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Headline
The study found that physician assistants (PAs) are acceptable, effective and efficient in complementing the work of general practitioners (GPs) in the English primary health-care workforce. PAs were judged competent and safe for the case mix of patients they attended, through consultation record review and observations. Patients reported high levels of satisfaction with PAs as well as with GPs although wished to ensure choice and continuity in primary care professional they consulted. PAs offer another source of mid-level practitioners that should be included in health service workforce planning. Consideration should be given to the appropriate level of regulation for PAs, with the attendant potential to be given the authority to prescribe medicines; this would maximise their contribution within primary care.
Abstract
Background:
Primary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs.
Objective:
To investigate the contribution of PAs to the delivery of patient care in primary care services in England.
Design:
A mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals.
Results:
The rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.
Conclusions:
PAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation.
Funding:
The National Institute for Health Research Health Services and Delivery Research programme.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Background
- Chapter 2. Methods
- Chapter 3. Findings: evidence at the macro and meso levels
- Chapter 4. Case studies: evidence from the practice as an organisation
- Chapter 5. Case studies: evidence from the consultation records and linked patient surveys
- Chapter 6. Case studies: evidence from the clinical review of consultation records and video observations
- Chapter 7. Case studies: evidence from interviews with patients consulting a physician assistant
- Chapter 8. Discussion and conclusion
- The deployment of physician assistants in general practice
- The impact of including physician assistants in general practice teams on the patients’ experiences and outcomes
- The impact of including the physician assistants in general practice teams on the organisation of general practice, the working practices of other professionals, relationships with these professionals and the practice costs
- Factors supporting or inhibiting the inclusion of physician assistants as part of English general practice teams at the micro, meso and macro levels
- Evidence synthesis
- Limitations
- Conclusions
- Recommendations
- Acknowledgements
- References
- Appendix 1 Advisory group membership
- Appendix 2 National Institute for Health Research health research management fellow report
- Appendix 3 Search strategy for PsycINFO
- Appendix 4 Patient survey
- Appendix 5 Coding for clinical records
- Appendix 6 Research team classification of the presenting problems for the individual patient
- Appendix 7 Appropriateness of the consultation review
- Appendix 8 Unit costs used in calculation of practice-level costs
- Appendix 9 List of commentary papers reviewed, by year
- Glossary
- List of abbreviations
Article history
The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 09/1801/1066. The contractual start date was in August 2010. The final report began editorial review in March 2013 and was accepted for publication in October 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.
Declared competing interests of authors
none
Corrections
- This article was corrected in March 2016. See Drennan VM, Halter M, Brearley S, Carneiro W, Gabe J, Gage H, et al. Corrigendum: Investigating the contribution of physician assistantsto primary care in England: a mixed-methods study. Health Serv Deliv Res 2016;2(16):137–138. http://dx/doi.org/10.3310/hsdr02160-c201603.
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