Case Study
The use of the Physician Associate role
in cancer sites in the South East
Introduction
The Physician Associate (PA) role is a growing and evolving profession and is being successfully implemented in trusts across the South East and increasingly within cancer tumour sites, including urology, colorectal, breast, Ear, Nose and Throat and haematology. The Physician Associate post has been evaluated under Agenda for Change at Band 7.
Physician Associates (PA) are healthcare professionals with a generalist medical education who work alongside doctors, physicians, GPs and surgeons to provide medical care as an integral part of the multidisciplinary team. They are dependent practitioners working with a dedicated consultant supervisor but are able to work autonomously with appropriate support. The PA is responsible for their own actions and decisions and the consultant clinician is ultimately responsible for the patient. Their intensive two-year post-graduate training includes a minimum of 1,600 clinical practice and is based on the PA Competence and Curriculum Framework. After achieving the PA post-graduate diploma or master’s qualification they can then register with the Faculty of Physician Associates (FPA) on the managed voluntary register.
Core PA skills include being able to: take medical histories, conduct comprehensive physical examinations, request and interpret certain investigations, diagnose and treat illness and injuries and counsel, or offer preventative healthcare. With additional training they can also undertake extended skills. Statutory regulation does not currently allow PAs to prescribe or request ionising radiation although this is under review nationally.
What was the issue/problem that needed to be addressed?
There is a national shortage of qualified Oncologist Consultants and the South East, in turn has challenges appointing to these roles. PAs are employed in the Breast, Urology and Colorectal Departments by East Sussex NHS Healthcare Trust. The PA works ‘in parallel’ with the Oncologist Consultant. A multi-disciplinary approach is key and at department Patient Multidisciplinary (MDT) meetings new patients are discussed and which ones can be allocated to the PA.
How can the Physician Associate role support the cancer pathway?
The East Sussex Urology and Colorectal PA, for example, is responsible to both the Urology and the Colorectal Consultants and will personally see between 40 and 60 patients in a week across 2 hospitals. Patients are already diagnosed with cancer and the PA will have previously sat in with the Consultant to fully understand the different treatments. They are then able to explain treatments, undertake bloods and review blood and scan results, undertake patient observations, develop management plans and hold their own patient clinics. Clinics include prostate cancer patient follow-ups, assessing patients on radiotherapy treatment and their response to the treatment, seeing new and follow-up patients with already diagnosed prostate cancer in a urology clinic, and seeing patients on systemic anti-cancer treatment. The PA can consult with the consultant if required. They will also attend governance and MDT meetings.
PAs will also follow up administration tasks such as checking all the follow-up dictated and the administratively typed up patient clinic letters, follow up referrals to other departments or services, blood and scan results and ring patients after MDT meetings as required.
PAs continue to develop their practice and undertake continuing professional development (CPD) by attending internal trust Non -Surgical Oncology Group clinical development sessions, and the Consultant Journal Club where cross-site oncologists look at and discuss cases and look at new papers on treatments and good practice, for example. PAs are also supported by the Kent, Surrey and Sussex School of Physician Associates and can attend face to face and virtual CPD sessions.
What difficulties and barriers needed to be overcome to implement the change?
The main initial issue was other clinical staff understanding the PA role and how it complemented the existing staffing structure. Although the PA saves Oncologist time, the use of PAs can result in a change in the allocation of Oncologist time as PAs need mentoring, supervision and training and when any queries come back from, or about a patient, they go to the Oncologist. Cancer services are changing quickly and increasingly moving from a consultant run to a consultant led service which the PA role can support.
Funding of the PA role is often a challenge and may come from the departmental oncologist workforce budget usually from vacancy underspend.
It is recognised that the tasks which the PA undertakes over a long period of time in one department could become quite routine and repetitive. PAs are generalists and by working for just one particular service makes them specialist in that area and many of their other procedural clinical skills could potentially be unused. One potential PA option could be a 6-month rotational model across cancer sites including acute oncology which would ensure PAs also maintain their procedural clinical skills which, in turn, would keep the role fresh and interesting and encourage retention. Potentially, as PA numbers increase in a trust a more senior ‘lead’ PA role could be implemented to provide some career progression. Other future developments could also be involving PAs with clinical trials and audit control to expand skills and interest.
What benefits have resulted from the change?
The PA role has been successfully implemented in cancer sites across the South East. There is positive feedback from patients and clinicians. Unlike junior doctors who go on rotation the PA role is consistent in the department and so gets to know the staff and patients. PAs themselves report that they find the role extremely satisfying and rewarding.
The Physician Associate is a really great role and has huge opportunities-the role is what you make it. Initially I felt I almost had to prove myself as it was a new role in the department, but I work with some really good consultants who are happy to push the boundaries and I get to follow patients through their cancer journey which I find so rewarding. As I have progressed in the role, I have become more confident and have developed my practice and skills and can now see more complex patients.’’ Phoebe Watson, Physician Associate, Urology and Colorectal, East Sussex Healthcare NHS Trust.
The benefits of the PA role are huge. The PA saves Oncologist time by helping to reduce more routine aspects of the role such as explaining drug and other treatments and procedures to patients and running clinics. This all assists with the various cancer targets and helps improve patient care and experience. Trusts who currently employ PAs cite that they are seeking to take on more of these posts due to their success and added value to the department.
‘’ We are hugely converted to the Physician Associate role. They are a very valuable addition to our workforce undertaking delegated tasks such as conversations with the patient and on-going monitoring and we would like to continue developing the role.’’ Dr Angus Robinson, Consultant Clinical Oncologist Urology and Upper GI and Clinical Lead for Oncology team East Sussex NHS Healthcare Trust
Wessex Cancer Alliance PA Recruitment Programme
Wessex Cancer Alliance (WCA) has seen the potential value of a new workforce – the PA role – in cancer services and utilised the NHSEI Elective Recovery Funds to pump prime a total of 9 PAs in their most challenged pathways of prostate, breast and gynecology: with the aim of adding capacity and building resilience within the teams using a skills mix approach, expediting the diagnostic pathway for patients. The funding will enable the PAs to be employed for 12 months and includes salary on-costs. WCA has received support for planning and implementing the posts by Thames Valley and Wessex Physician Associates Ambassadors who helped to draw up initial job descriptions and work plans for the PAs in collaboration with the clinical leads.
The roles need to complement the skills mix already within the clinical teams: the PA role in this programme sits within the specialist area of cancer yet needs to maintain the generalist skill set of the PA and creating a work plan for the PA that is varied, challenging and attractive to recruit to. The WCA will continue to work with the clinical teams to support evaluation of impact of the PA role with the aim of highlighting their value to the trust, so the posts are made substantive.
The WCA has dedicated some project management time to this work to facilitate the clinical teams to better understand the PA role and how it would complement teams and is currently supporting recruitment to the posts. In addition, an ‘Employer PA Toolkit’ is being compiled to support recruitment and training and provide a quick guide to all things PA for other Wessex cancer teams considering employing a PA.
‘Don’t underestimate the lead- in time to support, prepare and engage clinical teams and trusts prepare for, recruit to and implement a new role like the Physician Associate as many are not familiar with the role and how it can complement teams, increase department resilience and capacity and support the Oncologist and patients on the cancer pathway. We were fortunate in having some project management time to work with trusts and teams to identify where the role could be best utilised and we hope to set up a PA Peer Support Forum to support the role-holders in the future.’
Kathy Cooke, Workforce Programme Manager, Wessex Cancer Alliance.
Contacts
Dr Angus Robinson, Consultant Clinical Oncologist Urology and Upper GI and Clinical Lead for Oncology team East Sussex NHS Healthcare Trust angus.robinson@nhs.net
Kathy Cooke, Workforce Programme Manager, Wessex Cancer Alliance – Kathryn.cooke9@nhs.net
Thames Valley and Wessex Physician Associates and Ambassadors
Kent, Surrey and Sussex Physician Associates