Medical care practitioners: a necessary import?

To help patients get treated more quickly, Britain's health service wants to hire more workers to take medical histories; do physical examinations; order investigations; and diagnose, manage, and treat illnesses.

Sounds like they want to hire more doctors? Not quite. The planned additions to the workforce will make up an entirely new medical profession, with an idea effectively imported from the United States.

The new role, tentatively titled "medical care practitioner" for the UK, is based on the physician assistants in the US, who operate under the supervision of a doctor but can end up managing care for patients single handedly, particularly in primary care settings.

The move is part of a massive upheaval of who does what in the NHS, which is deeply in debt and short of staff, particularly after the introduction of the European Working Time Directive, which has limited the hours doctors can work. The NHS says that it wants to use each type of worker to the peak of their skills, which means doctors are becoming more specialised, nurses do some jobs once restricted to doctors, and some traditional nursing roles have been handed to healthcare assistants. The new role would fit in somewhere between a nurse and a doctor.

Sharing out work in an expanded medical team is a popular trend in many parts of the world, and it isn't new either: skilled assistants who were not doctors but who did medical work were employed in the Russian army from at least the 18th century, and formed a part of civilian health care in the Soviet Union.

The US physician assistant grew up out of a shortage of primary care doctors in the late 1950s and 1960s, much as exists today in the UK and elsewhere. Then, medical educators realised that although short of doctors, the US had plenty of competent medical workers, many of them service personnel trained in the Vietnam war.

The first cohort of future physician assistants began training in 1965, and now the profession is in the top three fastest growing in the US, with more than 60 000 members, says William Fenn, a professor at Western Michigan University, a physician assistant for 28 years, and chairman of his professional body's international affairs committee.

He says that physician assistants can deal with the common illnesses, leaving doctors to tackle more puzzling cases.

Care driven by physician assistants has attracted interest from other countries. Staffing low population density rural areas with doctors can be difficult financially, and the need for doctors in training to rotate between different specialties breaks continuity. In addition to the UK, Canada and the Netherlands are taking steps to bring physician assistant roles into their civilian healthcare systems, and Liberia and South Africa are interested, Professor Fenn says. Australia, New Zealand, and Guyana are among several other countries that have also made inquiries.

Physician assistants are generalists and basically do the jobs of a junior doctor. In the US, they diagnose and treat illnesses, order and interpret investigations, and prescribe drugs. "[Physician assistants] practise autonomously, but not independently, and that I think is a hard concept for doctors in this country to grasp," says Neil Erickson, one of an advance party of physician assistants who have started working in England in the past four years and president of the newly established UK Association of Physician Assistants.

SHOUT/REX
Whose job is it, anyway?

Training is at postgraduate level, rigorous, and medically based. Most courses are at masters level and take two or three years. After taking a national certifying exam, physician assistants, as for US doctors, have to get a state licence, and finally they must find a doctor to be their supervisor. But it is not always the assistant who is the employee. Sometimes physician assistants end up hiring the doctor.

Mr Erickson himself worked as a physician assistant in the US air force, in the federal prisons system, and in a rehabilitation hospital before running a surgery in the Arizona desert, where he saw 35-40 patients a day, "birth to death." Now he works in primary care near Bedford in England, where he has been for the past two years. He can count 27 physician assistants currently working in England, some in primary care, some in hospitals.

The first were hired in the West Midlands, in response to a local staffing problem. UK health planners had anticipated a coming shortage of primary care doctors, and the physician assistant role had found its way into a 2000 NHS reform plan and a 2001 report from the Royal College of Physicians. But little action had taken place to introduce the new job.

A nurse led general practice in association with the seven other practices of a primary care consortium based in Tipton, northwest of Birmingham, took its own look at physician assistants when it could not find a doctor to replace a retiring GP. Finding medical establishment voices in favour of the move and defence unions happy to insure the new practitioners, the consortium hired two US assistants in 2003, with doctors undertaking responsibility for their competence. The local NHS trust was so impressed that by mid-2004 it had hired another 12. A study by Birmingham University published in 2005 found both clinical colleagues and patients had responded positively to the new workers.

Things moved on at a national level partly in response to this success. With physicians' and general practitioners' royal colleges on board, a national management team drew up a proposed training curriculum and job description for a physician assistant-style medical care practitioner, and put it out to public consultation. The responses, published in July, showed a lack of consensus on who should regulate the new job, but most respondents agreed with the suggested framework.

The next steps are to decide who should regulate the new role and to get the necessary legislation through parliament. Then health authorities will be able to start employing the new professionals and commission training for more of them. The NHS stresses that it won't be forcing anyone to employ medical care practitioners, but that they will only get jobs if hospitals or primary care trusts want them.

Professor Fenn says that the prevailing consensus doesn't see legislation happening much before 2008, or 2007 for the most optimistic.

Ahead of the finalisation of the curriculum, several universities have expressed interest in training workers like physician assistants and two already offer related courses.

Things may move quicker in Scotland, which has recently hired about 19 physician assistants in a variety of disciplines.

Toby Reynolds, London



studentBMJ 2006;14:309-352 September ISSN 0966-6494