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PAs mooted as an alternative to service SHOs within the HSE

This summer, four physician associates (PAs) began working in the surgical directorate at Beaumont Hospital in Dublin in a pilot initiative. The move was a first for Irish healthcare and spearheaded by the RCSI, which commences a new two-year postgraduate PA studies course from January 2016.

Documentation obtained by the Medical Independent (MI) from the Department of Health under Freedom of Information legislation reveals that submissions to the Department from an RCSI-led steering group, in support of introducing the role at Beaumont, continued from March into late June this year (MI requested any documents dating to early 2014). It also reveals major doubts within the HSE as to the future of some SHO service roles.

The narrative woven by the documentation begins when a senior official in the Professional Regulation Unit in the Department was contacted by an RCSI representative in March.

The unit official was informed that Mr Liam Woods, HSE Interim National Director of Acute Hospitals, had in (then) recent days sanctioned Beaumont to employ five PAs this year.

The RCSI representative was contacting the unit to explore “how to add this group to a regulator such as CORU, or other, as deemed appropriate by the Minister and your office”.

Concern

This prompted concern at Hawkins House. While some Department staff knew of Beaumont’s interest in exploring the PA role, due to NCHD shortages, they were unaware of any detailed proposal submitted on the matter.

The Department’s Deputy Chief Medical Officer (CMO) Dr Eibhlin Connolly informed colleagues that she understood from other jurisdictions that the PA role is “of quite a specialised nature” and of a level of clinical risk, “which would place them ahead of some of the other proposed professional groups in terms of priority for registration purposes.”

The view of NDTP, outlined in a section of the submission, was one of strong support for the proposed pilot

The role’s introduction to a single hospital “without any clarity as to the professional governance, scope of competence, regulatory and fitness to practise frameworks within which they practise is not advisable and I am surprised that this would have been sanctioned without a national mandate or agreement”.

The Department’s CMO Dr Tony Holohan shared these concerns. Developing such a role and “dropping it into services” without clear regulatory, scope of practice and accountability arrangements would be “unsafe and unwise”, he said. 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.”

The unit official reverted to the RCSI representative, noting it was understood that Prof Arnold Hill, Head of the School of Medicine, RCSI, was due to meet with HSE Workforce Planning to initiate discussion on this matter. The RCSI was advised that consideration of PAs would require a detailed submission to the HSE/Department of Health.

Support

Later that month, an RCSI proposal was submitted to the Department. It said the College had “secured the support” of the HSE to “leverage ring-fenced funds” for unfilled (non-training) SHO surgery posts, to fill the gap in service delivery through a PA pilot commencing in July. The College also noted its plans to initiate a postgraduate course to qualify new PAs. Key drivers cited were NCHD shortages and the implementation of the European Working Time Directive.

PAs are trained and educated similarly to physicians and “therefore share similar diagnostic and therapeutic reasoning”, the RCSI proposal stated. The PAs would be supervised and undertake duties such as taking patient histories, administering medication and ordering/collecting specimens for routine lab tests. “The regulatory and fitness to practise framework options which might be applicable for this grade are CORU,” it read.

The submission proposed the HSE SHO salary scale of approximately 238,000 to 254,000.

In April, the Department’s Chief Human Resources Officer, Mr Graham White, wrote to the then HSE HR Director Mr Ian Tegerdine on the matter. He outlined that, in principle, Hawkins House would welcome consideration of the benefits of the proposed grade in the acute sector. However, this would have to be done in the context of the HSE’s future workforce planning and the statutory framework for approval of grades and terms and conditions of employees.

Ultimately, the HSE would have to submit a detailed proposal “seeking approval to introduce this new grade into the public health service… ”

He wrote: “Any detailed proposal received will be considered by relevant officials and policy units within the Department. However, it would be important that sufficient detail is provided and benefits arising identified if this Department and the Department of Public Expenditure and Reform are to approve the proposal.

“While a pilot is initially proposed, this would involve a pay rate for the envisaged grade and other terms and conditions that would require approval. There would also need to be IR engagement on the proposal.”

Details

In early June, a submission titled Physician Associate Pilot in Beaumont Hospital planned to commence in July 2015 was made to the Department. It came from the PA Steering Committee, which included a number of RCSI representatives, Beaumont Hospital CEO Mr Liam Duffy, Prof Eilis McGovern, Director of HSE National Doctors Training and Planning (NDTP), and Mr Paddy Duggan, HSE Workforce Planning, Analysis and Informatics, among others.

It noted that conversion of ‘service posts’ into training posts is worth progressing in circumstances where NCHDs are available to fill such posts and where there is a requirement to increase the number of training posts.

“This direction is not the best option for surgery in Beaumont, not only due to the current and projected supply of NCHDs but, more critically, the increase in NCHDs in surgery in this location would diminish the quality of training due to the demand placed on surgery time by the increased numbers of trainees…Physician associates will provide stability and day-to-day continuity of care. They can offer flexibility that medical locums or trainees cannot, enabling their deployment across a number of units to cover periods of sickness and in the longer term, their redeployment when service needs change.”

The submission proposed the HSE SHO salary scale of approximately €38,000 to €54,000. In other jurisdictions, it noted, the PA salary increases following experience and further study, such as a master’s degree.

The view of the NDTP, outlined in a section of the submission, was one of strong support for the proposed pilot.

SHO posts

This section, outlining the position of the NDTP, added a number of points on non-training surgical SHO contracts in Ireland. These posts are of six or 12 months’ duration and there is frequent turnover of doctors, whose quality is variable. Often, they are international medical graduates, which can result in language and communication problems.

The view of the NDTP was that the role of the service-grade surgical SHO is “not sustainable”. In contrast, the PA role “has been proven over many decades in North America,” it added.

In mid-June, a HSE/RCSI delegation met with Department officials to discuss the initiative. The Department thereafter sought extra detail on various issues, such as clarification on whether this involved a regrading from SHO or a new distinct grade, and what kind of career progression was suggested.

A further, more detailed submission, dated 30 June, was submitted to Hawkins House by the PA Steering Committee. The main role of PAs in the pilot would be reducing the number of hours spent by doctors on indirect patient care, it emphasised.

A time-motion study of surgical SHOs in training posts at Beaumont, developed as part of plans for the PA pilot, had found that indirect patient care accounted for 38.6 per cent of the total time recorded. Only 12.3 per cent of the SHOs’ time was spent in direct patient care.

The PA role was a “new distinct grade” and not a “regrading from SHO”. The equivalent of HSE level 3 SHO salary scale (€45,000) was proposed, with the scale to be considered following the evaluation of the pilot.

The PAs at Beaumont (who would number four) would maintain their home registration in the US and Canada. A detailed induction was planned and the CIS had agreed to indemnify the proposed roles. They would be subject to performance reviews twice a year with their supervisory consultant surgeon. In respect of working hours, it would be a 39-hour week, with day shifts only and no on-call. On proposed career progression for PAs, it was too early to say.

Future

A Department spokesperson told MI it has not made any recommendation to the Department of Public Expenditure and Reform in relation to the introduction of the PA as a permanent grade in the HSE.

“The Department has not yet undertaken any work in relation to the possible introduction of PAs in a wider or more permanent context. Any decisions regarding the future of a role for physician associates in Ireland would need to be taken in the context of the Workforce Planning National Integrated Strategic Framework.”

An RCSI spokesperson said the College is initially funding the PAs’ salaries for the pilot and “it is expected that RCSI will be reimbursed by Beaumont Hospital at a later date”.

The spokesperson added: “Over the duration of the pilot scheme, RCSI will make a funding contribution to the posts to reflect the time the PAs will contribute to teaching on the new proposed programme.”

Asked if the RCSI considers the PA role as a superior alternative to that of the non-training surgical SHO, the spokesperson said: “No, RCSI see the PA role as complementary to the existing healthcare teams.”

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