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Physician associates in the United Kingdom

Parle, James MD, MBChB, DRCOG, FRCGP

Journal of the American Academy of PAs: February 2015 - Volume 28 - Issue 2 - p 14–15
doi: 10.1097/01.JAA.0000459817.09661.24
Commentary
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James Parle is a professor of primary care at the University of Birmingham in the United Kingdom, chair of the UK and Ireland Universities Board for Physician Associate Education, and program director for the postgraduate diploma program in physician associate studies at the University of Birmingham. The author has disclosed no potential conflicts of interest, financial or otherwise.

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Similar to other developed countries, the healthcare system in the United Kingdom faces the challenges of rising demand and cost at a time of economic constraints. Workforce modernization is one of the strategies for addressing these challenges. Traditional job demarcations and conventional team structures are being challenged and redesigned to maintain quality while reducing cost. The deployment of physician associates is one part of this broader strategy for improving workforce performance. With five physician associate programs (Aberdeen, Birmingham, St George's London, Wolverhampton, and Worcester) and about 250 physician associates employed, mostly in hospital practice, an opportunity presents to ask: How did they get here?

The first American-trained physician assistants came to the United Kingdom in 2000 to work in the West Midlands as part of a demonstration project and to launch the UK physician associate movement. Although a few have remained, the leadership of the profession has shifted to UK-trained physician associates and the UK Association of Physician Associates. Within the National Health Service, physician associates have been seen as a threat by some clinicians (those who have never worked with a PA) or as the “best thing since sliced bread” by many of those who have.

In the early days, most physician associates worked in family practice (all UK citizens have the right to a family physician and 99% of UK residents are registered in a local physician's practice). Family practices were the primary employers more than big hospitals, probably because they are small independent businesses, more flexible, and able to innovate rapidly. Since 2010, physician associates also have been recruited extensively into hospital practice, particularly in acute internal medicine and emergency medicine. However, physician associates work in a wide range of specialties, including forensic psychiatry, pediatric intensive care, trauma, and orthopedics. Most UK physician associates now work in hospital practice and about 17% of UK hospitals now employ physician associates. Demand is outpacing supply for physician associate services.

One of the main challenges facing UK physician associates is the lack of legal regulation governing their activity. Consequently, they cannot prescribe nor order radiographs. Although work-arounds are the nature of innovative service delivery, the profession and the universities providing education are lobbying actively for statutory regulation, with strong support from the medical Royal Colleges and from employers. Regulation is viewed as important to protect patients (by having a compulsory register and protected title) and to set educational standards for pre- and postqualification, as well as politically to establish physician associates as a real clinical profession.

The UK physician associates are optimistic that the right to prescribe and to order radiographs will follow soon after statutory regulation is in place. The Royal College of Physicians of London has recently agreed to set up a faculty specifically for physician associates (the first exclusively nonphysician faculty it has instituted). This will provide a high-prestige home for the physician associate profession, will involve other colleges (including surgery, primary care, pediatrics, and family medicine), and is seen as a very positive step toward full acceptance and statutory regulation.

A number of strategies have been developed to better-inform the public and the medical community. Some examples involve having physician associates speak at medical meetings and conferences; and a presence on the web, Facebook, and Twitter. In March 2014, a highly successful conference was held in Birmingham, convened jointly by University Hospitals Birmingham (one of the biggest hospitals in the United Kingdom), the University of Birmingham, and the UK Association of Physician Associates. Published research and experience in various medical journals is critically viewed as essential for legitimation.1-4

Physician associates will not be employed unless the universities are able to train them in sufficient numbers. The United Kingdom has about 60 million citizens (one-fifth the population of the United States) and a pro rata number of working physician associates would be about 16,000, or about 800 times as many as currently employed! However, many UK medical schools and health sciences schools are looking seriously at opening physician associate programs. If statutory regulation is achieved, physician associate programs are likely in many more schools: an estimated 20 are needed, and 10 universities are exploring running programs.

Lastly is the response of employers to this new profession. As with clinicians, employers range from ignorant to evangelical.However, despite the low current output of physician associates (35 in 2013), physician associate jobs have been advertised across a wide range of specialties. The relatively small private sector in the United Kingdom also is taking an interest.

In conclusion, the physician associate profession is beginning to establish itself in the United Kingdom. To date, employers have been interested, especially when encountering physician associate students. With increasing support and more universities developing physician associate programs, the future, though not yet by any means certain, looks bright.

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REFERENCES

1. Ross N, Parle J, Begg P, Kuhns D. The case for the physician assistant. Clin Med. 2012;12(3):200–206.
2. Ostler J, Vassilas C, Parle J. Physician assistants: friends or foes to doctors. BMJ Careers. 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20008022. Accessed November 6, 2014.
    3. Williams LE, Ritsema TS. Satisfaction of doctors with the role of physician associates. Clin Med. 2014;14(2):113–116.
    4. Farmer J, Currie M, West C, et al. Evaluation of physician assistants to NHS Scotland: final report. UHI Millennium Institute, 2009. http://www.ukapa.co.uk/files/Scotland-PA-Final-report-Jan-09.pdf. Accessed November 24, 2014.
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