Accepted: 4 January 2017

DOI: 10.1111/hex.12542

O R I G I N A L R E S E A RC H PA P E R

Patients’ experiences of consultations with physician

associates in primary care in England: A qualitative study

Mary Halter PhD1 | Vari M. Drennan PhD RN1 | Louise M. Joly PhD2 |
Jonathan Gabe PhD3 | Heather Gage PhD4 | Simon de Lusignan MD5

1
Faculty of Health, Social Care and
Education, Kingston University and St Abstract
George’s University of London, London, UK Background: Physician associates are new to English general practice and set to ex-
2
Social Care Workforce Research Unit, King’s
pand in numbers.
College London, UK
3 Objective: To investigate the patients’ perspective on consulting with physician
Centre for Criminology & Sociology, School
of Law, Royal Holloway, University of London, ­associates in general practice.
Egham, UK
Design: A qualitative study, using semi-­structured interviews, with thematic analysis.
4
School of Economics, University of Surrey,
Guildford, UK Setting and participants: Thirty volunteer patients of 430 who had consulted ­physician
5
Department of Clinical and Experimental associates for a same-­day appointment and had returned a satisfaction survey, in six
Medicine, University of Surrey, Guildford, UK general practices employing physician associates in England.
Correspondence Findings: Some participants only consulted once with a physician associate and others
Mary Halter, Faculty of Health, Social Care & more frequently. The conditions consulted for ranged from minor illnesses to those
Education, Kingston University & St. George’s
University of London, Cranmer Terrace, requiring immediate hospital admission. Understanding the role of the physician as-
London, UK. sociate varied from ‘certain and correct’ to ‘uncertain’, to ‘certain and incorrect’, where
Email: maryhalter@sgul.kingston.ac.uk
the patient believed the physician associate to be a doctor. Most, but not all, reported
Funding information
This article presents independent research positive experiences and outcomes of their consultation, with some choosing to con-
funded by the National Institute for Health sult the physician. Those with negative experiences described problems when the lim-
Research NIHR Health Service & Delivery
Research programme (study number its of the role were reached, requiring additional GP consultations or prescription
09/1801/1066). The views and opinions delay. Trust and confidence in the physician associate was derived from trust in the
expressed by authors in this publication are
those of the authors and do not necessarily NHS, the general practice and the individual physician associate. Willingness to con-
reflect those of the NHS, the NIHR, NETSCC, sult a physician associate was contingent on the patient’s assessment of the severity
the HS&DR programme or the Department
of Health. or complexity of the problem and the desire for provider continuity.
Conclusion: Patients saw physician associates as an appropriate general practitioner
substitute. Patients’ experience could inform delivery redesign.

KEYWORDS
General Practice, Patient Acceptance of Health Care, Patient Satisfaction, Physician Assistants,
physician associates, Primary Health Care

1 | BACKGROUND within health-­care teams to ensure delivery of care.1 One category

of these is the mid-­level practitioner2 positioned to provide clinical
Health care is labour-­intensive, and in the face of medical shortages services which may be a substitute for, delegated from or an enhance-
and financial constraints, health-­care systems have designed new roles ment of medical practitioner services.3 One such mid-­level practitioner

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd

Health Expectations. 2017;20:1011–1019. 

wileyonlinelibrary.com/journal/hex | 1011
1012 | HALTER et al.

is the physician associate (PA), previously known as physician assis- techniques.26 This study reported mixed responses from patients in an
tant, in England and the wider United Kingdom (UK).4 The physician area where the PA had been the sole primary care provider for the pre-
assistant role developed in the United States of America (USA) in the vious two years, with the patients suggesting that they would some-
1960s with over 86,000 PAs employed in all health-­care settings, in- times prefer to see a doctor due to a) not having confidence in the PA
cluding primary care, in 2015.5 PAs are trained in the medical model (not being a doctor), b) already having a doctor or c) having a long-­term
to diagnose, treat and refer autonomously, as agreed with their super- condition requiring specialist care.26
5
vising physician, in line with local legislation. Building on the model Against this background, our study addresses the evidence gap re-
from the USA, PAs have been introduced to other health-­care sys- garding the patients’ perspective on the innovation of PAs providing
tems such as Canada, Australia, the Netherlands, Germany and India.6 general practice services, in a country where nurses are an established
In the UK, the first PAs employed in the mid-­2000s in the National part of the state funded, general practice team.27 The study draws on
7,8
Health Service (NHS) were American-­trained. The first UK-­trained the interpretative tradition28 and builds on our patient survey respon-
4
PAs graduated from post-­graduate diploma courses in 2009. Unlike dents’ evaluative judgements to address questions of how patients un-
PAs in the USA and the Netherlands, those in the UK do not currently derstood the role of PAs and their experience of health care provided
have the legal authority to prescribe and do not currently come within by a PA as a mid-­level health practitioner.
a state regulatory framework for health professionals.9 Concern about
current and predicted shortages in the general practitioner (known in
some countries as family physician) workforce, together with a policy 2 | METHOD
emphasis of greater delivery of care outside of hospital, has led to rec-
ommendations for more PAs to be employed in primary care10 and a The data reported here are from a larger study which involved six
policy statement by the Minister of Health in England that 1,000 PAs general practices employing PAs across southern England and six
will be employed in general practice by 2020.11 matched practices which did not.29 The practices were purposively
PAs are a recent innovation in UK general practice settings, and sampled to represent the different types of practice found in the UK
they have been mainly deployed to provide consultations to patients by list size and number of practice partners, in urban and rural settings
requesting urgent or same day appointments.12,13 PAs in this setting with varying levels of deprivation.29 Five of the practices employed
are formally defined as dependent practitioners to the general practi- only one PA, the sixth employed two; four PAs were female and three
tioner, but can work independently in the practice health-­care team, male; four had trained in the USA and three in England.
seeing and referring patients on and reviewing clinical test results.4 A Adult patients (n=430) were given a patient satisfaction survey,
review of evidence regarding PAs in primary care from 1950 to 2010 which included a request to volunteer for an interview, by recep-
found only six published studies from the United States which sought tion staff as they left a same day or urgent consultation with a PA.
14
the views of patients who had consulted PAs. Of these, five studies Completed volunteer forms, with contact details, were returned to the
used surveys and reported high levels of satisfaction.15–19 Within the researchers. A topic guide was developed to explore issues not cap-
UK, two short-­term pilot schemes to introduce US-­trained PAs to dif- tured by the patient survey, that is patient choice about whether they
ferent types of services, including primary care in the NHS in England saw a PA or not and their level of satisfaction with that experience
and Scotland, also reported high levels of patient satisfaction.7,8 An and associated reasons; the patient’s understanding about the PA role,
observational study in England comparing PA and GP consultation exploring information provision and experience of seeing PAs; their
records (n=932 and n=1,154, respectively), with a linked patient sat- experience of the PA consultation compared with their expectations
isfaction survey (n=490 and n=590, respectively), conducted by the of consulting a GP, probing issues of confidence and trust; how issues
authors, also found that the majority of respondents were satisfied or such as making a referral and prescribing were handled by the PA and
very satisfied with their consultation with both PAs and GPs, and all the impact of this on the patient’s experience; and their perspectives
but a very small number reported confidence and trust in the PA or on consulting a PA and/or GP in the future.
GP. Eleven patients (4.1%) reported they would prefer to see a GP in One hundred and fifty-­two patients expressed an interest in vol-
20
future. unteering for an interview as part of the qualitative study we report
The conceptual issues and limitations of patient satisfaction sur- here. Of these, contact details for 43 were incomplete, 40 did not
veys are well documented.21–23 Satisfaction is a relative concept, respond to the researchers’ contact attempts, and four contact de-
based on evaluative judgements,23 and in the instance of such a role tails were received after recruitment had closed. Researchers made
innovation as PAs substituting for GPs, it requires more in-­depth un- contact with 40 patients and, of these, 34 participated in an inter-
derstanding of the dimensions upon which the judgements are being view (all but one by telephone). Interviews lasted between 10 and
made.23 Calnan suggested that a conceptual framework for lay evalu- 20 minutes. Four interviews were not used when it became apparent
ation of health care should include elements of the level of experience that the consultation being discussed had not been with a PA or the
of health care and the goals of those seeking such care.24 In-­depth adult participant described a consultation for a child. With consent,
information about patient experience can be captured using inter- the interviews were digitally recorded and transcribed. Interpretive
views.25 (p9). However, only one study which sought the views of pa- analysis was conducted using thematic analysis30 by two authors (LJ
tients who had consulted PAs, conducted in the USA, used interview and MH) with another researcher. Transcripts were read and re-­read;
HALTER et al. | 1013

initial codes were developed through discussion and applied initially to

3.3 | Variation in understanding of the role of
a small number of transcripts, enabling further discussion and iteration
physician associates
of the thematic index. Coding against the index was undertaken by the
same three researchers, with at least two carrying out parallel coding The participants described the PA role in ways that varied widely.
of each transcript. Any disagreement was addressed through discus- We grouped participants’ understandings into three categories:
sion and further iteration to the analytical process if necessary. QSR “certain and accurate,” “certain and inaccurate” and “uncertain.”
International’s NVivo 10 Software was utilized in the analytic process. The first two groups expressed their understanding of who they had
The study was approved by a UK NHS Research Ethics Committee. seen with clarity, although their understanding may not have been
accurate.
The first group was certain they understood the role of the PA and
3 | FINDINGS
expressed this understanding accurately in terms of it being a close
relationship to doctors, but correctly realizing that it was a different
3.1 | Description of participants
role, one which meant they had a recognized education but could not
The thirty participants were unevenly spread across the practices do everything a doctor could do. For example:
(minimum two, maximum 11 per practice) but were diverse in terms of
gender (12 female and 18 male), age (range from 27 to 90 years), eth- My understanding would be somebody who’s less qualified
nicity (nine people were of black and minority origin and the remainder than a doctor but is able to deal with the sort of more rou-
were white) and socio-­economic background as defined by the Index tine things like earache I guess would be a good example
of Multiple Deprivation for their general practice31 (see Table 1). of it.
One participant was a carer who had accompanied their relative (Participant 15)
to the PA consultation. The types of health condition described by the
participants in consulting a PA ranged from simple conditions such as Participants such as these recounted well-­developed strategies
an ear canal impacted with wax, to acute illnesses requiring immedi- within the practice of informing patients about the PA role, for example
ate hospital admission via an emergency department and serious con- leaflets at reception and information given by the PA as soon as they
ditions requiring on-­going care, such as leukaemia. The participants entered the consulting room:
varied in their familiarity with the PA in their practice with 11 having
consulted only once while the remaining 19 had consulted the PA pre- They’re just like doctors. I mean when I first started to go
viously. Of the latter, three had consulted very frequently with the PA and I saw one, a long time ago,….I asked them [the recep-
in the management of an on-­going condition. tion staff] about Physician Assistants and they gave me a
leaflet and then I had a chat with the person himself, the
Physician Assistant and he explained about his education
3.2 | Thematic analysis
and his background in America and you know I realised
Four interlinking themes were identified as follows: then that they’re almost doctors, they just can’t quite do
everything here that they can, that a doctor could do.
1. Variation in understanding of the role of PAs (Participant 17)
2. Trust and confidence in the PA consultation
3. Comparison with a GP consultation Several participants in this group appeared to describe an inter-
4. Patient willingness to see a PA again. pretative process whereby they had picked up on clues that the PA
was not a doctor, most obviously with the issue of prescription signing
Each of these themes is described and exemplified below with having to be made by a doctor and not the PA, leading to comments
quotes from the transcripts. such as:

T A B L E 1 Index of Multiple Deprivation

Decile* of lower super output
of the practices at which interviewees
Practice employing a PA Number of interviewees area31
were registered
1 5 Eighth
5 11 Fifth
6 3 Fourth
10 2 Second
11 6 Fifth
12 3 Second

*where the first decile is the most deprived.

1014 | HALTER et al.

I worked that [the PA not being a doctor] out myself. The analysis of this theme then leads to the interlinked issue of
(Participant 29) trust and confidence in the physician associate and the general prac-
tice in which they were located.
The second of these groups was also confident in their perception of
the role of the PA, but was inaccurate. They framed their description of
3.4 | Trust and confidence in the physician associate
the PA as being closely related to a doctor, for example understanding
the PA as someone in training, “almost an apprentice” (Participant 17), Participants were generally positive about trust and confidence in the
or as a qualified doctor from another country who is simply unable to physician associate and the consultation although some were more
prescribe: cautious or contingent. Trust and confidence appeared to be both
influences on and influenced by the PA consultation through an in-
Basically, as I understand it, they’re basically a trained terplay of health system (that is the NHS), their general practice and
physician or trained doctor, but there’s just a few things individual consultation level factors.
that they can’t carry out, like signing the prescriptions and It was evident that confidence and trust were conferred on the PA
things like that, yeah. consultation, initially, through participant’s trust and confidence in the
(Participant 28) wider system of the NHS and in their own general practice, in particular
its senior partners. Participants reported that they trusted their GPs to
These participants were therefore clear that there were differences employ appropriate and competent staff and made general statements
between PAs and the doctors who were their GPs, and were aware of such as having confidence “in all our GPs….down there” (Participant
potential reasons for these but were not aware that the PA role was not 20). Trust was also described as engendered through knowledge of
in fact that of a doctor. the immediacy of access to a GP by the PA in any ­consultation, as in
The third group was uncertain about the PA role. Of concern were this example:
those who had felt confident that they had seen a GP at the time of
the consultation but had learned that they had seen a PA as a result I knew the difference [between the PA and the GP ] and
of the research process. Others in this category had understood at that the help was next door [the GP] if he needed it, so
the time that they had seen someone referred to as a PA but had not I was more than happy with seeing [PA’s name] and that
known what that meant. There were mixed views as to whether this would make me confident to see [PA’s name] again.
lack of clarity was appropriate for patients. One participant considered (Participant 34)
it to be “the right way to go about it” (Participant 19) to avoid patients
having concerns about not seeing a doctor, while others expressed Trust also appeared to be built through the experience of positive
puzzlement and a little disquiet about not understanding at the time consultations, that is, trust in the individual PA. Participants described
they had seen a PA rather than a doctor, with a sense of having been PAs as having good consultation communication skills, having time to
misled, as in this exemplar: listen and responding appropriately, as below:

I would have liked the receptionist to be a little bit more To get someone like [PA’s name]; because we’re in our 60s
upfront with me at the beginning when I booked the ap- that’s how doctors, doctors used to be, they knew their
pointment, and I perhaps would have liked when I went patients. I know they’re overworked now or got too many
into the room the physician assistant to actually explain patients but [PA’s name] has this ability and I think it’s a
the role. I don’t think it would have made any difference, I given, I think some people have it and some people don’t.
still would have gone in, and I still would have, I still would (Participant 14)
have felt that the treatment of me was very good, but I
feel, I feel that I would have understood a little bit more Participants also reported trust being built through judging the PA
about what was happening during my treatment. I don’t as competent in the clinical activities of assessing, making referrals, ini-
know why they didn’t tell me, I’m not sure whether they tiating treatments (through prescriptions for medication taken to the
didn’t want me to think [the PA’s name] wasn’t a doctor doctor to sign) and advising on self-­management. As in the quotation,
and to think that [the PA’s name] wasn’t going to do such participants were often experienced in their own health conditions and
a good job. used this as the basis for their judgements:
(Participant 03)
Well they’ve [the PAs] never given a diagnosis that I didn’t
Analysis of the participants’ accounts therefore indicated that vari- think was a good diagnosis, they’ve always given the right
ability in understanding of the PA role was linked to the provision of in- medicine in my opinion, it’s always worked. So I’ve never,
formation by the practice staff and by the PA, as well as to whether this ever had a problem, that’s why I feel confident with them.
was the first time they had seen the PA or had an on-­going relationship It’s as if you’re seeing a doctor.
with them. (Participant 17)
HALTER et al. | 1015

Clinical competence was also noted in the identification of addi- of examination and investigations, as they considered they would
tional health problems that the patient had not been aware of, as in this have received from a doctor:
exemplar:
….I had no idea that he wasn’t a fully qualified GP…..the
She pointed something out my dad wasn’t aware of. He questions he asked, he did an examination, the exam-
went with a certain complaint and then when she was ex- ination that he did for me was all really professional and
amining his body she saw like a sort of a lump in his neck exactly as I would expect him to do which is why, when I
and she was saying, ‘Mr X, what’s this?’ And he was saying, walked out of the door I said ‘thank you Doctor’ because
‘Oh, no, this is because of old age,’ and she was saying, ‘I for me he did everything I was expecting……
don’t think so, I think I need to refer you because maybe (Participant 03)
this is linked to what you’re complaining about’.
(Participant 02) A notable difference was when medication needed to be prescribed.
The participants had experienced different methods to organize this.
Judgements about competence also appeared to be contingent on One reported approach was for the PA to leave the consulting room
the patient’s previous experience of the PA. Some participants recounted to discuss the case with a GP and then return to the patient with the
trust in seeing the PA being based on the PA having known when the signed prescription while they waited either in the consulting room or
presenting condition(s) required the advice or additional assessment by waiting room. Participants also reported collecting the signed prescrip-
a GP as described here: tion from reception or having it faxed to the local pharmacy. The need
for prescriptions to be verified and signed by a GP was reported by most
I had no hesitation in going to an appointment with him participants to cause no apparent or significant delay. A small number
because I’d seen him before, so I was quite happy that he of participants reported delays of five to ten minutes with a minority
was confident and knew where his boundaries laid. reporting longer waiting times ranging from 15 to 30 minutes. While
(Participant 34) some considered this reasonable, others felt it unacceptable as in this
example:
Despite a high level of trust being expressed by many participants,
this was not universal and was certainly not the immediate response It’s quite annoying, actually, because, I mean, I feel that if
of everyone beginning a consultation with a PA. Some participants ex- people can prescribe it they should be able to sign it.
pressed less trust or confidence in the PA, initially as an unknown type (Participant 23)
of professional but also subsequent to negative experiences in consulta-
tion style or outcome. Such experiences raised the issue of boundaries to
professional practice and how these can have a negative impact on the
3.6 | Willingness to see a physician assistant again
participants’ experience in terms of incomplete or delayed care:
The majority of participants reported that they were not offered a
I went in there and I really was nearly in tears with the pain. choice of whether they saw a PA or GP when they booked their same
He (PA) listened to me in fairness, went out of the room day/urgent appointment. For the small number of participants who
because he has to then run it by a doctor. I waited 20 min- described having actively sought an appointment with a PA, the rea-
utes and it came back and his words to me were ‘she said sons included a shorter waiting time to see a PA, dissatisfaction with
you’ll have to come back tomorrow’. And I had to walk out prior appointments with GPs and trust in the PA based on previous
of that surgery in agony. Now that isn’t satisfactory…. contact.
(Participant 14) Many participants expressed their willingness to see a PA in fu-
ture consultations for any condition, while others expressed a will-
Analysis of the issue of trust and confidence therefore highlights ingness to return to consult a PA as conditional on the problem.
mixed, sometimes conflicting, experiences, apparently influenced by Minor conditions or less trivial complaints, for example, were seen
prior as well as “on the day” experience. as appropriate for a PA consultation. Participants who reported more
complex conditions or medication requirements felt this was some-
thing for which they would need to consult a doctor, as illustrated
3.5 | Comparisons with a GP consultation
here:
Participants were not specifically asked to compare their consultation
with a PA to that of a GP but many did so in explaining their experi- I think if it was just a general complaint he [a cared for rel-
ences in terms of what they usually received at their practice. Most ative] wouldn’t mind seeing her [the PA] but regarding his
participants perceived that their consultation with a PA was either no prescription, he’s a bit fussy about his medicine, he would
different from or was very similar to a consultation with a GP. They prefer to see a doctor.
described being asked the same questions and given the same types (Participant 02)
1016 | HALTER et al.

Willingness to return to see a PA again was also influenced by par- available to those interested in the development and changes in skill
ticipants’ motivation to help offset the pressures faced by general prac- mixes in providing same day or urgently requested primary care con-
titioners, as in this example: sultations – traditionally provided by doctors.32
Interlinking influences on and impacts of patients’ experiences
I understand the need sometimes to take the pressure off have been identified which we present as a theoretical model illus-
the doctors…..so I am very aware that I don’t want to take trated in Figure 1 and discussed below.
up appointments when it isn’t really that necessary. So The diversity of patients’ understandings of the professional role
the thought that there is a role within the surgery where I of the PA ranging from “certain and accurate,” through “uncertain” to
could go and see somebody who isn’t as pressurised as the “certain and inaccurate,” has been identified in other UK studies of
doctor,…..is a really good thing to have in the surgery and substitution by nurse practitioners for GPs33,34 and also in primary
I feel that I would be happy to utilise that again, definitely. care dental services in the substitution of dentists by dental thera-
(Participant 03) pists.35 It was evident from the participants’ accounts that the differ-
ent forms of information used by general practices to explain the role
For some participants, regardless of how satisfied they were with had only been partially successful in ensuring that patients understood
the PA consultation, maintaining continuity of care with a particular the nature of the physician associate substituting for the doctor. The
professional was equally if not more important than having a preferred absence of prior warning and explanation created situations in which
type of practitioner. Consequently, if a participant had already con- confidence in the clinical care from the PA and in the general practice
sulted a GP about a particular problem, their preference was to consult as a whole was at risk. Confidence and trust are linked concepts.36
them again. There were examples, however, where participants were In health care characterized “by uncertainty and an element of risk
choosing the PA to provide that continuity of care, giving positive ac- regarding the competence and intentions of the practitioner on whom
counts of the PA’s ability to recall details such as a medical and family the patient in reliant”37 (p2), trust is considered to be crucial. It was ev-
history, as well as the PA being seen as part of the community. For ident that where patient confidence in the PA, was apparent, it derived
example: from the public health system, noted in one other substitution study,35
but primarily from the general practice itself, as well as from the ac-
I’m trying to make her [the PA] my regular, I say doctor, tions of the PAs themselves. Development of trust in nurse substitutes
but my regular person I see at the surgery…she seems to for doctors, through actual consultations, has been noted before.33,38
understand my needs. I get on really well with her……… As I We see a close relation to the model of Rowe and Calnan,39 who not
said, because it’s a [type of practice], you’re sort of shuttled only describe the interplay of different levels of trust, but also consider
around from doctor to doctor. You don’t really get to make that trust relations in the NHS are increasingly based not only upon
a relationship with anybody, and appointments are very traditional clinician–patient roles of embodied, affective trust arising
quick as well, as in, you’re sort of shuffled off really quickly, from status-­based reputation, relationships and interaction, but also
like a conveyor belt. upon informed, cognitive trust arising from rational judgements and
(Participant 21) performance, that is, trust is conditional.39
On a more practice-­based level, while the majority of participants
confirmed a positive view of the consultations with PAs, there were
4 | DISCUSSION those reporting less positive experiences. These were consultations in
which the boundaries of the PA’s knowledge or jurisdiction had been
Our findings presented differing patient experiences of consultations reached, resulting in a transfer of the patient to the doctor or unac-
with PAs, although most were presented positively. Participants in ceptable delays in obtaining signed prescriptions. Similar patient views
general were unworried about the GP’s task being substituted by a have been expressed regarding nurse practitioners substituting for GPs,
PA who appeared to act similarly to a GP, and who inspired high trust which has resulted in repeat consultations and more time being spent
and confidence. However, participants were displeased if the role was by patients in more visits to the general practice.33,38 In the UK, a parlia-
not explained to them, feeling deceived by their practice and the PA. mentary Health Select Committee report has recommended that phy-
Many felt that the PA was competent to perform a GP’s role, but were sician associates should be included in state regulatory processes as a
sometimes frustrated by the restrictions around the role, particularly matter of urgency,40 with the objective particularly of allowing the issue
the inability to prescribe. Willingness to see the PA again was differ- of prescribing rights to be addressed. While this would address some of
entiated by presenting condition, as well as by experience and views the concerns our participants raised, it would not eliminate all experi-
on continuity of care. ences of episodes of care not being able to be completed at one visit.
This article has presented greater depth of understanding of the Chapple et al38 suggested that the way in which patients accepted
patient’s perspective, as to the experience of consulting with a new seeing a nurse rather than a doctor was in having their needs met in a
type of health practitioner, a PA, who was substituting for a doctor way they expected a GP would have carried out. Similarly, in our study,
in general practice. While the findings were broadly reflective of the it was evident that patients constructed the new role of the PA in the
larger survey’s results,29 the qualitative findings extend the knowledge context of their understanding of the medical role and their willingness
HALTER et al. | 1017

Uncertain understanding based on:

incomplete informa on provision
or
incomplete understanding
or par al deduc on

Accurate understanding based on:

Inaccurate understanding based on:
informa on provided
lack of informa on/ choice
or
pa ent deduc on
Knowledge and
understanding
of the Posi ve influences
Physician Associate Macro: trust in the NHS
role Meso: trust in the general prac ce
Micro: PA conduct and communica on;
Unfavourable against GP benchmark: adherence to boundaries
-Having to check with the doctor
-delays to assessment;
-inability to prescribe
Trust
Competence of the and
Physician Associate Paent experiences confidence
in comparison of the in the
with GPs Physician Associate Physician Associate
role in
general pracce

Favourable against GP benchmark: Nega ve influences

-Same/expected ques ons, examina on, Meso: 'decep on' by the prac ce about the PA
inves ga ons Micro: 'decep on' by the PA about their role;
-Prior nega ve experience with a GP adherence to boundaries
-Posi ve view of PA communica on skills
Con ngent willingness
to consult with a
Physician Associate
again

Willing:
-for some condi ons Unwilling
-for any condi on

Co-dependencies:
-con nuity
-wai ng mes
-whether choice is offered by the prac ce

FIGURE 1 A representation of the interlinking influences on and impacts of patients’ experiences of a physician associate in general practice
in England

to consult the PAs in the future was contingent on their own view of clinical care scenarios. Such support was not unanimous amongst their
who was needed to treat their presenting problem, alongside a de- participants and varied by previous experience of physician assistants
sire for receiving the continuity of care that they considered used to or nurse practitioners, and by income group, type of health insurance,
be provided by their GP. There are different elements in continuity age and ethnicity of the patient. Our qualitative data do not allow us
of care – relational as well as the management of the health condi- to consider the role of such variables, and the issue of point of care
tion.41 As the organization of general practice in the UK has changed, cost to the patient is not relevant to the UK context; however, we do
achieving continuity of care has become more difficult.41 Some par- also report a discerning approach from patients about the choices they
ticipants offered insights that the consulting style of the PAs together make – when offered a choice – to seeing physician associates or GPs
with the perceived ease of access made them a preferred alternative for different clinical conditions. The extent to which this holds in prac-
to the GP. Ease of access, in terms of waiting time, is reported else- tices which organize in different ways, for example, personal patient
where as related to the concept of acceptance of seeing an alternative lists for GPs, would require exploration.
42
primary care provider to the physician. These authors report that, This study was limited in that the volunteer participants were self-­
although a physician remained the first choice of provider for about selecting, rather than purposively selected; however, they represented
half of the respondents, acceptance of seeing a PA or a nurse practi- diversity in their characteristics and experiences of PA consultations.
tioner increased as the wait to see a physician increased in less urgent Our practices and PAs were also volunteers and were small in number;
1018 | HALTER et al.

we do not claim that these findings are generalizable, but the numbers 5. Bureau of Labour Statistics. What Physician Assists Do in Occupational
of PAs in primary care are currently small and we achieved a range of Outlook Handbook 2014-15. http://www.bls.gov/ooh/healthcare/
physician-assistants.htm#tab-2. Accessed December 1, 2015.
practices. We chose to use telephone methods to overcome logistical
6. Hooker RS, Hogan K, Leeker E. The globalization of the physician as-
problems which added to the immediacy following the consultation. sistant profession. J Physician Assist Educ. 2007;18:76–85.
We are aware that, while there are suggestions from some studies 7. Woodin J, McLeod H, McManus R, Jelps K. Evaluation of US-
that telephone interviews can yield lower quality in terms of missed trained Physician Assistants working in the NHS in England. 2005.
Unpublished report. http://www.birmingham.ac.uk/Documents/
reporting43, with the interviewer having no visual cues,44 others con-
college-social-sciences/social-policy/HSMC/publications/2005/
clude that the same amount and quality of data can be gathered in Evaluation-of-US-trained-Physician-Assistants.pdf. Accessed January
telephone and face-­to-­face interviews.45,46 22, 2017.
8. Farmer J, Currie M, Hyman J, West C, Arnott N. Evaluation of phy-
sician assistants in National Health Service Scotland. Scott Med J.
2011;56:130–134. doi:10.1258/smj.2011.011109.
5 | CONCLUSION 9. Ross N, Parle J, Begg P, Kuhns D. The case for the physician assistant.
Clin Med. 2012;12:200–206.
Patients’ experiences of new health-­care professionals when substitut- 10. Health Education England. The future of primary care Creating teams
for tomorrow. 2015. http://hee.nhs.uk/work-programmes/prima
ing for another’s role are important for understanding public accepta-
ry-and-community-care-programme/primary-care-workforce-com
bility and for embedding the new role. Largely positive views reported
mission/. Accessed December 1, 2015.
here of 30 PA consultations, in six GP practices in England, when seen 11. Hunt J. New Deal for General practice. 2015. https://www.gov.uk/
as similar to those the patients have with GPs, are tempered by other government/speeches/new-deal-for-general-practice. Accessed
views containing some critique of the role and how it is being commu- December 1, 2015.
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nicated. These experiences raised issues around patient knowledge
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desire for continuity with a trusted clinician. Underpinning these was 13. Drennan VM, Chattopadhyay K, Halter M, et al. Physician assistants in
a gap regarding patient choice. Maintenance of trust and confidence English primary care teams: a survey. J Interprof Care. 2012;26:416–
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in the general practice and the professionals in various roles employed
14. Halter M, Drennan V, Chattopadhyay K, et al. The contribution of
within it require recognition and prominence in the organizational de- Physician Assistants in primary care: a systematic review. BMC Health
livery of the general practice. Qualitative analyses can provide valu- Serv Res. 2013;13:223. http://doi.org/10.1186/1472-6963-13-223.
able insight into the effectiveness of health system transformations. 15. Hill RF, Greenwood JG, Wert FS. An evaluation of a remote, rural clinic
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Exploration of patient experience provides insights into the strengths
16. Mainous IAG, Bertolino JG, Harrell PL. Physician extenders: who is
and limitation of the PA in primary care. using them? Fam Med. 1992;24:201–204.
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CO NFLI CT OF I NTE RE ST 18. Kane RL, Gardner J, Wright DD, et al. Differences in the outcomes
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No conflicts of interest have been declared. tioners. J Fam Pract. 1978;6:133–138.
19. Hooker RS, Cipher DJ, Sekscenski E. Patient satisfaction with
physician assistant, nurse practitioner, and physician care: a na-
ACKNOWLE DG E MEN TS tional survey of medicare beneficiaries. J Clin Outcomes Manag.
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The authors would like to thank patients, general practitioners, physi- 20. Drennan VM, Halter M, Joly L, et al. Physician associates and GPs
cian associates and practice staff whose involvement made this study in primary care: a comparison. Br J Gen Pract. 2015;65:e344–e350.
doi:10.3399/bjgp15X684877.
possible, and our patient and public involvement panel.
21. Carr-Hill RA. The measurement of patient satisfaction. J Public Health
Med. 1992;14:236–249.
22. Sitzia J, Wood N. Patient satisfaction: a review of issues and concepts.
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