Title: Investigating the contribution of physician associates (PAs) to secondary care in England: a mixed methods study
Funder: Department of Health and Social Care

Abstract: This study aims to investigate the contribution and impact of including physician associates (PAs formerly known as physician assistants) to medical teams on the organisation and delivery of patient care in hospitals in England. Increasing numbers of hospitals in England are employing PAs in a widening range of medical and surgical specialties. Demand for PAs from hospitals is outstripping the supply of PAs graduating from UK Universities. In response, the Minister of Health announced in August 2014 the doubling of NHS funded training places and there is anticipated to be 500 PAs graduating a year by 2018. The Royal College of Physicians is establishing a Faculty for PAs under its governance. Student PAs have a first degree, usually in a bio-medical science, and are trained at a post graduate level in the medical model to assess, investigate, diagnose and commence or change treatment under supervision of a doctor within their agreed scope of practice. While they have a 50 year history in the United States they are new or unknown to most British health care settings. There are currently nearly 300 PAs, mostly UK trained, employed in medical teams in hospitals. We know little about how PAs are deployed in different teams, what activities they undertake, what difference their involvement makes to patient pathways, costs and service delivery systems. Likewise little is known about the patient perspective on the involvement of this new type of professional in their medical team. This mixed methods study proposes to investigate these questions in order to better inform the public, managers, clinicians and commissioners. Four interlinked research work-streams are proposed. Work stream I investigates the extent of the employment, deployment and role of PAs in hospital medical teams using two electronic surveys; one to medical directors of NHS acute Trusts and the other to PAs through their professional organisation. Work stream 2 investigates evidence of impact and factors supporting or inhibiting the adoption of PAs through a systematic review and policy review. Work stream 3 undertakes a more detailed investigation in four different types of hospitals each employing between 4 and 20 PAs in different specialties. These case studies include a) interviews with patients, managers, team and service members, b) analysis of routine management data and reports, c) observation of PAs at work and PA diaries of their activities, and d) a comparative analysis of patient outcomes and costs between consultations with PAs and doctors in the minors section of the emergency department. The final work stream is a synthesis of evidence from the other work streams, which is then presented in emerging findings workshops with invitees from the research participants, the patient and public forum and other advisors to the study. Throughout the study, papers will be submitted for publication in professional and lay journals and a final report will be submitted to the funding body.

Lay abstract: This study aims to investigate the impact of including physician associates (PAs) to hospital medical teams in England. Increasing numbers of hospitals in England are employing PAs in a widening range of medical and surgical specialties. Demand for PAs from hospitals is outstripping the supply of PAs graduating from UK Universities. In response, the Minister of Health announced the doubling of NHS funded training places for PAs and there is anticipated to be 500 PAs graduating a year by 2018. Student PAs have a first degree, usually in a biomedical science, and are trained at a post graduate level in the medical model to assess, investigate, diagnose and commence or change treatment under the supervision of a doctor. PAs are a new professional group to the NHS. We previously investigated their contribution to working in general practice under the supervision of general practitioners. We found that PAs were acceptable to patients and staff, safe, effective and efficient in complementing the work of GPs. There are currently nearly 300 PAs employed in medical teams in NHS hospitals. There is little published evidence as to what work the PAs undertake in the medical teams or what difference they make to patients’ medical treatment, the quality of the service or the cost. Likewise little is known about the patient perspective on the involvement of this new type of professional in their hospital medical team or indeed the views of other professionals such as junior doctors and nurses. We propose to investigate these issues through a study with a number of work streams. We have included the views members of the public and patients in the design of our study. They raised questions as to whether involvement of a PA rather than a doctor might mean an inferior service or might mean double handling i.e. having seen a PA the consultation was then repeated with a doctor. Four interlinked research work-streams are proposed. Work stream I investigates the extent of the employment, deployment and role of PAs in hospital medical teams using two electronic surveys; one to medical directors of NHS acute Trusts and the other to PAs through their professional organisation. Work stream 2 investigates evidence of impact and factors supporting or inhibiting the adoption of PAs in the medical workforce through a systematic review of published research and review of NHS policies. Work stream 3 looks in more depth and detail at the issues by undertaking research in 4 hospitals in the West Midlands and the South of England employing some of the largest number of PAs in different services e.g. emergency departments , orthopaedic surgery , paediatric intensive care, geriatrics. In each hospital we will investigate our questions through: a) interviews with patients, managers, consultants and other members of the health care teams b) analyse routine hospital management data and reports e.g. numbers of patients treated , patient safety reports, c) observe the PAs at work and ask them to complete diaries for a week and d) a comparative analysis of patient outcomes and costs between consultations with PAs and doctors in the minors section of the emergency department. The final work stream is where we bring together the findings from all the work streams to answer our questions and issues. As we do this we will invite participants and our patient and public forum members to workshops in which we discuss the emerging findings to inform the final report.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE