The PAs were all employed in practices that also employed other professionally qualified staff, including
salaried GPs, NPs and practice nurses (Table 10). The PAs in the study had a variety of work experience and training backgrounds, including some who were UK and some US trained.
Physician assistant activities: an overview from the work diaries
The work diaries (confirmed in interviews with PAs) indicated that the majority of the PAs’ working hours
were spent in providing clinical consultations (direct patient contact in face-to-face or telephone appointments), although the proportion of the time they reported on this ranged from 58% to 92% (Table 11). The majority of these hours were in same-day appointment sessions but PAs also undertook booked appointment sessions. These were mostly for the follow-up of patients with long-term conditions. The non-clinical activities could be related to either patient consultations, such as arranging referrals or processing laboratory results, or other professional activities such as attending practice meetings or training days. The most frequently reported non-clinical activities by PAs were dealing with test results and referrals to other professionals. Some PAs also reported attending training and carrying out clinical governance
activities and condition/case-specific duties (such as child protection work). It was evident that the wider
the range of non-clinical activities, reported by individual PAs, the greater the proportion of time spent on these activities compared with clinical activities (as with PA 10) (see Table 11).
TABLE 10 The professionally qualified health-care staff in the PA practices
Practice study ID Patient list size Practice partners (WTE) Employing salaried GP(s) Employing NP(s) Employing nurse(s) Employing PA(s)
1 5001–10,000 1–3 Yes No Yes Yes
5 5001–10,000 1–3 Yes No Yes Yes
6 > 10,000 4–6 No Yes Yes Yes
10 < 5000 plus walk-ins 4–6 Yes Yes Yes Yes
11 > 10,001 1–3 Yes No Yes Yes
From the staff interviews, it was evident that each practice deployed the PAs according to a number of
parameters. These included deployment thatfitted with the practice organisational requirements, for
example to telephone triage in a practice that used that system, or by clinical competence as judged by the senior or lead GP, as in this exemplar:
[The PAs] don’t usually see under-1s but depends on [their] experience.
GP 11–5 This is further explored in the following sections, where the variety in the scope of practice reported to be undertaken by the individual PAs is clear.
Same-day appointment clinical consultations
The deployment of PAs in the practices was primarily to provide clinician time for same-day/urgent appointments. The range of scope of practice was evident in the manner in which same-day appointment patients were assigned to a PA or to a GP. In some practices, it was evident that the receptionists treated PAs as the doctors assigned to that type of surgery, as noted here:
He [the PA] sees a surgery of patients morning and afternoon every day, which are almost entirely unselected. We have selected out under ones because he is not trained for those, but other than that he sees the full range of problems that present.
GP 1–2 In other practices, more nuanced systems had been developed so that the GPs and PA were seeing
different types of patients, with the GP more likely to see either the more complex patients or those with more chronic conditions, as in this exemplar:
So the doctors and the physician assistant, the nurses between them have developed a, like a list, a triage type list. So if someone rings up and says ‘I’ve got this, that or the other’, they [the reception staff] can look on the list and decide whether it should see a doctor or a physician assistant or a nurse practitioners, depending on who’s on. So they’re a sort of triage but not in-depth triage, just pointed in the right direction.
Practice manager 6–4
TABLE 11 Proportion of reported hours spent by PAs in clinical and non-clinical activities
PA
Time reported
Total hours reported on
Clinical activities Non-clinical activities
Hours Per cent of reported time Hours Per cent of reported time
1a 125 111 88.8 14 11.2 5b 37.75 21.75 57.6 16 42.4 6 No diaries received 10a 11.75 74.5 62.7 44.25 37.3 11c 8.75 7.75 88.6 1 11.4 12d 36.25 33.5 92.4 2.75 7.6
a Based on 4 weeks’ diaries.
b Based on 3 weeks’ diaries.
c Based on 1 day’s diary.
The practices varied in the length of the appointment slots they assigned to PAs. Most– but not
all– assigned longer slots (15 minutes) to PAs than to GPs (10 minutes), but often shorter appointment
times than those allocated for nurses.
Chronic disease management consultations
The extent to which PAs were involved in the ongoing management of patients with chronic diseases also varied among practices. For example, in one practice the PA undertook the diabetic review clinic, among other chronic condition review clinics. Another PA estimated that about 50% of the patients he saw were ‘regular routine follow-up of chronic patients’ (PA 5–3).
Some of the practices had nuanced ways of separating the work the PA undertook in chronic disease management from that of the nurses in the practice. For example, in most practices the nurses were described as not seeing patients with depression or other mental health problems or with musculoskeletal problems, whereas the PAs would attend to those types of patients. In general, the division of labour
appeared to be based on clinical expertise and confidence, as in this example:
When the physician assistant that we have here, when she started a lot of my chronic disease patients [were] then allocated to [the PA], especially COPD, she does spirometry, which she’s been trained for . . .
Practice nurse 10–3 It was observed by a number of participants that the difference between nurses and PAs in their chronic disease management was often recognisable through the point at which the patient was referred back to the doctor. PAs were described as often managing more problems and transition points, whereas the nurses referred back for any problem or change. The differences in activity between the PA and the NP
were exemplified in this description:
She [the PA] does all the things the nurse practitioner will do on the day but she also does a couple of other things because she’s covered the training. So she is happy to see straightforward depressions, which the nurses, none of our nurse are prepared to at present . . . And she is happy to see back pains also which the nurses haven’t covered so they don’t do that. Another difference is the PA will do some of her own referrals [to secondary care] whereas the nurse practitioner would refer the patient to the doctor who would be responsible for doing the referral.
GP 6–2
More evident in the descriptions were situations in which PAs and nursesflexibly covered the work
required in the practice as the demands of each day unfolded. These were reported by PAs, nurses and practice managers; for example, PAs might cover the work of nurses absent through sickness, while one nurse described assisting with booked chronic disease management review patients in the absence of a PA.
Income-generating work
In addition, some practices were also developing their PA to undertake work that contributed specifically
to the practice income as part of either Quality and Outcomes Framework (QOF)93indicators, such as
maintaining the register of people with learning disabilities, or clinical activities that attracted specific payments under local or nationally agreed enhanced service elements of the General Medical Services
(GMS) or Personal Medical Services (PMS) contract,23for example initiation of insulin in primary care. Each
of the activities referred to by the PA in this exemplar is an activity associated with specific payments:
What else do I do? I’m responsible for the warfarin patients, I do all the bridging for surgery [changing the warfarin pre-surgery to another drug and restarting post a surgical operation]. I do contraceptive implants and there’s only one or two in the practice who do that so that’s quite a big role . . . and I do a lot of paperwork, so I run the palliative care meetings 3-monthly . . . the GP would normally do that but I’ve taken that off their hands. And I’m now starting to do initiation of insulin in primary care. We had one GP that was doing that but he retired.
PA 6–3
Authority and lack of authority to order tests, refer and prescribe
There was a reported difference between PAs in different practices and between PAs and nurses as to the recognised authority to order pathology and radiological tests and also to make referrals to secondary care. In general, the PAs were described as having been given more authority to order tests and make referrals to secondary care (although some needed countersigning in some areas by the GP) than the nurses, who mainly described usual practice as referral back to the GP, as described in this exemplar:
Interviewer:Can you authorise an X-ray referral?
Practice nurse 5-1:No that goes on our prescription board [a way of leaving items such as prescriptions
for the doctor to sign] and the doctor will sign it. Obviously it is a trust thing, they know what I can do and trust me.
Interviewer: And if they needed investigations of any other kind, would there be something you
authorise or . . .?
Practice nurse 5–1:Bloods. I would obviously do that myself and authorise myself. I think X-rays,
most other things, scans and things would be the doctor or PA.
Interviewer:And if they need a hospital referral?
Practice nurse 5–1:Yeah doctor or PA because they wouldn’t take any notice of me at the hospital.
Physician assistants are not authorised to prescribe medicines in the UK. The lack of ability to prescribe was reported to cause frustration and additional time to the PAs, the GPs and the patients. Each practice had developed systems to try to minimise the delay caused by getting the GP to sign prescriptions. This varied
from a system of knocking on the GPs’ consulting room door, messaging by computer, hovering in
corridors to speak to the next available GP, and leaving the prescription in a designated place for the next available doctor to review the notes and sign, to offering to send the signed prescription to the local pharmacist later for collection. It was evident that the GPs developed trust in the clinical competency of the PAs over time, which had the effect of reducing the amount of time they spent reviewing
consultations before signing prescriptions, as illustrated in this exemplar:
When I first qualified and also when any new doctor starts there’ll be a period where when they are signing my prescription you would tend to give them a lot more information about what you are doing . . . explain a bit more what it’s about, because they have got to learn to trust you and understand it, because ultimately they are signing the prescription, . . . so it’s just about building up a trust and an understanding of your competencies which is fair enough.
In the PA-employing practices, the nurses with the qualifications to prescribe medications were in the minority. Consequently, most of the nurses, whether with a title of nurse practitioner, senior practice nurse or practice nurse, were using the same systems as the PA to obtain GP signatures on patient prescriptions.