Interim Evaluation Physician Assistants

1
Interim Evaluation Physician Assistants

• Jane Farmer
• UHI Millennium Institute

Centre for Rural Health Research Policy
2
Core Research Team

• Jane Farmer (Innovation in health), UHI
• Mags Currie (Researcher), UHI
• Professor Jeff Hyman, University of Aberdeen (HR
  management)
• Christina West (nurse/manager)
• Dr Neil Arnott (GP)
• (Patient representative)

3
Introduction to evaluation

• Aim evaluate impact contribution of PAs to
  effective healthcare
• Objectives
• assess role contribution of PAs -
• Scope of practice
• Patient safety
• Team working
• Productivity
• Patient satisfaction
• Costs, benefits resources
• Cultural and social adaptation
• receptiveness of participating NHS Boards
  partnership forums
• assess the extent to which PAs integrate into
  current clinical teams
• evaluate time taken effectiveness of clinical
  supervision
• evaluate impact of PAs

4
Current situation with PAs

• Started with 12 PAs
• 1st October 10 PAs
• 3 left, 1 leaving, 1 arrived Oct. 2007
• 4 more at recruitment stage for 2 NHS boards (new
  settings)
• All new PAs continue in evaluation

5
Data collected by 1st October 07 (1)

• Feb/ March 2007, group ( individual) PA 1st
  interviews
• Exit interviews with PAs who have left
• Feb-April 2007 1st interviews with team members
• Written descriptions of Scope of Practice (SoP)
• Monthly MS-PA interaction forms Jan. 2007-
• MS time in supervision/ patient safety/ current
  topics
• Activity data for PAs / team members - March 2007
• 2nd round data collection taken place/ happening

6
Findings Scope of Practice

• SoP often not mapped prior to PA arrival
• PA role like junior doctors/ SHOs, GPs
• PAs bring continuity (context of MMC, etc)
• Unclear SoP
• may have negatively impacted integration
• team members take time to assess competence
• easier in small teams
• Concerns re PA often from poor understanding of
  PA concept
• Ability to demonstrate full capacity?
• prescribing
• deployment
• Does the project cover all settings that could
  benefit?

7
Scope of Practice PA flexibility

• I dont know whether its just his personality
  or what, but I mean this guy is Mr Blue Peter and
  can turn his hand to anything, hes very
  accommodating, very enthusiastic and even
  thoughI think he feels that his skills are being
  under-utilised on it, because its a protocol
  screening thing and so weve taken that on board
  and the idea is that well use him relatively
  short term to get the project up and running.
  Once its going then well sort of dovetail a
  nurse in at the back end and have perhaps
  different nurses doing it through the course of
  time but you know youve got confidence with
  name of PA that it doesnt really matter what
  you set him, hell go off
• (Medical Supervisor, C)

8
Patient Safety Satisfaction

• No significant patient safety concerns reported
• 2 cases of mistaken names detected before
  problems
• PAs considered confident autonomous
• Deal with cases in their SoP - seek help outside
  this
• Recruitment adverts not always matching final
  placements
• Comments about patients response to PAs positive
• take time with patients
• explain things to patients
• approachable and easy to talk to

9
Patient Safety

• Im very happy with what she does I have a look
  at her triage surgeries. Ill have a quick kind
  of squint down through patients to see what shes
  done to see if it would be what I would do with
  them. But shes very good. I mean today she came
  along and kind of blethered through a couple of
  patients with me, which was great. And she had
  made up her mind and she was just wanting to say
  Is this okay? Is this what you would do?
  Absolutely the same.
• (Team Member 2 C)

10
Team working

• Assessing competence small vs. large teams
• Initial scepticism as PAs settled in
• Issues related to PA integration/introduction
• preparedness of the team prior to PA arrival
• understanding of what a PA is
• team size
• perceived need or gap
• feedback for PA
• Flexible team working vs delegation within the
  team (systems culture USA-UK NHS)

11
Cultural and Social Adaptation

• Time of arrival
• Support network of other PAs
• PA / Team interaction
• Introduction to setting and Scottish NHS
• Some inductions better than others
• NHS complex and confusing
• Main reasons for PAs leaving
• Social and cultural/ personal

12
Productivity

• Similar to junior doctor in secondary care
• Relieve GP workload in primary settings
• Likely to increase with time
• Good on explaining/reassurance/advice sometimes
  impacts on time with patient
• Difficult for team to calculate?
• Comparative activity data collected used for
  discussion

13
Costs, Benefits and Resource Implications

• Viewed difficult to judge at this stage
• More beneficial with perceived need /gap
• Good - continuity in a setting
• Cost effectiveness
• Salary in relation to other professions
• Cost of training not presently incurred by NHS
• Cost of (perceived?) increased investigations

14
Costs and benefits

• In a sense, we have in a PA, a well trained
  clinically competent individual who comes with a
  wealth of experience who doesnt require much in
  the way of training, so she comes as a complete
  package, if you like. Or almost a complete
  package. As opposed to trying to train one of our
  local nurses up to sufficient standards, so its
  a quicker option and therefore theres not the
  investment in training so I would imagine
  (Medical Supervisor A)
• Id initially been sceptical because I had
  argued that well why are we importing people from
  America, why cant we just train our nurses
  better. However, having had it here, I would
  recommend a PA well over the way that we
  currently have our nurses trained. It is more
  like having a second GP in the practice, rather
  than a couple of nursing staff. (Team Member 3
  C)

15
PAs NPs

• Similarities
• Similar to junior docs
• Day to day running of wards
• Similar task profile
• Similar manager role
• Deal with problems nurses dont deal with
• Role appreciated by consultant

• Differences
• PAs more confident to ask suggest to consultant
• NPs all training in situ noted PAs quick
  adaptation
• NPs limited capacity to move between jobs

16
PAs where they fit

• There does seem to be a difference in terms of
  what a PA does, in terms of what a nurse does but
  its difficult to find it within a team thats
  already fairly cohesive because all these teams
  are fairly cohesive. You know, there are, theres
  no obvious gap for this person to sit, except
  perhaps in place where there just wasnt enough
  doctors. (Medical Supervisor C)
• They the PAs get very fed up if theyre fed
  into a kind of protocol driven environment so if
  you get them to do chronic disease management
  like a practice nurse, it doesnt seem to light
  their fire. They find it too easy. Theyre much
  more challenged by new diagnosis and, you know,
  full work ups or spotting things that dont fit
  with a protocol and trying to figure out whats
  going on. They like that much more so. It would
  suggest that they work much more like a doctor
  than they do like a nurse. Hopefully Im not
  being patronising as I say this. Medical
  Supervisor - C

17
Time taken effectiveness of clinical supervision

• Varied between settings
• Different to USA interaction
• Perceptions of what it should be time taken -
  differed MSs/ PAs
• Supervision received from a range of sources
• Some MSs unprepared for what PAs require/want
  in supervision/ getting used to new system

18
Time taken effectiveness of clinical
supervision - quote

• And my supervisor is great and I feel, I can
  go to my supervisor any time with questions
  and if I see the doors open and my
  supervisors got a minute Ill sit down and say
  Okay, well I had, this is, whats this? That
  sort of thing. But in general I feel I can go to
  any of the doctors which is nice to be able to
  do. (PA - B2)
• It all works very differently in the States and
  they all have one supervisor and thats it. But
  the way we work, we have to sort of transpose it
  into the doctor type model because I cannot
  guarantee, I do a shift pattern, and I cant
  guarantee being on duty all the time with my PAs.
  So what weve done is weve done exactly what we
  do with the juniors. Im educational supervisor
  for various junior doctors, doesnt mean Im on
  with them all the time but there is always a
  consultant on. (Medical Supervisor B)

19
Flavour of whats to come

• Hints from current data collection
• Most are happier than last time
• But there are still some fragile areas
• Accept they are unable to change NHS?!
• Supervisor-PA relationship vital
• Feedback, interest, trust
• Team members are noting distinct roles
• NPs protocol driven
• PAs can do the grey areas

20
Concluding remarks

• Many findings related to early stages arrival/
  settling in
• Many related to culture shock expectations
• A lot to expect people to uproot to Scotland/ NHS
  for 2 years
• A disruption for teams MSs too
• How differentiate the USA PAs from the real
  importance of the role in Scotland?
• If we grew our own PAs would they be like these?