working practices of other professionals, relationships with
these professionals and the practice costs
We address each of the sections of this study question in turn.
Impact on the organisation of the practice
From the scoping survey (see Chapter 3, The scoping survey), it was evident that those closely associated with general practice could see a potential role for PAs within general practice teams but were looking for more evidence with regard to impact. From the case study element (see Chapter 4), the PA and practice
staff interviews revealed that PAs were employed tofit into the organisation of the practice and the aim
was for minimal impact per se, as with any other member of staff. The newness of both the occupational
group and, in some instances, the individual’s qualification had some effect. For those practices new to
employing PAs, one effect was the need to ensure that other staff understood this new-to-the-UK role. The next effect was a need to assign a supervising doctor and ensure time for that supervision (whether
about an individual patient consultation or as a regular supervision session), and for newly qualified PAs to
arrange ongoing professional development. The extent to which the role of the PA developed within each practice appeared to depend both on the interests and knowledge of the PA and on the opportunities presented within the organisation of the practice. This is captured in the discussion of deployment, earlier in this chapter (see The deployment of physician assistants in general practice).
Impact on the working practices and relationships with other professionals
In the case studies, it was evident that the PAs had an impact on the working practices of some of the
GPs. In some practices, they were employed specifically to release GP time for attending to more complex
with more complex needs and patients outside the scope of practice of the PA (see Chapter 4). This was
confirmed in the clinical consultations entered into the case study, where it was evident that PAs were
consulted by younger patients with a lower incidence of measures of comorbidity compared with those consulting GPs (see Chapter 5, Consultation records). A previous UK study of a smaller sample of PAs suggested that PAs saw older patients than GPs but concurred that the PAs saw a similar but less complex
case mix to GPs.62This was also evident in the observation of clinical meetings (see Chapter 4), in which
the GP partners were focused on the care of patients with multiple physical, mental health and social problems and also on ensuring that salaried GPs, GP registrars and nurses were supported in the management of such patients.
The extent to which PAs impacted on the work in each surgery of the supervising doctor varied depending
on the experience of the PA and the systems in place to signal the PA’s need for consultation about a
patient and/or prescription signing. While PAs’ lack of authority to sign a prescription was an issue in all of
the practices, it should be set in the context that,firstly, in most of the practices the nurses did not have
prescribing qualifications and were also dependent on efficient systems (see Chapter 4) and, secondly, that
most consultations (with either a GP or a PA) did not result in the issuing of a prescription (see Chapter 5). The types of actions to minimise the consequences from lack of authority to sign prescriptions have been
noted before in the UK context61–63,72and in other countries developing the PA role.164,209
The boundaries between the work of the PA and that of the nurses in the practices were described as delineated and agreed without overlap (see Chapter 4), a point also noted in the primary care pilots of PAs
in Scotland.61The PAs were reported to beflexible in their skills, and so were often able to cover nurse
absences, a feature again noted in the earlier study of PAs in England.60It was evident from the interviews
with the practice managers and GPs (see Chapter 4) that the priority was to deploy available staff most
efficiently against the practice service delivery needs and the demands of each day. While some GPs noted
that there had been disquiet from some NPs when PAs werefirst employed, we were able to find evidence
of only positive relationships and working practices between PAs and nurses in the case studies. This has
been noted before in the UK60,61and in other settings where PAs have been introduced in primary care
more recently.209
The impact of including the physician assistants on practice costs
This study has shown that, after controlling for case-mix differences, GP and PA consultations resulted in similar levels of prescribing, referral, tests, procedures, reconsultations and patient satisfaction. The observed difference in consultation times between PAs and GPs (16.8 minutes vs. 11.3 minutes) is very
similar to the national data for NPs and GPs (15 minutes vs. 11.7 minutes).119After adjusting for
covariates, a PA consultation for the‘average’ patient is 5.8 minutes longer than a GP consultation for the
same patient, at a marginal cost of £6.22. Although PAs’ consultations are longer than GPs’, they
document giving more advice to their patients, and the lower costs associated with their consultations mean that they still deliver care more cheaply. This analysis does not, however, take account of extra costs associated with the use of PAs, including GP time in supervising, training and signing prescriptions, which
was not quantified in this study.
In the absence of other studies of the relative costs and effectiveness of PAs and GPs in the UK setting, comparative evidence can be drawn from research that has compared GPs with NPs, another mid-level
practitioner group. Thefindings of one randomised controlled trial in English general practice over a
decade ago were similar to those in the current study of PAs; the NPs had similar rates of prescribing,
referring, testing and reattending as GPs, and they delivered more advice in longer consultations.92
Another UK-based comparison of GPs and NPs at about the same time concluded that the clinical care and costs of GPs and NPs were similar; a higher propensity of NPs to order tests and for patients to return for
follow-up appointments offset lower consultation costs.91A systematic review showed that patients were
more satisfied with NPs than with doctors, and while there were no differences in prescribing, referrals and
reconsultations, NPs had a higher propensity to order investigations.39A modelling study based on the
because the GP time that goes into the supervision and reconsultations arising from the use of NPs offsets the lower consultation cost per minute of NPs, although sensitivity analysis showed that if the supervisory
time input of GPs was halved, NP consultations were cheaper.210In a recent study in the Netherlands,
NPs provided equivalent outcomes to doctors for a lower cost; the mean saving per consultation was
€ 8.21,211,212which is similar to the saving recorded for PAs in this study of £6.22.