have to do is make the key decisions. That hugely improves flow. Ultimately, what you want is for them in their own right, within their constraints and capability and training, to be able to make decisions as well.”

When Northern Ireland’s first PA students graduate, Dr Stevens says he would “like us to have put in place a good recruitment process, have in place a foundation year for them, and that at the end of the foundation year we have a really good evaluation of the progress they have made and the contribution they have made”.

In England, PAs are seen as one of the means of addressing the general practice workforce crisis. Dr Tom Black, Chair of the Northern Ireland GP Committee of the British Medical Association (BMA), is positive about their potential impact within his specialty in the North.

“The first thing to understand is, we don’t have enough GPs,” he tells MI.

“We have increased the training numbers for GPs up to 111 per year of GP trainees, and over the next five years we should gather up probably 550 — the workload commitment for that cohort will probably be about 60 per cent, though that equals the number of GPs we will lose in the next five years, so if all goes to plan we’ll be at a standstill in five years’ time.”

Today, Northern Ireland has fewer GPs per head of the population than in the 1950s, according to Dr Black.

 “We have more than 2,000 patients per whole-time equivalent GP — now, that is making life very difficult because GPs are having to work harder because patients are sicker. The way around this conundrum, of course, is to bring in the multidisciplinary teams. In Northern Ireland, we have a very effective pharmacist-in-practice scheme, which has started in the last two or three years. Every practice in Northern Ireland now has a fully-funded part-time pharmacist in the practice helping with all the prescriptions. They are hired and employed through the GP federations.

“… So in my area, the GP federation for Derry has hired enough pharmacists to put one in half-time in every practice and as of April this year, each of these pharmacists will be full-time, so there’ll be a full-time pharmacist in every GP practice.

“Now, you can imagine how that helps with the workload — that is step one. Step two, obviously, will be practice nurses; we have some, but we need more. Step three will be mental health workers, then social workers, and we see physician associates being part of this pattern of delivery of care, mainly because there is so much work and not enough GPs in the workforce.”

However, if GPs commit to training PAs, there must be a return for general practice and a funding stream for recruitment, says Dr Black.

But could PAs be used as leverage to not sufficiently improve GPs’ terms?

“I don’t see that the application of multidisciplinary team-working will undermine our terms and conditions, mainly because there is no end of work,” he responds.

“There is no end of needs, wants and demands. Nobody can do what GPs do — which is risk-based care, dealing with undifferentiated presentations, and there is really nobody who can do what we do — we have a ‘USP’ — we work very hard, we provide 13 million consultations per year in Northern Ireland… and we provide the bulk of the consultations throughout the system.”

Dr Black acknowledges “significant concern among our juniors and our medical students that PAs might be a challenge to them for jobs in the future.

“I don’t see it that way mainly because, as I said, there is so much work, so much need, and we are just so good at keeping people alive with complex comorbidities… I am cognisant of the concerns of the juniors and medical students and we will keep a very close eye on it.”

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