Findings at the micro level: perspectives from hospital senior managers and clinicians

The following six chapters report the findings from workstream 4: the micro level of the study within six hospitals. The research questions (see Chapter 1, Aims and objectives) of deployment and factors supporting and inhibiting PA employment, as well as impact on patient experience and outcomes, organisation of services, working practices and training of other professionals, relationships between professionals and the service costs influenced by deployment were investigated and were reported from different perspectives (see Chapters 4–9). Chapter 10 reports on the pragmatic comparison of patient records for patients attended by PAs and doctors in training in the ED.

This chapter presents the findings from the perspectives of senior managers and senior clinicians in the study hospitals. These were senior members of staff responsible for the strategic direction and management of the hospital and its services, as well as individuals with specific leadership roles in relation to the workforce, professional leadership and medical education and/or PAs. Telephone interviews were undertaken with 21 senior leaders in all of the six hospitals (Table 8). Eight participants were women and 13 were men.

The involvement of senior managers and clinicians in the employment of PAs in their hospitals reflected their respective roles and length of time in their particular trusts. Senior managers and clinicians without a specific lead role had sometimes had prior involvement in the education of PAs or exposure to the use of PAs elsewhere. The consultants with lead roles responsible for PAs each had some previous involvement with PAs, which motivated or inspired them to champion and develop the role. This prior involvement included observations in US hospitals with extensive use of PAs, having PA students on placement and working with PAs while a registrar elsewhere.

Aspects of the participants’ current involvement with PAs included:

• making decisions at a director level to employ PAs
• oversight of employment issues
• promotion of the PA role and the deployment of PAs
• promoting the training of PAs
• involvement in governance issues (particularly MDs)
• setting strategy and developing budgets for the inclusion of PAs.

Irrespective of the hospital, there were similarities in the participants’ views and reported issues, with very few differences. We first present evidence about factors supporting the employment of PAs, issues on governance and then factors inhibiting the employment of PAs. We then turn to report on the perceived impact and contribution of PAs. Finally, themes concerning the development and retention of PAs are described.

Factors supporting the employment of physician associates

In this section, we consider the themes concerning factors supporting the employment of PAs, including issues shaping the decision to employ PAs, decision-making on PA posts and factors for successful adoption and implementation of PAs.

Issues shaping the decision to employ physician associates

Some people spoke explicitly about why PAs had initially been employed in their trusts, whereas others referred to it indirectly in the context of discussing the impact of PAs on the organisation of services. Necessity, in order to address four problems, was the most commonly cited reason for beginning to employ PAs:

1. To address a decrease in the availability of junior doctors and an over-reliance on locums to cover medical shifts.
2. To ensure that junior doctors were able to pursue their training rather than being diverted to cover service rotas – an issue that had been the subject of a deanery review in one trust.
3. To address an increase in workload and challenges in ensuring sufficient medical team presence on inpatient wards.
4. To improve quality of care; this included the necessity to improve the performance of a hospital under scrutiny by the CQC.

Some participants described the problems particularly in relation to shortages of doctors to meet service requirements as ‘a crisis’ or a ‘burning platform’. Many participants discussed redesign of their workforce as an ongoing process. One reason given by some for considering the employment of PAs was to find new sources of staff and not to deplete other groups that had their own shortages:

We’ve looked, over the last 5 years or so, very hard at what work actually needs doing rather than which members of the workforce should be doing it . . . But as time goes on the workforce in every department is limited and so to move pharmacists or nursing staff across to do what have traditional previously been medical roles, means that we’re then robbing another profession of their workforce which they desperately need as well.

Decision-making when creating physician associate posts

Most clinicians and senior managers described decisions concerning actual posts for PAs (or others) as being departmentally driven by local assessment of need rather than within an explicit strategic framework:

We have a devolved clinical structure here. It’s up to the clinical business units to decide really on the model of care and the resource that they believe that they need to be able to manage that.

Only one of the trusts was reported to mention PAs in their workforce development strategy: this is perhaps a reflection of the decentralised approach. At the departmental level, the process was thought to be both considered and opportunistic. Some thought that decisions were often partly principled and partly pragmatic, based on the availability of those with advanced clinical skills and financial considerations. One MD even described the process as ‘completely irrational’, although they thought that it worked well enough.

It was also suggested that people tended to employ staff in roles with which they were already familiar: opting for nurses when colleagues were familiar with the extended nurse role and for PAs when they had encountered PAs before. Other factors, such as the source of the funding for a post, were also reported to be influential. A senior nurse manager explained:

So if we’re using medical money and it’s covering the medical rotas then it has to be a PA rather than . . . a nurse consultant or an advanced nurse practitioner.

Some interviewees focused on the skills and attributes that were needed and which professional group was likely to have them:

PAs have got those general medical skills, so for example, if on an orthopaedic ward somebody was poorly, a PA could sort that out I think. They could take a history, they could do an assessment, they can do an examination, they can come up with a management plan and I think they could decide what investigations to get. Now, I think it’s pretty unusual that a nurse, an ANP [advanced nurse practitioner] would be able to do that . . . what the nurse practitioners are very good at doing is working to protocol for a specific problem like chest pain or COPD [chronic obstructive pulmonary disease].

Given the relative newness of the employment of PAs in secondary care, it was unsurprising that some people noted that the situation was evolving and the use of PAs, alongside other staff, was developing in new specialties.

Successful inclusion of physician associates in the workforce

A wide range of factors were identified as supportive of or conducive to the successful employment of PAs.

Organisational factors

Having the necessity for introducing a change in workforce widely recognised by the senior staff in the organisation was seen as conducive. However, more specifically, the need for support from the top of the organisation was repeatedly stated. This support was from both individuals at the highest level of the organisation (e.g. joint support from medical and nursing directors) and organisational statements and commitment of resources, such as:

• organisational willingness to embrace cultural change
• organisational commitment to quality improvement
• organisation-wide staff engagement programme to encourage acceptance of PAs
• management support for the business case, particularly if the introduction of PAs needed initial additional finance
• opportunities for sharing learning from what has worked between different departments
• identified clinical champions at a senior level.

At the clinical unit or department level, it was considered important to be precise about what was needed and how PAs offered that as well as how they fitted into existing structures. A track record of being innovative was also thought to bode well for the likelihood of welcoming new roles. Clarification about reporting arrangements was also considered to smooth the introduction of PAs. Occasionally, there was a perception that clarity about what was required had not been fully achieved and that PAs had been ‘dumped in’ and then problems had to be sorted out. A number of senior clinicians also cautioned against seeing PAs as ‘a quick fix to medical staffing problems’.

The review of hospital trusts’ public documents (i.e. annual reports, board minutes and operational plans) demonstrated variation between them in the extent of visible senior management and clinician support and resources. In two trusts, there was documented evidence of the chief executive’s and chairperson’s support and celebration of the ‘pioneering’ and ‘innovative’ work within their trust to develop a PA workforce and PA education. Three trusts reported partnership working with other organisations to secure funding and create educational opportunities for PA students and internship posts. By the end of the study period, five trusts had documented descriptions of including and increasing the number of PAs in their workforce planning for their medical establishment.

Understanding of and response to the physician associate role

Understanding the role of PAs by others in the service was reported as important. It was thought to be made easier when people had been exposed to PAs through previous practice or by working with PA students on placements. Many people described the growth of understanding through familiarity as PAs and other health professionals worked together. One person saw advantages of being a relatively small organisation in which people know each other and in which PAs stayed as members of teams for long periods.

In some trusts, considerable efforts had been made to improve the understanding of PA roles. Activities included:

• information giving at consultants’ meetings
• coaching for the whole team on working with PAs and what they do
• explanations of the PA role given to junior doctors during inductions
• publicly displayed posters introducing PAs
• promotion of sources of information about PAs.

Clinicians and senior managers either recalled no particularly problematic relationship issues or attitudes, or – more commonly – spoke of initial resistance and concern from groups such as nurses and junior doctors, most of which dissipated as people became familiar with the new roles. Some staff were reported to be positive about having PAs as part of the team, particularly in the context of effective multidisciplinary team working. We return to this in Factors inhibiting the employment of physician associates.

Valued attributes of the physician associate role

Some aspects of the PAs and their roles were described as particularly valuable and valued by doctors and other staff groups, for example:

• The fact that PAs were trained in the medical model.
• They supported new junior doctors and freed up their time.
• PA training promoted caring qualities as well as academic standards.
• They offered enhanced skills and different skills to doctors and would, therefore, be valuable even if there was not a medical recruitment issue.
• Their adaptability and flexibility.

One MD said:

So there’s so much they can do in terms of clerking patients, listening to patients and organising things and doing practical things. And it’s not just that they free up doctors to do those things that only doctors do, it’s much more about the positivity of what they bring.

A number of the PAs were essentially pioneers in new roles, so some people considered that it was difficult to know how important personal factors might turn out to be in the longer term. It was thought to be good to have a substantial number of PAs in a trust for mutual support and as role models for one another.

Governance issues

It is worth reviewing comments made about governance issues, as these are relevant to both what was considered to work well in employing PAs and what was considered not to work so well in employing PAs. The lack of regulation of the profession was particularly relevant and linked to issues of clinical governance within trusts. The prospect of the regulation of PAs was seen as positive and, indeed, by some, as essential.

In so far as they were discussed, it seemed that trust boards generally were not profoundly involved with the governance arrangements. Typically, detailed work on PAs, including governance arrangements, was taken on by designated PA boards or committees, which had sometimes had changes in leadership. MDs were commonly the link between the PA board and the trust board.

The issues that PA boards or committees considered included:

• setting up structures (e.g. deciding whether PAs come within medical or nursing administration)
• the scope of PA roles (i.e. addressing what they could and could not do)
• clinical supervision arrangements
• reporting lines to management on non-clinical issues (e.g. leave and rotas)
• encouraging the organisation with using PAs
• issues in relation to PAs not being able to prescribe or order ionising radiation
• the ways in which PAs could work with others [e.g. advanced nurse practitioners (ANPs) and prescribing pharmacists]
• arrangements for PAs continuing education and study leave.

As mentioned previously, many of these issues linked to factors inhibiting the employment of PAs, which are considered in the following section.

Factors inhibiting the employment of physician associates

Senior managers and clinicians identified the following issues as inhibiting the employment of PAs in secondary care or making it more difficult. These were the lack of regulation with the concomitant lack of authority to prescribe and order ionising radiation, attitudes of others, the lack of PAs to recruit and lack of clarity on governance issues. It should also be noted that one MD thought that too many people focused on the negatives in relation to PAs and one senior manager perceived no negative factors in relation to employing PAs.

Lack of statutory regulation

Senior managers and clinicians saw the absence of regulation as a potential obstacle, particularly as it was associated with a lack of prescribing rights and the right to order ionising radiation. Some senior clinicians felt that it was more important to stress what PAs could do and contribute, rather than dwell on what they could not do. It was viewed by all as a very unsatisfactory situation, described by one senior manager as ‘absolutely bonkers’, explaining that the PAs ‘can put, you know, a chest drain in a patient but they can’t prescribe paracetamol’. This situation was felt by many to detract from the utility of the PAs to the medical team and the service:

I think a number of our consultants kind of stopped at the point where you said ‘Well they [PAs] can’t prescribe and they can’t ask for X-rays’, and metaphorically threw their hands up and said ‘Well what use are they going to be for me then?’.

It was thought by many that PAs’ roles were better suited to some contexts and specialties than others, although there was no consensus as to what factors might be positive or negative in this respect.

Attitudes of others and lack of understanding of the role

Almost all of those who were interviewed mentioned the culture of the organisation and the attitudes of other staff as hugely important. Negative attitudes towards new roles were seen to potentially hamper the successful utilisation of PAs. Clinicians and senior managers spoke of initial resistance and initial concerns, most of which dissipated as people become familiar with the new roles. In one trust, it was said that older consultants were starting to welcome PAs, although that was not their initial position, but that they saw the benefits in practice. Some who were resistant or initially unenthusiastic were reported to have become became advocates for the role. In some trusts, there were reported to have been some issues from some junior doctors and nurses concerned or opposed to the deployment of PAs. For the most part, the interviewees reported not so much outright opposition as ‘puzzlement’ and general lack of understanding of what PAs were and what they could do. To some extent, this was also reported to be more of an ongoing issue among doctors in training as they rotated from one hospital to another and had to become familiar with PAs. A number of interviewees considered that there was also some residual suspicion among doctors that PAs might be seen as cheap labour. The advent of PAs as new members of the workforce at an unsettled time for junior doctors when their new contract was being negotiated was considered to have led some to view the PA role with suspicion and concern. This was reported to have largely dissipated as staff came to see the value of PAs.

It was generally argued as unhelpful to view PAs in terms of substitution for junior doctors; however, it was also recognised that this view was not easy to reconcile with reasons given for the introduction of PAs to the workplace (i.e. reasons were often framed in terms of the lack of junior doctors to fill rotas). Interviewees pointed to the types of actions taken to ensure the successful inclusion of PAs in the workforce, described in Successful inclusion of physician associates in the workforce.

The final point that was raised in relation to factors inhibiting employment was the lack of PAs in the UK to recruit.

We turn now to report on the perceived impact of the PAs.

Contribution of the physician associates

The impact of PAs had not been specifically evaluated in any of the hospitals. The general view was that it was hard to separate out PAs from the rest of the team. None of the senior managers could offer routine management data or reports that could quantify impact or costs.

However, all interviewees were able to offer their perceptions of the impact of PAs in contributing to the safe running of the service, greater efficiency, continuity of care for individual patients and continuity across the organisation, and service improvements. In the context of a shortage of junior doctors, the presence of PAs contributed to the safety of the service:

I’ve had times when I’ve been on the wards and for various reasons . . . all the juniors have been away, I’ve had a PA there and actually with a consultant and a PA you can cope . . . so you know, having a PA is absolutely vital and I’ve certainly managed a ward for several days with myself and a PA and felt it’s all been pretty safe.

The PAs were reported to contribute to service efficiency through supporting doctors and nurses. Specific examples were given:

• PAs working shift patterns to complement the junior doctors that enabled an outpatient clinic to extend its hours with greater patient throughput.
• Increased patient flow through the ED.
• Improved access for nurses to raise concerns about a patient to a member of the medical team (e.g. when all the doctors were in theatre).
• In some areas of work, PAs were considered to free up consultants’ time.
• PAs were also considered to contribute to the hospital meeting national quality targets (e.g. on discharge processes and ensuring policy).

Their presence on the inpatient wards was considered to offer continuity to the medical team that, in turn, supported good patient experience:

I think that they are the glue that pulls the team together, I think they’re a constant source for the nurses for advice and, you know, keeping the patients cared for.

There were no quantitative data offered and there was a commonly held view that it was difficult to disaggregate the impact of individual types of staff in team and department provision. Generally, positive answers drew on the PAs’ apparent popularity with patients and the lack of complaints: in some hospitals, PAs were thought to be effective at nipping complaints in the bud. There had also been some positive feedback (e.g. on a hospital website and from surveys of patient satisfaction). In addition, one chief executive noted that the CQC was happy with PAs.

There was a suggestion that the satisfaction levels of junior doctors in one service area had improved because of the pressure being lifted by the presence of PAs. A few people made particular mention of the impact of PAs on medical education. One MD recalled that he had been initially aware of both positive and negative views on the possible impact on junior doctors’ training and that to some extent views remained mixed. However, generally senior managers and consultants felt that concerns about PAs possibly taking training opportunities away from junior doctors were unfounded, and it was more likely that the role of PAs in service delivery actually freed junior doctors for training. PAs were reported as also contributing positively to the training of junior doctors: in induction, in helping them to understand hospital procedures and sometimes in procedural skills.

Therefore, this group of senior managers and clinicians viewed the PA contribution as positive. However, some also cautioned that to develop the PAs to their greatest utility and also to retain them required investment from the organisation beyond the support for initial introduction. Some of these elements were identified in Governance issues, such as ensuring appropriate clinical supervision. We now discuss the interviewees’ perceptions of the longer-term issues of retaining this staff group.

Developing and retaining physician associates

Senior managers and consultants, with one exception, shared the view that PAs might feel that they lacked career development opportunities. Pay and other factors were considered as relevant, particularly in areas where the cost of living was high. Although recognising a relatively flat career structure, PAs were thought to enter at a relatively high NHS salary level. Some made the point that the assumption that PAs might rapidly leave in order to train as doctors had not been borne out. Some pointed out that the flat career structure of PAs was not unique within the NHS; for example, consultants also tended to have a flat career structure, typically taking a consultant post in their thirties. Although, taking a different view, a chief executive argued that that young people do not think so much in terms of careers for life, so doctors may not stay in medicine and all kinds of changes were needed to maintain a medical workforce. Some considered that it might not be helpful to make comparisons with doctors’ careers; rather, it may be more useful to look at some of the newer roles, such as paramedics and operating department practitioners, who faced similar issues.

Although noting that some PAs wished to continue as they were, with a focus on practical, hands-on care, a variety of observations were made as to how individual hospitals and services provided or were considering providing career development for PAs. These included:

• opportunities to work across different areas, thereby developing their skills and providing variety to their workload
• opportunities in quality improvement and patient safety projects
• senior PA roles for a group of PAs.

Training opportunities were considered essential, and there were examples of shared training with junior doctors and with nurses. One trust gave PAs an annual training bursary. A final observation from some was that career development may become a bigger issue once PAs have been in post for longer periods and more PAs are in posts.

Summary

Senior managers and clinicians described the shortages of doctors together with a need to ensure quality in services as the driving forces in introducing new roles at advanced clinical practitioner level. PAs were only one group that they were considering, but they were mindful of depleting other groups, such as nurses, that were also facing shortages. A variety of change management strategies were described, although not all in place in every hospital, to ensure the successful introduction of this new group. The main inhibitors to employment were thought to be the lack of regulation, with attendant lack of prescribing rights, and the lack of knowledge (with attendant puzzlement rather than hostility) about the role among other staff. Where PAs were employed, they were reported to make significant contributions to efficiency in the organisation and continuity of care for the patients. The lack of PAs for the growing number of jobs meant that PAs could easily move to jobs that offered greater career development. Introducing PAs into a workforce was known to require support structures, ongoing training and provision of appropriate clinical supervision and mentorship. None of the participants were able to quantify impact or costs. They all pointed to the difficulties of separating individual impact/contribution from a team endeavour.