Findings: evidence from the reviews and surveys

This chapter reports on the evidence identified through workstreams 1 and 2, consisting of a survey across English hospitals, a systematic literature review and a policy review. From macro- and meso-level perspectives of health-care systems, it identifies the factors influencing the extent of the adoption and deployment of PAs in English NHS hospitals as well as research evidence of the impact of employing PAs within the medical and surgical workforce. We report first on the systematic review of evidence, then on the national surveys and finally on the policy review.

The systematic review

From 5472 references identified through the search strategy, 161 papers were selected for full-text reading, of which 16 papers32,94–108 met the inclusion criteria (Figure 2). Brief characteristics of each of the included studies are presented in Table 4 and in full in Appendix 10. The studies were all from North America (mainly the USA) and addressed different types of questions using a range of methodologies with different outcome measures. Seven studies were in emergency medicine,94–100 six were in trauma and orthopaedics,32,101–105 two were from internal medicine and one was from mental health.106–108 No studies from acute medicine or care of the elderly were identified.

FIGURE 2 The PRISMA60 flow diagram of the included papers. Adapted with permission from Halter et al.109 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. (Figure not reproduced here; see the original article.)

The studies were of variable methodological quality. The most important methodological flaws in the included studies were the failure to adjust the analysis for confounding variables, the absence of information to evaluate participants’ selection adequacy and the lack of information about baseline and/or demographic information of the investigated patients or PAs. The evidence in the following sections is presented by specialty and framed by the quality dimensions of interest.50

Emergency medicine

Of the seven studies of emergency medicine,94–100 treatments offered were reported in three studies, a clinical outcome and length of stay were reported in two studies and waiting times were reported in one study. Only two studies reported PAs substituting for doctors.94,97

Treatments offered

In terms of analgesia prescribing,96,97,99 the studies gave conflicting results. Secondary analysis of national (USA) ED survey data reported a higher proportion of patients receiving prescriptions, and within that for opiate analgesia, when attended by PAs compared to physicians and nurse practitioners.96,99 This contrasted with a survey study of a similar-quality study, although based on patient self-report, reporting that those attended by an emergency physician had adjusted odds of 3.52 for receiving pain medication compared with those attended by PAs.97

Clinical outcome of care

A clinical outcome of care was reported in only two studies.98,100 The older study reported that experienced PAs had no statistically significant difference in wound infection rates compared with other medical staff providers (medical students, residents and attending physicians) in a large sample of patients presenting with lacerations at the ED.100 The other, newer, large study98 reported a significantly lower 72-hour re-attendance rate to the ED for children aged ≤ 6 years for those patients treated only by a PA (6.8% vs. 8.0% for those treated by an emergency physician; p = 0.03). However, these rates were unadjusted, with PAs seeing the older of the children, who were much less likely to be admitted.

Length of stay

The studies by Arnopolin and Smithline94 and Ducharme et al.95 showed contradictory results. In the study with PAs as additional staff, patient length of stay was reduced by 30% (mean 80-minute reduction).94 The study of experienced ED PAs substituting for physicians95 reported a statistically significant longer mean length of visit (8 minutes) for patients of PAs but noted a range of difference (5–32 minutes) by diagnostic group. This study also considered costs through total charge (hospital and physician charge) for the visit and reported a small but statistically significant decrease per patient reported when patients were treated by a PA,95 although, again, this varied by diagnostic group.

Waiting or access outcomes

As an additional staff resource, the PA’s presence significantly reduced the likelihood of a patient leaving without being seen by 44%, and the odds of a patient being seen within their benchmark waiting time was 1.6 times greater; this was further increased to 2.1 if a newly appointed nurse practitioner was present instead.91

Trauma and orthopaedics

Six papers reported on PAs working in trauma and orthopaedics.32,101–106 PAs were substituting for doctors (residents105 and GP surgical assistants101,103) in three of these studies.

The impact of PAs on access and service delivery time was ambiguous in three studies.32,101,105 PAs acting as substitutes for doctors were reported to shorten waiting times in the ED but the authors attributed this in part to other service redesign, such as there being more registered nurses.32,105 Waiting times for surgical procedures were also reported to be reduced,101 attributed by the authors to the use of two operating theatres by the surgeon, made possible by the PA preparing and finishing the case. However, one study examining in detail the impact of PAs in teams on time to, in and from theatre found no statistically significant difference.32 In two studies, PAs were found to release the time of doctors for other activities: for supervising physicians for 2 hours a day32,103 and for GPs (not quantified), who had previously acted as surgical assistants.101

Length of hospital stay was examined in three high-quality studies,32,104,105 with one showing a significant reduction (of 3 to 4 hours) for all patients when PAs were an addition to staffing.104 The studies in which PAs substituted for doctors found no difference in length of stay.32,105

Health outcomes were reported as improved in two studies.32,104 One study reported that the presence of PAs decreased postoperative complications measured by antibiotic and deep-vein thrombosis prophylaxis use.32 The presence of PAs in the clinical team was found to reduce mortality by 1% for a trauma panel and by 1.5% for general surgery residents’ teams,104 although some of this could be attributed to other contemporaneous service improvements. Two studies found no overall difference between groups in mortality105 and in the likelihood of fracture malunion.102

Patient satisfaction was surveyed and reported as positive from a small103 and large101 number of respondents, without a comparator, in two studies.101,103 Responses from staff were more equivocal, with physician team members being positive on the contribution of PAs and nursing staff expressing concern about the overlap of work.101 A different study found that although staff appreciated the continuity and PA skills in the operating room, they did not consider that the role could offer everything a previous surgical extender did postoperatively, despite being collaborative team members.103

There was also mixed evidence regarding impact on cost. One study in which PAs were an addition to the team reported specific cost savings in the ED and operating room, although it was noted that only 50% of PA costs were reimbursable.101 Another study32 suggested that although the costs of employment were similar to those of the GPs assisting in the operating room, there was an opportunity cost for others through released time for supervising physicians.

Internal (acute) medicine

Two studies investigated PAs in internal (acute) medicine and both examined resource use and clinical outcomes.106,107 Neither study reported any significant differences in length of stay (used as a proxy for severity of illness). Cost in terms of relative value units (based on billing information for physician-ordered items, excluding administrative costs outside the physician’s control) was also mostly similar, although laboratory relative value units were lower for PAs (i.e. they ordered fewer investigations after adjustment for demographics in each diagnostic group).107 Capstack et al.106 reported a statistically significantly lower mean patient charge for the expanded PA group with physicians [US$7822 vs. US$7755 for the conventional PA group (3.52% lower, 95% confidence interval (CI) 2.66% to 4.39%; p < 0.001]. Inpatient mortality was stated to be higher for the PA group in pneumonia care only,107 although the authors reported neither the percentage nor the statistical values, and the larger study reported no significant differences in mortality or 30-day all-cause readmission.106 The authors concluded that PAs used resources as effectively as, or more effectively than, residents107 at the same time as providing similar clinical quality.106

Mental health

One study was included from mental health services.108 Participants described improved access to primary care for patients; more timely access to psychiatric appointments and longer appointments; equal team cohesion for the PA or the psychiatrist; decreased waiting times and improved access to tertiary care and screening programmes; and implementation challenges of triage hierarchy and patient understanding of the term ‘physician assistant’.

Summary

Sixteen papers were included; four were published in 2017.98,102,103,108 Most were from emergency medicine and trauma and orthopaedics specialties, with two from acute medicine and one from mental health. All studies were observational, and quality varied widely. The synthesis was further complicated by the difference between studies in which the PA was a substitute for doctors or was an additional staffing resource, or in which the introduction of PAs was only one of a number of contemporaneous service changes.

Although every paper reported the contribution of PAs as positive overall, it is important to contextualise within these issues of method and methodological quality. Summarising across the specialties, we have reported five studies in which PAs were an addition to the team.32,95,103,104,108 In these studies, more patients are reported to have been treated; waiting times, time in EDs and time in operating rooms are said to have been shorter and mortality to have been lower; however, assessment of the contribution of PAs as opposed to any increase in team capacity is limited. Eight studies that compared outcomes of care by PAs and physicians when either one or the other was providing care or when PAs were substituting overall for physicians94,97,98,100,101,105–107 presented mixed results: either no or a very small difference in length of stay, reduced resource use but at equal or reduced cost, some time savings to senior physicians, lower analgesia prescribing, no difference in wound infection rate, inpatient mortality or re-attendance or acceptability to staff and patients. In three of the studies carrying out secondary data analysis, we do not know if the PAs were additions or substitutions, but two studies reported higher prescribing by PAs96,99 and one reported no difference in negative outcomes from fracture.102

The strength of this review was its systematic method. Although it may be considered a weakness that only some specialties were included, this strengthens its applicability to the UK in that these are the specialties most frequently employing PAs in the NHS. We excluded any studies including intensive care data as these overlapped with acute medicine in many abstracts and we could not separately draw these out. Similarly, we excluded studies with medical and surgical specialties combined. We note that this literature appeared to include a greater proportion of studies with stronger study designs, including prospective and randomised designs; in particular, we have excluded the recent matched controlled large study from the Netherlands in which several specialties – some within and some not within our inclusion criteria – were studied.110,111

A meta-analysis was planned but the heterogeneity of papers precluded this. Although narrative review is more limited in its precision, in following a framework for this, we have aimed to provide a clear rationale for the synthesis and conclusions we draw from it.

All of the included papers were from North America, with the majority from the USA, where health service organisation and the PA role may differ from that in other countries developing the PA role. In the USA, PAs can prescribe and order ionising radiation, and are, as a body, more experienced than those in countries more recently embracing this role.

The studies included in this review can be seen as complex interventions in complex systems and yet this has not been considered in the conclusions drawn by the authors. Well-controlled studies are needed to fill in the gaps in our knowledge about the outcomes of PAs’ contribution to secondary care. The review is published in full elsewhere.109

We now turn to consider the evidence from the macro level of the policy context in England.

The policy review

At the point when the policy review was finalised in the preceding primary care study17 (in August 2013), it was concluded that ‘there was no reference to PAs in English policy documents’. By the end of the year, that had changed. In response to an acute shortage of doctors in emergency services, HEE (the executive non-departmental body responsible for NHS workforce planning as well as funding of training in England) had identified PAs as one of a number of non-medical roles that it would support to address the shortages.8 Over the subsequent 4 years, we identified 17 published statements of policy intent at the macro level regarding PAs within the NHS workforce in England.6,112–127 These are listed by type in Table 5.

In all the policy statements, the problem being addressed was a shortage of doctors. Initially, this was in emergency medicine;6,120 later, GP shortages were the identified problem that a state-supported increased supply of PAs was aimed at addressing.6,112,115,117–127 In all the policy documents, increased supply of other groups were also specified as in this exemplar from the GP workforce plan.119

NHS England, HEE and others will work together to identify key workforce initiatives that are known to support general practice – including e.g. physician associates, medical assistants, clinical pharmacists, advanced practitioners (including nursing staff), healthcare assistants and care navigators.

The state support for the training of PAs became marked in 2015, with financial support for numbers of PAs in training increasing by 854% from 24 in 2014/15 to 205 in 2015/16.121 This was quickly followed by a growth in English universities providing PA courses.128 The only other group with a large increase in financial support for training over the period was paramedics, with numbers increasing from 853 in 2014/15 to 1231 in 2015/16 (44%).121

The limitation of the PAs not being within the state regulation framework and, thus, being unable to prescribe or order ionising radiation was noted in the 2014 HEE workforce plans.120 Two years passed before the intention to consult on the state regulation of PAs was announced113 in November 2016, and a further year passed before this actually commenced (in October 2017). The reasons for this gap between problem identification and action is not apparent in the documents.

At the macro level of the health-care system, sustainability and transformation plans (STPs) were developed in the winter of 2016 across 44 areas of England.129 These were plans for the NHS and beyond, agreed and informed by health and social care partners across defined geographies. Among other issues, the workforce had to be considered in the plans. We analysed the 41 publicly available plans130 for stated policy intent to develop the PA workforce. We identified that under half were planning to increase the employment of PAs and were specified mainly in support of primary care (Table 6).

In summary, the policy review identified macro-level support for the development of the PA workforce to address the problem of clinical workload and the immediate and predicted shortages of doctors. The support included not only positive statements but also state funding for training places to increase the supply to employers, particularly general practice. At the meso level, using the STPs as the evidence source, not all plans included the detail of planned growth of advanced clinical practitioners, although this may have been an artefact of the way these were written rather than actual intent. Of those specifying growth in advanced clinical practitioners, four plans did not include PAs and 18 plans did. The majority of plans that specified a sector for support of growth of PAs referred to primary care rather than secondary care.

We now turn to examine the employment of PAs in the secondary care sector through views from the meso and micro levels of the health-care system.

Survey of medical directors

At the time of the survey, there were 214 NHS acute and mental health trusts in England; MDs from 33% of trusts (n = 71) replied. Of these, 68% (n = 48) were acute trusts.

Physician associates were employed in 20 of the responding trusts, only one of which was a mental health trust. Most trusts (n = 16) employed fewer than five PAs but three employed more than 10. MDs reported that PAs were employed in a total of 22 specialties, both medical and surgical (adult and paediatric). The most frequently reported specialties for PA employment were acute medicine (n = 7 trusts), trauma and orthopaedic surgery (n = 6 trusts) and emergency medicine (n = 5 trusts). The majority reported that the supervising doctor was a consultant. Eight MDs reported that their trust was expanding its number of PAs owing to a positive experience to date.

Of the remaining respondents, 61% (n = 44) were considering employing PAs at their trusts and 10% (n = 7) were not considering employing PAs.

Respondents were asked to report supporting and inhibiting factors to the employment of PAs. In general, MDs at trusts employing or considering employing PAs reported multiple supporting factors whereas those at the seven non-employing trusts reported only inhibiting factors.

The most frequently reported supporting factor was to address gaps in medical staffing and to support medical specialty trainees. Other common factors were to improve workflow and continuity in medical/consultant teams, to help address the management of junior doctors’ working hours to be compliant with the EU Working Time Directive,13 and to reduce staff costs.

It was also reported that a number of trusts were piloting or testing out PA roles. Some had specific strategies to increase the numbers of PAs they employed through linking with university PA course providers.

The inhibiting factors that were cited most frequently were the lack of statutory regulation for PAs and the consequent lack of authority to prescribe. The relative lack of PAs to recruit was another commonly reported problem, as was resistance to their employment from (some) consultants. Seven of the 20 respondents reporting PA employment also indicated that PAs had left and not been replaced. Most indicated financial reasons or lack of PAs to recruit. One stated that the consultant considered that a doctor was more effective and efficient than a PA in that particular team. The small number of respondents not considering employing PAs offered a slightly different perspective, suggesting that other professionals – either nurses or doctors – were better placed to meet their trust’s employment needs.

This survey provides evidence of the changing employment context for PAs in England at one point in time and, for this reason, offered insights, not available elsewhere, from those in medical leadership positions within NHS trusts. The survey was conducted at the time of the junior doctors’ strike in England,131 which may help explain the low response rate, although other surveys of NHS MDs report similar rates.132 The supporting and inhibiting factors reflect those previously reported by us from our survey of the GP employers of PAs.17 Shortages of doctors have also been the most commonly reported reason for employing PAs in the USA.133 Although this survey suggested that there was an appetite for employment of PAs in secondary care, it also suggested that there were issues that needed addressing, such as state regulation. Eighteen months later, a consultation on regulation116 was launched; however, this survey suggested that there might be other issues that will need attention, such as senior medical staff resistance to employment.

A full account of this survey has been published elsewhere.134 We now turn to report findings from the survey of PAs in secondary care.

Survey of physician associates

Out of the 223 PAs on the UK voluntary register and practising in primary and secondary care in the UK at the time of the survey, 63 PAs working in secondary care in England completed the online survey. Of these, 49 provided responses to all 18 questions. Three additional participants started the survey but were filtered out as they were practising in a country other than England.

The majority of respondents had trained in the UK (Table 7) and the mean length of time since qualification was 3.1 years [standard deviation (SD) 2.1 years]. Most worked in large acute hospital trusts. The respondents reported working in 33 medical or surgical specialties; the most frequently reported was acute medicine, followed by elderly care medicine and trauma and orthopaedic surgery (see Table 7).

The most frequently reported setting that the PAs reported working within was the inpatient ward (n = 38), with 25 describing multiple settings including outpatient clinics and operating theatres. Of the 54 PAs who provided information on their line management arrangements, 44 (82%) were managed solely by consultants. Day-to-day supervision was reported by 48 PAs as being by a consultant or other grade of doctor. Two PAs said that they did not have a day-to-day supervisor. PAs were working within variously configured teams; the most frequently reported team composition (n = 16) was consultant led with other grades of doctors and clinical nurse specialists. PAs were mainly working day shifts (only 1 out of 50 reported working night shifts) from Monday to Friday [although 14 out of 50 (28%) reported working at least one weekend shift during the previous 4 weeks]. Some reported that their work was shaped by the absence of others in the team, for example covering for the clinical nurse specialist or for the registrar when on annual leave or while training.

This cross-sectional survey provided a snapshot of the specialties, teams and working patterns of PAs in secondary care in England and, for this reason, provided new insights, even though the response rate could not be accurately established. The types of specialties reported mirrored those of the annual census by the FPA,59 giving some confidence in the breadth of coverage. The survey provided evidence around questions such as the nature of supervision, to be taken into the next workstream of the overall study, which we report on in Chapter 4. The full report of the PA survey is published elsewhere.135

Summary

This chapter has presented international evidence as well as evidence from the macro and meso levels of the English health-care system. We now turn to report the findings from the micro level.