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A 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 below)

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 Nursing Organisation, says NZNO remain 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, said the evaluation showed that 'no harm' had been by the PA demonstration but she too had 'no idea' why New Zealand would want to start afresh with PAs when NPs could already do all the work of PAs and more, including prescribing, without supervision.

George Froehle, a PA who was part of the pilot and is a spokesperson for the Physician Associates Society, said it was misleading 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 anyway limit our scope of practice.”  He said supervision involved ensuring the supervising physician and PA developed a scope of practice plan that reflected 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,” said Froehle.

Ruth Anderson, group manager of HWNZ, said there were 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," said Anderson

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

Graham-Smith said with HWNZ having spent in excess of $1.2m on the most recent pilot that NZNO was pleased that there would 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, said she believed the evaluation was properly conducted and efficient but she regretted 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 added that she could not see why New Zealand should need to go to all the '"extra trouble'" of regulating the PA role when "we have yet to fully utilize the NP model fully". 

The government recently announced HWNZ was 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

During the Phase II PA demonstration three PAs were based at practices in Hamilton's Radius Medical group offering drop-in clinics, 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 (CMDHB) 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 workload of existing staff.  Patients surveyed were equally satisfied with the care they received from PAs and the existing health workforce.

The survey said 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," said 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 said that if the PA role was to develop into a 'homegrown' role then issues that needed to be considered included 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 to doctors may be a "powerful driver' to develop the PA role further.

 

*Article amended on Aug 10 to add comment from George Froehle.

*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.