From the editor

Physician assistants revisited

Last year Clinical Medicine published Ross et al's article ‘The case for the physician assistant’.¹ These professional health workers in the UK have a training background involving a two-year postgraduate diploma, equally split between theory and clinical practice. While over 80,000 physician assistants (PAs) are employed in the US, where the profession first developed and has been growing for over 40 years, Ross et al cited a figure of 130 graduates from UK programmes at the time of writing. They pointed out the immense potential value to the NHS of a cohort of professionals, with generic competencies, providing continuity of care as they work under the supervision of qualified doctors. In this edition of Clinical Medicine White and Round publish a qualitative analysis of the experience at St George's Hospital in London following the introduction of PAs into the paediatric intensive care unit.² Despite some, not unexpected, teething problems – many of which reflected a lack of clarity and uncertain expectations of the role that PAs would play – they report that after time had passed PAs had become ‘an indispensable part of the team’.

The Department of Health, as long ago as 2006, published Competence and curriculum framework for physician assistants,³ prepared in association with the Royal College of Physicians and the Royal College of General Practitioners, and to many it seemed that this was a step on the way towards establishing a statutory framework for the profession. This process has now stalled, as part of a wider government decision against statutory regulation of further health professions in the future.⁴ This is despite the fact that at first glance the PA profession appears eminently appropriate for regulation under the Health and Care Professions Council, which regulates many groups of health workers with the common attribute of well-delineated professional qualifications. While the tide of events a few years ago might have foretold a steady increase in the number of courses training PAs, the reverse has happened, with only St George's University of London and Aberdeen currently accepting students. It seems likely that the lack of progress on statutory regulation plays a significant part in this unexpected trend reversal. Universities may feel uncertain about running, and NHS Trusts about supporting, these courses, which, although they lead to an academic qualification and acquisition of defined competencies, do not bring with them entry into a profession as recognised as, for example, physiotherapy or nursing. Students may well be deterred and prefer the option of training for entry into a statutorily regulated profession. Despite this, growth in PA employment in the NHS continues and demand will continue to outstrip supply until new courses are developed. And the lack of statutory regulation brings with it clear limitations in the fulfilment of the role that PAs could reasonably be expected to play – most notably an inability to prescribe, but also, for example, barriers to ordering radiological examinations.

The training followed by the deployment of PAs mirrors in an interesting manner the training and deployment of physicians. PAs, like medical students, receive a clinical training that is very broad – though clearly much shorter than the medical students'. However, thereafter, particularly in hospitals, they adapt to fill the requirements of the services within which they work, be that orthopaedics, neurology, orthogeriatrics or acute medicine (for more detail of fields in which PAs are employed, see the UKAPA website at http://ukapa.co.uk/). The report of White and Round reflects that this period of role-definition and training, and indeed this adaptation, not only to the branch of medicine, but also to the particular arrangements in a particular service in a particular location, may well underlie the worth that PAs may bring. Nonetheless recertification in clinical knowledge ‘across the board’ is a requirement for them and maintaining this broader medical perspective is one distinction from both nurse practitioners and indeed from most doctors in the hospital service. Another key difference also from those cadres is that PAs remain under supervision by doctors.

Much past debate concerning the provision of emergency medical care, the staffing of acute medical units and indeed the training of generalist vs physicians has taken place against assumptions of a traditional background of consultants and doctors in the training grades, and the reality, therefore, that much of the assessment and treatment of acutely ill patients will be done by, in some cases, very recently qualified medical staff. At certain times in the yearly cycle, as tyro staff commence working, the burden of supervision on senior staff accelerates – only slightly ameliorated by the recent introduction of a period of shadowing by new trainees before they take up their substantive posts. While the task of training the next generation of doctors may, in grandiose terms, be described as a privilege, it seems unlikely that senior staff would regret the presence of a more permanent tier of health workers, working under their supervision, with skills that would become adapted to the environment within which they work. Adding to any medical team one or more trained individuals who have adapted to the particular workload and the specific environment within which they are working, are familiar with local custom and practice, and are working long-term in that environment, providing continuity to the service, would benefit care and provide a valuable resource for trainees passing through what, for them, is unfamiliar territory. There is a legitimate argument that the lack of statutory regulation may be inhibiting the development of this.