Findings at the micro level: perspectives from the doctors

This chapter presents the findings from the perspectives of the doctors working with the PAs. Forty doctors were interviewed across the six study sites: 23 senior doctors (i.e. consultants), 10 middle-grade doctors (i.e. registrars and senior specialty doctors) and 7 early-career doctors (i.e. Foundation Years/core training doctors). They worked in a wide range of specialties (Table 11).

Overall, the analysis was concerned with the way in which PAs work within the teams of doctors, the understanding of their role, the level of work undertaken and views on the perceived impact or contribution to the service as well as to medical training.

We commence with the consultants’ accounts of why PAs have been employed in their services and then turn to descriptions of the work and role the PAs were fulfilling. We describe their views on the contribution made by PAs and of patients’ attitudes to PAs, before turning to factors inhibiting working with or employing PAs. The chapter ends with a discussion of views on the measurement of the impact and costs of PAs.

Factors influencing the employment of physician associates

Most consultants described the main driver for employing PAs initially as a shortage of doctors to cover the medical rotas for their service. They indicated that this shortage had come about through a set of interconnected demand and supply issues: the enforcement of the working time directive on junior doctor hours, the 2016 junior doctors’ employment contract, changes in medical education requirements, reduced numbers of junior doctors in training, difficulties in obtaining visas for overseas doctors as well as the expansion of their service:

We introduced them because of junior workforce doctor issues. So fewer junior doctors being given training numbers and we foresaw that we were going to expand and that we would probably need more junior doctors or more, more people on a junior tier.

Most accounts described the employment of PAs as addressing two main interconnected issues:

1. providing sufficient medical team presence, particularly on inpatient wards during the daytime, to ensure high-quality, efficient and safe patient care
2. ensuring that junior doctors in training were able to meet their training requirements without detriment to the service needs.One is continuity of care at junior level. People are doing full shifts and so covering wards are quirky . . . You needed somebody who understands the team, who’s a member and part of the team, who knows the ethos of the team, to be able to be there at all times. That was our thought anyway before we employed them [PAs], in that they would be ward based, team based, and they will be there at all time.ID 114, consultantYou can’t just have them [doctors in training] now doing ward work, that’s not seen as educational or part of their training. They have to be more involved in various other things . . . So that is where PAs come in, for ward work.ID 68, consultantSeveral of the consultants described that although the initial impetus was to address staffing shortages, it had become evident over time that PAs, particularly experienced PAs, could contribute in a range of ways to service delivery:[There was] a specific problem to do with excessively long clinic times for complex clinics, which I do one a week, my colleagues each do one a week, [PA name] will come along to these now and she will see these patients and, effectively, she’ll be like another SHO [senior house officer] or another registrar in clinic.ID 125, consultantThey also described the way in which this innovation was then taken up by other consultants and services as they observed the contribution the PAs made:I think consultants started seeing the possibilities as to where else you can use them [PAs] . . . and then everyone goes ’ah, oh they’re quite good, I want one of them, they could do all this and this for me’.ID 119, consultant

There were consultants who described their ideal team as one staffed with a skill mix of doctors, PAs and other advanced practitioners.

However, at the other end of the spectrum of opinion were a small number of consultants who, having tried PAs as an innovative solution to medical staffing problems, reported not favouring replacing them in their specialty when the current PAs left. Some other consultants reported that they were aware of PAs not being replaced in other departments when they left. These were specialties with high-dependency patients requiring frequent medical procedures and changes in medication. We discuss this in more detail in Factors inhibiting working with and employing physician associates.

Many of the consultants described trying out a variety of new workforce roles. Some consultants reported trying clerical support roles to doctors, such as medical assistants, but ceasing these in favour of PA roles, valued for their clinical knowledge and input. In many of their services, there were also a range of other mid-level posts, such as ANPs, clinical nurse specialists and prescribing pharmacists. In particular, many consultants preferred to use a mid-level profession such as a PA, with their training in the medical model to work in a medical team, because of the work and role they required of them. This was not to say that they did not value the other types of role and described the work as complementary in delivering high-quality and safe patient care. This links to the next theme of the actual work and role of the PAs.

The work and role of the physician associates

The doctors in all of the medical and surgical specialties, apart from emergency medicine, reported that PAs mainly undertook inpatient ward work:

I see our PAs’ role based on the inpatient workload, and delivering the inpatient work, and the quasi-medical management of the patient.

So the main role of the physician associates is the running of the inpatients and the preoperative work-up for the patients coming for surgery that week.

The level that they worked at was described as equivalent to a spectrum across Foundation Year doctors and senior house officers (SHOs):

They’re pretty much equal to an FY2. Some of them are almost equal to senior SHOs, after finishing the core training level.

Some of the consultants emphasised that the focus and clinical level to which PAs worked was dependent on the individual’s experience and in-post training. Newly qualified PAs were described as needing support and further in-work development to build their skills and knowledge in that specialty. In one trust, PAs were offered the opportunity to work in different departments to broaden their knowledge and skills.

Building trust in the competency of the individual PAs was a process reported by all three groups of doctors:

When our first PA started, clearly as doctors we weren’t entirely sure, I think a lot of us, what PAs could or could not do. And I think we’ve realised how competent our PAs are and how trustworthy, it’s been, you know, a revelation, we’ve been able to give them more and more jobs to do.

Yeah. The good thing with [name of PA 1] and [name of PA 2] is that I know them, and I trust them and it’s a really good thing because I know they have deep clinical knowledge, so I don’t need to check again the patient if they’re telling me something about the patient.

I wouldn’t inherently trust them [PAs in a specialty she had just started working in] because of their job title. If I had asked the PA on the [specialty] ward I would trust him, not because of he’s a PA but because I’ve seen him, I’ve heard him, I know what he’s like and I trust him.

Consultants reported that there had been no patient safety incidents involving PAs. All of the doctors considered the PAs who they worked with to be clinically safe, often citing the PAs as appropriately seeking advice or alerting them to a patient’s deteriorating condition:

Yeah, and they are very careful, they know their limits and they will, you know, just ask for help.

All of the consultants and mid-grade doctors described their supervision of the work of the PAs and junior doctors as integral to the work of the team. The type of specialty and the organisation of the medical team were reported to determine the extent of clinical decision-making by PAs and others. For example, in some specialties, all clinical decision-making was undertaken by the consultants and senior registrars:

I think we are quite senior led, as a general rule . . . for example, where our sickest patients are, they would be seen every day by a consultant, and most of the decision-making is taken away from even the senior registrar . . . and then for the other patients, we do operate a system where our department wants the senior registrar to see every patient every day.

This senior-led decision-making contrasted with other specialties, such as emergency medicine, in which the PAs were expected to be able to assess, plan and manage certain types of patients, seeking senior advice as necessary:

They’re quite independent, they do a lot of the work themselves; sometimes they come and ask us as registrars like questions just to confirm certain things or like prescriptions. But on the whole, they pretty much do everything, see their own patients and they’re just like a normal member of the team really.

A few doctors reported some confusion regarding whether most junior doctors in the team were supervising PAs or working alongside them, a situation compounded by the junior doctors being asked to authorise prescriptions and ionising radiation for patients seen by the PA. We return to this issue in section Lack of authority to prescribe medicines and ionizing radiation. However, it was also linked to the extent to which the PA role was understood:

I think the challenges that we have had is when people haven’t understood what a PA is and what they’re not, and we’ve just had that a couple of times in that some of the doctors haven’t sort of understood what [name of PA] can do and how she sits within the team, and that’s created a little bit of tension that we’ve had to iron out just a couple of times.

Some of the consultants described making it explicit to the new doctors in training about the role of the PA(s) in their team:

So when the junior doctors start, I explain to them what a PA is and how I view them in the team.

Although some of the mid-grade doctors and early-career doctors also reported this type of introduction to the PAs in the team, others described a more ad hoc form of learning about the role, their place in the team and activities that they could (or could not) undertake. This was either from the PAs themselves or through observation of the PAs working in the team:

I think I’m kind of learning through being with them, but I don’t think anyone has ever said what their role is.

Many of the early-career doctors were familiar with the PA role through previous jobs or placements as medical students. They recognised that there was variation in what PAs were allowed to do and that this was something they had to understand early on in that job:

I just had to clarify . . . what they were and weren’t allowed to do, because I think depending on both experience and other bits and pieces, and also what the trust says a PA can and cannot do differs slightly between trusts.

One mid-grade doctor described uncertainty as to what the intended parameters of the role were and queried whether or not the scope of individual PAs had increased over time in an unplanned way. Some of the consultants reported that not all consultants agreed with each other as to the presence of the PAs, the procedures they were allowed to carry out or their position in the team:

I think there still is probably a split among the consultant staff as to what the role of a PA is precisely. I’m not sure that that’s even explicit within the consultant staff what people are happy for them to do and what people aren’t happy for them to do.

We return to this point in section Some specialties with high-dependency patients. First, we consider the consultants’ views on the overall contribution of the PAs to the medical team.

Overall view of the contribution physician associates made

Most consultants provided a positive view of the contribution that PAs made within their specialty. This was echoed by the middle-grade and early-career doctors:

They work alongside our junior doctors, support the junior doctors, and are clinically very valuable. Well, almost invaluable now.

So my experience with PAs has been very good, they are a really important part of the team.

The ones [PAs] that we have here are really good, yeah and they’re very useful.

As noted previously, there was a small number of consultants who had a less positive view, which we return to in section The negative views of some doctors and some senior nurses about physician associates.

The contribution of PAs was described by the doctors in terms of (1) supporting good, safe and efficient patient care and (2) supporting the junior doctors in training. The doctors described different ways in which they saw the PAs contributing to the medical team’s work, which we have grouped into five interlinked themes. These were:

1. providing continuity and stability in the medical team
2. undertaking some of the doctors’ workload and filling gaps in rotas
3. enabling doctors to focus on patients who were more acutely ill, were more complex or required assessment or procedures that only doctors could undertake
4. supporting patient flow
5. induction of doctors in short-term training posts and supporting release for training activities.

Providing continuity and stability in the medical team

All of the doctors described the PAs as bringing continuity and stability to the medical team by virtue of their working in one place with one team mainly during weekday daytime hours, in contrast to the junior doctors in training. This meant that the PAs were knowledgeable about the consultants’ usual clinical management, clinical guidelines, trust systems and infrastructure, and this contributed to good and safe patient care:

Our SHO-equivalent doctors rotate all the time . . . so what they [the PAs] really provide is this amazing continuity of how the system works . . . how we care for patients who’ve had [specialty] procedures, how we manage patients with different [specialty] conditions.

Junior doctors’ shift patterns meant that they could be absent from the wards for some days, during which period the patients or their condition could have changed. PAs were reported to be an important means for ensuring that the rest of the medical team had up-to-date knowledge about the patients:

It’s that continuity, like I’ve been on call so I’ve not been on the ward for 5 days, I’m like ‘what’s going on?’ and they’re [PAs] like ‘7 and 5 are the sick ones and 10 is the one we’re trying to get out’. And like they know that and that’s very helpful.

Some of the doctors in all groups commented that their continuous presence on the wards meant that the PAs knew the patients and their histories very well, which was an asset to the team, both for patient outcomes and in efficient use of time:

If I have an elderly patient . . . my PA knows what their needs are and everything. So, that makes a big difference for us to make the decisions. So, there’s a good outcome for the patient.

Yes, they’re [the PAs] the continuity, so, and when they go on holiday, it’s a strange experience . . . So, I had one of them on annual leave when I was last covering all the ward patients, and actually it meant that I had to find every single thing about these patients myself, because the SHO had moved into the ward at the same time as me, and the PA normally filled that gap.

Nurses on wards were reported to find the continuous presence of the PAs helpful, for example in accessing a member of the medical team:

What nurses want is help if they need some support outside their area of expertise, and they want medical input . . . their assurance comes from knowing they can call someone. The great thing about our PAs is they’re available . . . They’re not stuck in theatre, they’re not in clinic and they’re the conduit to us, and that works very well.

Continuity and stability were also linked to the ways in which PAs contributed to taking some of the medical workload; we now turn to this issue.

Undertaking some of the doctors’ workload and filling gaps in rotas

Many of the doctors across the three groups commented on the PAs’ positive contribution in managing the workload of the junior doctors, and that PAs were missed when they were not on duty:

The experience that I’ve had is that they do make sort of your junior doctor’s day-to-day workload considerably lighter.

I will say that whenever she is not here I miss her and without her it becomes quite difficult at times to manage the ward or do our usual daily work.

Although it was not clear in many instances whether the PAs were in addition to the numbers of early-career doctors or substitutes for a doctor’s post, some of the early-career doctors could quantify the impact of the absence of PAs on their workload:

It just takes me longer [without a PA], when I first started here I would often leave reasonably on time, but then as PAs started leaving, that time got later and later, and now commonly I’m leaving an hour and a half or 2 hours or more later.

Several doctors commented on the benefit to patient care of utilising PAs compared with having locum doctors:

Better for patient safety to have the PAs than using people that you don’t know, locums coming in can create chaos.

Although the 2016 junior doctor strike was an unusual event, two of the middle-grade doctors described how the PAs, working with the consultants, had been invaluable in patient care during that time. A more commonly reported experience was that the PA presence enabled doctors to attend the more complex patients.

Enabling doctors to focus on patients who were more acutely ill or more complex

Doctors in all of the groups described the ways in which a PA presence in the team allowed them, and other doctors, to focus on the more acutely ill patients, or those requiring more medical knowledge or requiring procedures that only doctors could undertake:

They’re [PAs] just great at coming in and just taking off those little jobs that will really slow you down unnecessarily and paving the way for the more important sicker patients to get more of your time and attention.

And then for example if you get very complex patients that need us [the doctors] then we can see them and then when you’ve still got a busy department you’ve got trust that actually they can carry on, the PAs, to see the other patients. So you’re not having to then worry, you know that actually you’ve got team members who can see them, so it keeps the flow.

The presence of the PAs in the team positively assisted in ensuring that individual patients, and consequently their patients as a population, progressed. This referred to a progression both in their treatment plan and also physically through and out of the hospital. We use the term ‘patient flow’ to describe this concept and discuss this theme next.

Facilitating patient flow

Many of the consultants and middle-grade doctors described the PAs as a positive addition to the medical teams’ ability to efficiently manage the patient flow and deliver a good patient experience:

[The PA] helps the ward round flow and when the ward round flows, jobs get done earlier and when jobs get done earlier, people leave the hospital earlier because everything happens a bit more expediently.

Some of the doctors described this in the context of two types of complexity. The first was the complex system of modern health care with advanced technology and diagnostics. The second was the complexity of the lives of sections of the patient population using the services, including the increasingly aging patient population. This next example describes this interaction and the perceived benefit of the PAs in the team in ‘smoothing’ the processes:

The kind of very advanced care that we can offer to patients in hospitals, it’s such a complex system . . . it brings a multitude of logistical challenges . . . to liaise within teams, to liaise with other departments, to book a test, to get in touch with a GP, to book a bed for a patient which [sic] is frail and elderly, which [sic] need antibiotics a few days before, comes from far away . . . and they [the PAs] can really help for that organisational aspect a lot, and also help in the more clinical aspect . . . I think they [the PAs] smooth things out with many issues that need to be prepared and planned for.

Another doctor described the way in which the PAs added to this smoothing of medical care using a mechanical metaphor with the PAs acting like oil:

I don’t think it’s a problem when they’re [the PAs] not there, it’s just better when they are. They’re the lubricant as opposed to, you know, the actual engine.

Another way in which the PAs were seen to contribute to patient flow was through the induction of new doctors in training.

Induction of doctors in short term training posts and supporting release for training activities

All doctors described the frequent movement of doctors in training to new teams, departments and hospitals. Many of the consultants and middle-grade doctors described the PAs as important in the induction of doctors new to their service. In some cases, this was a role that was formally assigned; in others, it was viewed as a more informal process in the course of working together:

So, whenever new junior doctors come in, my PA has to become their trainer, to train them how we work in this ward . . . there are a few things we have to do very specifically in this team.

The middle-grade and early-career doctors confirmed how helpful they had found the PAs during this period and considered that they had not only helped them personally but also helped patient experience and team efficiency. Some of these doctors described how it was easier, and preferable, to ask a PA about hospital systems and ‘lower-level things’ than to bother a senior doctor.

Some of the consultants and middle-grade doctors noted that the presence of the PAs on the wards allowed the Foundation Year and core trainees to leave the wards to attend other training opportunities, such as in the clinics and theatres. This was said with the proviso that the overall medical staffing level was adequate. Some of the early-career doctors confirmed that this was their experience:

Having the PAs frees me up because as trainees we like to go to clinics.

There was some discussion by a few of the early-career doctors regarding whether or not their learning opportunities to undertake certain procedures were restricted as the experienced PAs were competent in these. There was some speculation regarding whether or not consultants would prefer their experienced PA to carry out these procedures rather than teach each new junior doctor:

If they [PAs] get really good at that [procedures and assisting in theatre] and it’s much easier for the senior doctors, the consultant to say ‘I’d rather have the PA in there, because I don’t have to teach him, he’s done it a thousand times, I want him there’. Rather than get the junior doctor who’s never done it, he has to take time and – if they just fit in the niche, when do we get the opportunity to learn those skills and procedures?

One middle-grade doctor suggested that she had observed such situations. However, other early-career and middle-grade doctors described the ways in which learning opportunities were given to doctors in training by their seniority and there was no ‘competition’ with PAs for opportunities. More than one consultant noted that the workload was such that learning opportunities were plentiful and they remained cognisant of the importance of teaching their doctors in training.

We turn now to the doctors’ views as to patient responses to the presence of a PA in their team.

Patient responses to physician associates in the medical team

Most of the doctors reported that patients and family members were very positive about the PAs’ contribution to their care. They attributed this to factors such as communication style, constant presence on wards, accessibility and reliability:

They’ve got very good feedback from the patients . . . I’ve heard parents complimenting [name of PAs], the way they talk and the way that they’ve been looking after patients. I’ve never heard any of the doctors being complimented by the patients.

However, most doctors thought that patients, despite their best efforts in providing introductions, did not understand exactly who or what the PAs were, other than a member of the medical team. They reported that the PAs were always introduced and introduced themselves to patients as such. One doctor described formal introductions by the consultants as part of the ward rounds to separate doctors and PAs:

So normally I’m used to introducing myself as [interviewee first name], I’m a medical doctor, but when the consultants are introducing you to the patients it’s ‘This is Dr [interviewee surname] my medical registrar, this is [PA first name], the PA’, and making it really clear that [PA first name] is not a doctor.

Some doctors reported that patients very occasionally asked for explanations of what a PA was but most just accepted them as part of the medical team.

Factors inhibiting working with and employing physician associates

Overall, although the doctors were positive about the contribution of PAs, there were aspects they identified as negative and potentially inhibiting to their employment:

• lack of authority to prescribe medicines and ionising radiation
• some specialties with high-dependency patients in which the knowledge and skills of doctors, rather than PAs, were considered more useful to the overall work of the medical team
• lack of PAs to employ and issues in retention
• the negative views of some doctors and senior nurses about PAs.

Lack of authority to prescribe medicines and ionising radiation

All of the doctors, when asked if in their view there were factors that inhibited the employment of PAs, cited PA inability to prescribe medicines and order ionising radiation. For some, this was a drawback rather than an absolute reason not to employ or work with them. Most described practices whereby the doctor working with the PA wrote the prescriptions and implied that it was manageable:

I’m more than happy to prescribe for them; more than happy to prescribe all of their radiation . . . It allows me to discuss with them their plans for the patients.

However, some described the ways in which this lack of authority added to the workload for the team:

But at the same time if the rules are not changing in, especially in prescription, there will be this misunderstanding because if I’m working with another doctor, my workload is different than working with a physician assistant . . . I can say they [PA] can contribute for 70% [of the work required], but it can be fine when it’s a good day, but if it is a bad day, it’s really bad!

All of the doctors considered that PAs, with the appropriate training, should be able to prescribe certain medications and order ionising radiation to improve their utility to the team. There was a degree of puzzlement as to why they could not do so:

This is what I can’t understand. They can see a patient in resus [resuscitation section of ED] but when we come to a prescription of paracetamol, they can’t do it?

One consultant commented that if PAs had the authority to prescribe there would be less that differentiated the PA and the junior doctor role, and that some doctors would see that as problematic.

Some specialties with high-dependency patients

Linked, to some degree, with the inability to prescribe was the reported preference of consultants in some specialties with high-dependency patients to employ doctors, rather than PAs, having worked with PAs:

Actually I think our experience with PAs has, for many of us [consultants], has not been positive . . . but the SHOs are a joy and it’s much easier, and they come in and from day 1 they’re able to do [the required medical work].

Again, this is a very different, difficult environment . . . I’m not sure we would go back to them [PAs] because the doctors just become, within a few months, just become much more useful, I guess . . . the difference between the doctor and them [PAs] is that the doctor has been through, already by the time they get here, multiple other specialties. So, they have a much broader understanding of what else might be going on.

These consultants noted that they only had experience of a small number of PAs and speculated as to the extent to which individual personalities were influential. Although these consultants would not seek to re-employ PAs, others described a lack of PAs to employ, which is now discussed.

Lack of physician associates to employ, retention and career development issues

Many of the consultants described a shortage of PAs to employ as a significant issue. Some described workforce plans that had included multiple PA posts, but they had only managed to recruit one or two PAs. Some consultants then described how without a full complement of PAs, they were unable to create jobs that were attractive to PAs, which meant they then left for more attractive posts. The consultants described the least attractive posts being those that involved only inpatient ward work with high levels of medical clerical work and no clinical development opportunities. A number described rethinking job descriptions in order to attract and retain PAs.

Doctors at all levels discussed the problem as they saw it of the lack of development for PAs and the lack of a clear career progression path:

Something I worry about as an individual is there is no clear progression for them, especially with the young ones. You don’t want to be doing what you’re doing now in 10 years’ time, you want some career progression.

Some consultants described initiatives to support the development of PAs, for example through rotation schemes or training in a specific clinical procedure. However, issues such as confusion over what funding there was was to support PAs’ training and resistance by others to extending their skills were reported to sometimes hamper PA career development. For some consultants, a lack of development opportunities was linked to the problems of retaining PAs. For other consultants, it linked to problems of PAs maintaining up-to-date knowledge. For others, it linked to problems with the position of PAs within the medical team. As they saw it, PAs staying in one specialty would develop deep knowledge of particular types of conditions, diagnostics and treatments – more in depth than junior doctors joining the team. However, they thought that PAs would not have the breadth of knowledge of the junior doctors, but they foresaw this as giving rise to tensions and problems. We turn now to the theme of negative views about PAs.

The negative views of some doctors and some senior nurses about physician associates

Some consultants and other registrars were reported by interviewees to be opposed to the concept of the PA role and, therefore, did not support their employment and avoided working with them. Negative attitudes were demonstrated by the way some registrars worked with the PAs, giving them delegated tasks only and not engaging with them. A consultant noted that some doctors saw PAs as just ‘clerical’ help and treated them that way. Although many consultants said that the junior doctors welcomed the PAs, a few observed that there were sporadic issues of tension between junior doctors and the PAs as to the PA’s position in the team:

Some of the junior doctors are feeling very vulnerable and very defensive about their role and there’s been a fair bit of antagonism with some, again, personalities but it’s a sort of recurring issue. ‘What are they allowed to do, who’s supervising them, is it me?’

One consultant argued that some PAs did not see themselves as assistants to the doctors, particularly those new to the team, but that the doctors did see them that way, and this caused tension. Some of the consultants talked about the frequent change of doctors in their teams and that managing new personalities was always part of their work.

Although most of the doctors reported that nurses, particularly at the ward level, were positive about PAs, some negative views and points of tension were also reported. Some senior nurses were reported to actively block their employment and development, preferring to support ANPs:

She’s [chief nurse] the person who has the worst opinion of our physician associate role . . . her ambition is for more ANPs . . . she wants all development monies to go there.

All of the consultants involved in the introduction of PAs in their trusts talked of having spent considerable efforts in actively engaging with the nurses to allay fears of professional encroachment and do ‘a lot of public relations work about PAs’ (ID 119, consultant).

One part of overcoming some negative views was said to be demonstrating the contribution that PAs could make to services. This links to the next theme of the measurement of impact.

Measurement of the impact and costs

Questions on available evidence about impact and how impact could be measured were particularly directed to the consultants and middle-grade doctors. None of the participants was able to offer any completed internal quantifiable assessment of the impact of the PAs. Most considered that it was a very difficult task to single out one person or type of professional from what was a team activity:

I think it would be extremely difficult to look at patient outcomes because you measure what teams do, you don’t measure what individuals do.

They offered examples from ‘hearsay’ of high levels of patient and family satisfaction – some stating that this had improved since a PA had joined their team, as described in Overall view of the contribution physician associates made. The consultants within the ED setting were able to talk about outcomes for individual patients seen by PAs but pointed out that these were still within a consultant-led and supervised team. Chapter 10 provides this analysis.

Regarding cost, most consultants considered that the employment of PAs rather than doctors, particularly locum doctors, was cost saving. One consultant argued that because of the salary paid to PAs combined with the investment in developing them, particularly those who were newly qualified, the difference in cost between PAs and junior doctors was not as great as some may think. Nearly all of the consultants went on to point out that the major issue for them was not finance (although important) but ensuring that they had the right staffing to provide high-quality, safe and efficient patient care. Some were able to point to aspects of improved patient flow (and consequent reduced costs per patient) in which they thought that the presence of PAs had made a difference:

Overall they have improved our cost, I will say, helping us to reduce the patient stay [in elderly care] . . . but no, I haven’t any analysis for that.

Summary

Forty doctors were interviewed across the six hospital study sites. Initially, the main driver for employing PAs was the shortage of junior doctors and the need to protect their time for their training requirements rather than routine medical inpatient work. Most PAs were employed to undertake the medical inpatient ward work and preoperative preparation as part of the consultant-led medical team. Within the ED, they attended patients independently but as part of the consultant-supervised team. Most doctors of all grades viewed their contribution to the team and patient care positively. However, a few consultants, in high-dependency specialties, considered that doctors were of greater utility in that setting and that they would not replace PAs that left. The continuity and stability the PAs brought to the team were described as an important contribution. This, in turn, ensured a smoother experience for doctors joining the team as well as maintaining or improving quality and safety in patient care. PAs helped junior doctors manage the workload and were missed when they were absent. The presence of PAs on the wards released early-career doctors to undertake training and meant that nurses had easy access to a member of the medical team. PAs were described as contributing to patient flow and patient experience. PAs were considered to increase or significantly contribute to inpatient satisfaction, although most felt that patients did not understand what the PA role was.

The inability of the PAs to prescribe and order ionising radiation was seen as a problem that could be managed, but for some it meant that working with PAs added to their workload, in comparison with a junior doctor who could prescribe. These doctors thought that the PAs should be given the authority to prescribe and order ionising radiation. The lack of supply of PAs to recruit was an inhibiting factor and retention was also reported to be difficult in some areas owing to a lack of development opportunities and no obvious career trajectory. A different problem was identified in the division of views among doctors themselves as to whether or not they supported the concept of the PA role. Tensions were sometimes reported between early-career doctors and PAs. Some differences were noted between doctors of different levels of seniority, with a few (but not all) of the most junior being more likely to perceive PAs as a threat to their training opportunities. A few senior nurses were also thought to view the employment and development of PAs negatively.

The overall consensus was that measurement of the impact on outcomes by individuals and individual roles within hospital teams was very difficult. None of the consultants was able to offer quantifiable evidence, but suggestions were made by some on patient satisfaction levels and shorter lengths of stay in the setting of care of the elderly. No quantifiable evidence was offered on costs, although many consultants argued that using PAs rather than locums to cover gaps would automatically reduce costs. Views were mixed as to the cost of PAs, including their development. The concern of most of the consultants was not about costs but about maintaining the quality and safety of their care to patients. Many of them directed the researchers to the managers for evidence of cost. The next chapter reports their evidence.