Nurses unconvinced by positive PA evaluation

August 2015 Vol 15 (4)

A positive evaluation of a Health Workforce New Zealand-funded physician assistant (PA) pilot in primary health has been released. HWNZ has no plans to take further steps to initiate a PA training programme but more US-trained PAs are being sought by practices and an application for regulation of the role is in the pipeline. FIONA CASSIE reports.

Jenny CarryerA just-released evaluation of the $1.2 million pilot of physician assistants working in general practices is generally positive about the new health role.

But nurse leaders remain sceptical of the usefulness of importing an unregulated workforce needing doctor supervision when New Zealand is yet to make the most of the nurse practitioner (NP) model.

The evaluation report was on Phase II of the physician assistant (PA) demonstrations commissioned by Health Workforce New Zealand (HWNZ), which involved seven US-trained PAs being brought in to work in four general practice or rural settings across the country. (See more about PA role and pilot on the next page.)

The report was commissioned to consider the potential contribution of the PA role to the existing health workforce and found that the vast majority of demonstration site staff believed PAs made a valuable contribution and patients were satisfied with the care they received from the PAs. The report concluded that all demonstration site employers were ”very keen” to maintain the PA role beyond the end of the demonstration pilot and it did not receive any evidence to suggest that this should not happen.

Hilary Graham-Smith, associate professional service manager for the New Zealand Nurses Organisation, says NZNO remains unconvinced the PA role is required in New Zealand. “NPs do not need supervision and PAs do – limiting, we believe, their scope and usefulness across the sectors where they would be most useful e.g. primary care.”

Professor Jenny Carryer, executive director of the College of Nurses, says the evaluation shows that no harm has been done by the PA demonstration but she too has no idea why New Zealand would want to start afresh with PAs when NPs can already do all the work of PAs and more, including prescribing, without supervision.

No PA training plans

Ruth Anderson, group manager of HWNZ, says there are no plans to offer further HWNZ funding to establish, or support training infrastructure for, the physician assistant role in New Zealand.

“The Ministry will evaluate any applications for regulation of the role according to the criteria and processes employed for all applications,” says Anderson.

She adds that employers are currently able to recruit PAs as long as the PAs do not undertake work regulated under the Health Practitioners Competence Assurance Act or other legislation.

Graham-Smith says NZNO is pleased that there will be no further investment in PA training by HWNZ.

“In our view, the pilot was unnecessary and was conducted in a vacuum without any policy work to support the introduction of the role.”

Carryer, who was a member of the demonstration advisory group, says she believes the evaluation was properly conducted and efficient but she regrets that a million-plus dollars was spent on an experiment for a “workforce that we do not need if we got our act together with the existing workforce”.

“More investment in NP positions and more investment in postgraduate education for primary health care nurses would have been a better use for that money.”

Carryer adds that she cannot see why New Zealand should need to go to all the ‘”extra trouble’” of regulating the PA role when “we have yet to fully utilise the NP model fully”.

The New Zealand Medical Association (NZMA) and the New Zealand Physician Associate Society (NZPAS) have confirmed that they are working together on a submission to HWNZ asking for the PA role to be regulated under the Health Practitioners Competence Assurance (HPCA) Act. It is understood the submission is currently in draft form and once lodged HWNZ would make a recommendation to the Minister of Health. An NZMA spokesperson said the Medical Council of New Zealand has agreed to provide regulations if the Minister backs regulation of the PA role.

Meanwhile Health Minister Jonathan Coleman recently announced HWNZ is to allocate $846,000 to pilot a one-year dedicated training programme for 20 would-be nurse practitioners in 2016, which has been warmly welcomed by nurse leaders.

PAs welcomed by practices

During the Phase II PA demonstration, three PAs were based at three drop-in clinics run by Hamilton’s Radius Medical group (now called Tui Medical). Two went to a Tokoroa practice, one to Waikato-based iwi provider Raukura Hauora o Tainui, and one was based at Gore Hospital’s emergency department. (The Phase I trial of the PA role involved two PAs working at Middlemore Hospital in Counties Manukau District Health Board in 2012.)

The evaluation report found the physician assistants undertook more than 30,000 patient consultations during the evaluation period and surveys indicated that doctors, nurses and other staff believed the PAs made a “valuable contribution” to their clinical settings, including improving patient throughput and reducing the workload of existing staff. Patients surveyed were equally satisfied with the care they received from PAs and the existing health workforce.

The survey says most nursing respondents indicated there was no negative impact on nursing and that the two roles complemented each other. “In a few cases, some nurses indicated that they had stopped doing some tasks they had previously undertaken, such as suturing, and a nurse at one of the sites indicated a concern that the autonomy of nurses at the site had been reduced,” says the report. The report also noted that some interviewees expressed concerns that the growth of the PA role would come at the expense of developing the NP role.

Senior managers of the three host employers emphasised the cost–effectiveness of the PA role. The evaluation report noted it was commissioned only to look at the “potential contribution of the PA role” and not to look at PA regulation, establishing training programmes or long-term integration of the role. But it says that if the PA role is to develop into a “homegrown” role then several issues need to be considered. These include regulation and medico legal issues (including prescribing and supervision boundaries), the cultural fit of US-trained PAs, implications for developing existing professions, and whether in some settings the reduced costs of PAs, compared with doctors, may be a “powerful driver” to develop the PA role further. :

*The usual title given to the profession is physician assistant and this is the established title in the United States. But since the demonstration got underway, HWNZ has been using the alternative title of physician associate.


NZPAS says supervision doesn’t limit PA usefulness

George Froehle, a spokesperson for the New Zealand Physician Associate Society (NZPAS), says it was misleading [for NZNO and the College of Nurses] to say the need for supervision limited PAs’ usefulness in primary care.

“While PAs do operate under supervision, that supervision is not overly burdensome to the supervising physician and it does not in any way limit our scope of practice,” says Froehle.

He says supervision involves ensuring the supervising physician and the PA develops a scope of practice plan that reflects the PA’s specific skills sets; the physician being available to answer questions either in person or over the phone, and retrospectively reviewing the PA’s caseload every few months.

“The trial specifically showed that PAs were incredibly useful in primary care, delivering high levels of care to over 30,000 patients without a single incident of harm,” says Froehle.

Froehle is working with NZMA on the submission for PAs to be regulated under the HPCA Act (see main story). 

Tui Medical keen for more PAs

Froehle was one of three pilot PAs who worked alongside a nurse practitioner and four more nurses on the NP pathway at three Hamilton drop-in clinics.

Rebekah Elphick, quality manager for Hamilton’s Tui Medical Centres (formerly part of Radius Medical) as well as a clinical master’s qualified nurse on the NP pathway, says Tui is keen to employ more PAs to work in its clinics.

“We have found that the PAs and nurses training to be NPs have worked incredibly well together, particularly in the acute medical and accident scope of our services and in our larger free clinic with the high-needs population,” says Elphick. She says of the three pilot PAs starting out in Tui’s clinics, two were still working with Tui in August and the third had returned to the United States at the end of her two–year visa for personal reasons.

Elphick says Tui has advertised for more PAs from the USA and was near to offering jobs so it could add more PAs to its team. She says one of the two original PAs would be staying on with Tui, as she had no visa issues due to being married to a New Zealander. Froehle is returning to the USA at the end of his two-year visa but says he plans to continue as president of NZPAS to support the role in New Zealand and may return once regulation is established.

PAs: the current position

  • PAs undergo generalist training based on medical training.
  • PAs can be delegated to carry out patient assessment and prescribing under physician supervision.
  • (During the New Zealand trial, PAs were unable to sign prescriptions or file ACC claims etc). 
  • In the United States training is a two-year postgraduate qualification, with about half coming from a nursing background and the remainder from other health professions, such as paramedics and physiotherapy.
  • A US Department of Health report says that there were approximately 106,000 nurse practitioners and 70,000 physician assistants practising in the US in 2010 (55,000 of the NPs and 30,000 of the PAs were practising in primary care).
  • Other countries that have adopted the PA role in some form include Canada, the United Kingdom and the Netherlands.
  • Australia has trialled PAs and the Australian Society of Physician Assistants reports on its website that Australia is reviewing its legislation and government position.

HWNZ role in demonstration sites

  • HWNZ developed a governance document making it clear that the medico-legal responsibility for unregulated PAs’ work lies with the supervising doctor. The supervising doctor also sets the scope and responsibilities of the PA and must be available for consultation by the PA at all times.
  • HWNZ facilitated the appointment of PAs, including taking part in interviews and offering funding support for travel, visa and relocation costs.
  • HWNZ also funded professional development for the PAs and general project coordination.

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