Physician assistants:a UK perspective onclinical need, educationand regulationNick Ross and Jim Parle, School of Medicine, University of Birmingham, UK

BACKGROUND: GRASS-ROOT’S DEMAND FORPHYSICIAN ASSISTANTS

In this paper we describe someexciting developments in anew (to the UK) profession,

and how we, in the West Mid-lands, and others aroundEngland have responded to NHSneeds by developing a UK ver-sion of the physician assistantprofession (definition by theAmerican Academy of PhysicianAssistants is ‘health care profes-sionals licensed to practice med-icine with physiciansupervision’).1

Some 5 years ago the Bir-mingham Medical School wasapproached by a group of GPs fromthe West Midlands who wereemploying physician assistants(PAs) who had been recruited andappointed from the USA. The PA’srole was to consult with patientson behalf of the GPs, workingindependently, but under super-vision. They could take histories,examine patients, order investi-gations and refer as appropriate,all under the General MedicalCouncil’s (GMC’s) ‘delegation’clause.2 They could not (and stillcannot) prescribe independently.So convinced were the employing

GPs of the value of PAs to healthprovision that they wished toexplore with us the possibility oftraining similar professionals inthe UK. Our contact with local NHStrusts, both primary and second-ary, soon identified that there wasa wide interest in such a role. Over20 American-trained PAs haveworked in the West Midlands overthe last few years and some 50or so in the UK as a whole.Simultaneously, the University ofWolverhampton implemented aMasters programme for PAs.

The PA role has been in exis-tence in North America for some

The PA’s rolewas to consult

with patients onbehalf of GPs

Practicalteaching

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30 years and its value as part ofoverall clinical provision is wellproven. However, it was consid-ered important to evaluate it inthe UK setting. An independentevaluation3 confirmed the super-vising doctors’ initial impressionsof the transferability of the role tothe UK context; initial disquietamong the multi-professionalteam was generally lessened byworking directly with the PAs.It should be noted that both theinitial impressions and the sub-sequent evaluation related to acadre of highly experienced prac-titioners. When newly trained PAsenter employment in the UK, itwill be vital to adjust expecta-tions accordingly.

THE SCOPE OF PRACTICE OFPAs

In the American health care sys-tem, PAs work across the whole

range of medical fields, with themajority supporting specialistpractitioners (e.g. paediatri-cians), both in the ‘office’ and inthe hospital, including the emer-gency room (accident and emer-gency department or A&E in theUK). A significant minority workin family practice, particularly inareas of socio-economic andhealth deprivation. In contrast,most PAs currently working in theUK are based in primary care,although some work in A&E andacute medical units. Box 1 high-lights the ‘added value’ of PAs inthe secondary care context. Bothin the USA and in the UK, thescope of legitimate practice ofPAs is limited by that of theirsupervising doctor. Working undermedical supervision means thatalthough, in most instances, theywill be able to see and treatindependently, internal referral

within a unit or practice is alwaysavailable.

THE NHS CONTEXT

Workforce pressures in the NHSarise from a number of sources,including reductions in doctors’available working hours (set tobecome more acute in 2009 whenthe European Working TimeDirective is fully implemented),increases in medical retirement,the increasingly elderly popula-tion profile and increasing publicexpectations allied to the growingnumber of available therapeuticinterventions in an increasinglyconsumerist environment. In re-sponse to these pressures andtogether with local experimenta-tion with the PA role referred toabove, the UK Department ofHealth (DH) instituted the newpractitioner programme, whichwas aimed at encouraging thedevelopment of new professionalroles. Examples of such new rolesinclude anaesthesia practitioners,surgical care practitioners and, ofcourse, PAs.

To lead the PA development,a steering committee was con-vened by the DH, involving theRoyal Colleges of Physicians andGeneral Practitioners, universityrepresentatives, American-trainedPAs and others. The group wasgiven the task of developing acompetence and curriculumframework for the PA professionin the UK.

Box 1. The benefits of physician assistants (PAs) in secondary care settings

Patient continuity: PAs will be in a position to take the traditional house officer role, by being the continuingpresence in the unit. Currently changes in patterns of medical teamworking mean that consultants often findthemselves working with a succession of junior doctors, few of whom are part of their firm or know what (from amedical perspective) has happened to patients admitted before their shift.

Career stability: PAs, without the pressure of specialist career development, can be expected to stay in one clinicalsetting for a longer period of time. As the more junior levels of doctor move through settings at an ever-faster pace,this will become increasingly important, for patients, the junior doctors and the rest of the health care team.

Generalist gaze: with ever-increasing specialisation among doctors, the presence of a diagnostician with a moregeneralist gaze becomes more important. In the USA (and enshrined in the DH framework) there is an expectation thatre-accreditation of PAs will be on the basis of a broad spectrum of clinical knowledge, whatever clinical field theyhappen to be working in.

Most PAscurrentlyworking in theUK are based inprimary care

It allows themto play to theirown strengths

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PUBLIC ANDPROFESSIONAL CONCERNS

The required public consultationon the framework document wasundertaken in 2005, and a re-vised version was published in2006.4 Among mostly positivecomments, concerns were raisedabout the potential for PAs totake roles that might otherwisehave provided advancement forexisting professions, or to reducetraining opportunities, e.g. forjunior doctors. More recently, thepossibility of medical unemploy-ment has come to the fore andneeds to be taken into consider-ation.

THE COMPETENCE ANDCURRICULUM FRAMEWORK

This sets out the knowledge,skills and behaviours expected ofPAs on qualification, as well asguidelines for both theoreticaland clinical learning. For thelatter it sets minima for time tobe spent by students in variousfields (Figure 1). Although thelevel may be different, the theo-retical learning required mapsclosely to medical education(bioscience, ethics, behaviouralscience, etc.). The frameworkdoes not set out to provide anational curriculum and leavesconsiderable freedom for highereducation institutions (HEIs),and the NHS (in both primary andsecondary care), to provide clin-ical experience. It allows them toplay to their own strengths (e.g.research centres), to local needs(e.g. disease prevalence – Fig-ure 2) and educational expertise(e.g. problem-based learning).However, it has been agreed thatthere will be a national assess-ment of the common corerequirements for all programmes.Until the establishment of formalregulation and registration, thisis being managed by the Univer-sities’ Board for PA Programmes(see Table 1 for current member-ship). The national assessmentwill cover knowledge (using

Community medicineminimum 280 hours

General hospital medicineminimum 350 hours

Accident and emergencyminimum 160 hours

Mental health minimum 70 hours

Obs and Gynae minimum 70 hours

Paediatrics (acute) minimum 70 hours

1600 hours of minimum clinical experience

1000 hours of specified clinical experience

600 hours of additional clinical experience

of which up to 200 hours may be spent in clinical skills centres

6001000

200

Figure 1. All PA programmes will be required to provide their students with a minimum of 1600 hoursof clinical experience of which a maximum of 200 can be in a clinical skills centre setting. Only 1000

hours of experience in particular clinical fields is specified with the remainder being dependent on

resources and opportunities within an institution’s training circuit. The Competence and Curriculum

Framework suggests that this be used to extend experience in the fields identified above, rather than

other specialist areas.

Population variation:high prevalence of sickle cellanaemia

Nationalcore

Research strength:centre for immunology

Expertise:communication skills

Institutional core

Student selected

Figure 2. The national competence and curriculum framework leaves considerable scope for individual

institutions to play to their own academic and clinical strengths, or to focus on issues of particular

relevance to their local communities (institutional core) and to offer additional learning opportunities

from which students can select.

Formalregulation andregistration of

the [PA]profession are

essential

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multiple-choice questions orMCQs) and skills (using objectivestructured clinical examinationsor OSCEs) although individualHEIs will have their own pro-cesses for monitoring andassessing professional behaviour.Recognising the importance ofclear national standards for thisnew clinical profession, the HEIs,through the Universities’ Board,are actively collaborating instandard setting using Angoff forMCQs and the Borderline Groupmethod for OSCEs. Most HEIsintend to recruit graduates tointensive courses equivalent incontent to traditional 3-yeardegrees.

STANDARD SETTING IN THEINTERNATIONAL CONTEXT

Recognition of the difficultiesthat have arisen in trying to agreeEurope (EU)-wide standards forexisting professions developedindependently in member coun-tries, it is important that we graspthe opportunity to develop such astandard for PAs from the start.Productive initial discussionshave been held with HEIs in otherEuropean countries. We believethat the EU may also have a roleto play in facilitating the devel-opment of the PA profession inless well-developed countries.Links with the powerbase of the

profession in North America areequally important and the Amer-ican Academy of PhysicianAssistants has a continuinginterest in facilitating these dia-logues.

REGULATION ANDREGISTRATION

Although PAs currently qualifyingin the UK will be able to workunder delegation clauses in thesame way as their Americancounterparts, formal regulationand registration of the professionare essential. However, the time-table for the required primarylegislation has been disrupted bythe recent reviews of registrationand regulation for health profes-sions.5,6 Independent prescribingrights are also vital if the NHS isto maximise the ‘value added’ byPAs and will have to follow rapidlyafter regulation. A voluntary reg-ister is currently being estab-lished, but provision of a formalregister for PAs is of particularimportance because it is antici-pated that most entrants will benew to health care.

LOCAL WEST MIDLANDSDEVELOPMENTS

As can be seen in Table 1 there arefew PA students currently in

New roles arebeingdeveloped andold barriersbroken down

Table 1. Physician Assistant Programmes

InstitutionUndergraduatemedical education

First cohortadmitted

Highest annualintake to date

Anticipated new pla-ces in academic years

2007–08 2008–09

Hertfordshire Sept 2005 11 20

Kingston and St Georges 4 20

Surrey 20

Wolverhampton Sept 2004 8

Birmingham 4 60

Warwick 4

Discussions with colleagues in the Universities Board for Physician Assistant Education suggest that the aboveinstitutions will either be continuing their programme, or starting a programme in this or the coming academic year.It gives target figures for student intake in each institution/collaboration.

)

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training, but developments areproceeding apace and by 2010 weanticipate that there will be atleast 100 PAs qualifying fromBritish institutions per year. Morethan half of this number will betrained in the West Midlands,where the NHS has committeditself to support local HEIs inresponding to the grass-rootsneeds. The resulting programmeswill be collaborative across atleast three HEIs, involving shar-ing of facilities, materials, staffand clinical placements, anddrawing on the strengths of eachof the institutions involved.

ISSUES FOR CLINICALEDUCATORS

As few PAs are in post in the UK,most NHS clinicians will be unfa-miliar with the profession anduncertain of their educationalrole, in terms of both what theycan expect of the students andwhat the students can expectfrom them. The Universities’Board for PA Programmes recog-nises this as an important issue,particularly for the PA studentsthemselves who will need profes-sional role-models. In collabora-tion with the NHS, therefore, wewill endeavour to ensure thatsufficient PAs are recruited toboth teaching staff and the clin-ical area, and that institutions,

using this enhanced PA presence,will invest significant resources intraining and support for doctorsin this new education role.

CONCLUSIONS

The professional map of UK healthcare is changing. New roles arebeing developed and old barriersbroken down. Local, uncontrolledinnovation can create new rolesthat do not necessarily have theconfidence of patients or thehealth care team. We have there-fore invested considerable effortin the development of nationalframeworks, as well as continuingto work with the clinicians, at thegrass roots, who were the first topromote this role in the UK. Wefully expect that the conjunctionof local initiative, national cur-riculum development and thenecessary legislation will allow usto provide British-trained PAs forthe local health services by 2010.

With or without PAs, the NHSfaces a period of continuingchange and uncertainty. Wewould argue that, by dialogue andcollaboration (between profes-sions, between HEIs, betweeneducation and health providers,and across national boundaries)we can establish clarity for bothpractitioners and public. Further-more, we suggest that PAs have a

significant contribution to make,which will strengthen the healthservice and ultimately the healthof the public.

REFERENCES

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nfo1.html (accessed 15 April 2007).

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4. Department of Health. The compe-

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