Exploring the role of physician associates in Aotearoa New Zealand primary health care

Introduction

Primary health care, including general practice, is often hailed as the cornerstone of any health care system given that it serves as the initial point of contact for those seeking medical assistance from either a physician or other health professional.^1–3 However, persistent shortages of primary care clinicians has jeopardised the sector’s ability to meet public demand, placing added pressure on the existing workforce to deliver such essential health services.^4,5

Recently, Manatū Hauora (the Ministry of Health) has put forth a proposal to regulate the physician associate (PA) profession under the Health Practitioners Competence Assurance Act 2003 (HPCAA) of New Zealand, with some scholars labelling it as a potential solution to Aotearoa New Zealand’s primary and secondary care workforce shortages.^6,7 Currently, there is no statutory regulation for PAs in New Zealand. While they have the option to voluntarily register with the New Zealand Physician Associate Society, the lack of statutory regulation limits their present clinical roles and responsibilities. Regulating the PA profession could help overcome problems with primary care physician (or general practitioner (GP)) shortages and reduce untenable workloads being placed on other health care professionals. However, there are also numerous concerns and considerations that need to be addressed in order for these valued health professionals to become integral members of the existing health care team. This article explores the potential contributions and challenges of incorporating PAs into New Zealand’s primary care, with a specific focus on the implications for general practice.

Method

A variety sources of literature that were relevant to the role, impact, and perception of PAs in primary care were selected for inclusion in this article. These sources included: journal articles, websites, legal material and reports produced by medical professional bodies.

Results

Physician associates (or physician assistants in the United Kingdom) are recognised internationally as essential members of the health care workforce, including in countries such as the United States, Canada, the United Kingdom, and the Netherlands, among others.^8–10 Although not doctors, PAs are skilled mid-level medical professionals capable of managing a variety of clinical responsibilities semi-autonomously.^10,11 These tasks include: taking medical histories, diagnosing illnesses, performing clinical examinations, and formulating treatment plans, often performed under the supervision of a doctor.^10,11 Prescriptive authority for PAs varies among countries. In the United States, PAs have the authority to prescribe, while in the United Kingdom, PAs are unable to prescribe due to a lack of regulation.¹² In a systematic review primarily examining the clinical outcomes and cost-effectiveness of PAs in secondary care settings, it was found that PAs are generally a cost-effective resource, and the quality of care provided by PAs to patients was comparable to that provided by physicians, when considering factors such as complications of care, mortality, hospitalisation, and readmissions.¹³ However, studies specific to general practices showed mixed results. An American study indicated savings of up to US$52 592 per annum when employing a full-time PA instead of a full-time family physician for equivalent clinical tasks in a family medicine practice in southwestern Pennsylvania.¹⁴ In contrast, a study in England indicated marginal savings per consultation with PAs compared to GPs (GBP £6.22 less per PA consultation).¹⁵ However, the average PA consultation was 5.8 min longer than that of GPs, offsetting the savings in direct consultation costs.¹⁵ A scoping review also found that patients were generally satisfied and receptive towards the use of PAs in primary care.¹⁶

However, the literature also highlights recurring concerns regarding the PA role. Such concerns include: limitations in clinical knowledge and practice of PAs, the lack of clarity around the role, competition with doctors’ training, and fears that PAs may be portrayed and used as a cheap substitute for fully qualified doctors.^17–21 PAs, although trained similarly to medical students, are not doctors.²² Therefore, even the most experienced PA would still require some form of appropriate on-site supervision. In the majority of U.S. states, PAs lack authorisation to practice independently and must work under the supervision of a licensed doctor.²³ New Zealand GPs who are considering employing PAs into general practice face challenges concerning supervisory burden and potential medico-legal issues arising from inadequate supervision.

Discussion

New Zealand’s primary care sector is facing significant challenges due to rising demand caused by factors such as population growth, an ageing population with increased comorbidities, and projected GP shortages.^4,24 To tackle these challenges, the primary care sector needs to adopt sustainable practices and enhance the existing skill mix. Introducing foreign-trained PAs into New Zealand’s primary care, who would work alongside other health care professionals, offers a potential solution to prevent further strain on the existing health workforce and help increase public access to primary care services. Like with other primary care health professionals, PAs also follow a curriculum that includes general clinical and academic modules. However, the unique aspect of PAs is that their curriculum is structured around a medical care model similar to that of medical students.^7,12,22 This distinctive approach better equips them not only to diagnose, analyse test results, and treat diseases based on their pathology and disease processes but also to recognise and identify medical conditions with varying degrees of complexity and risk. This comprehensive training makes them ideally positioned to work alongside GPs in managing day-to-day community-based illnesses. PAs could be instrumental in reducing GP workforce burnout as by managing common and low-risk medical conditions, it frees up time for GPs to focus on more complex medical cases such as patients with chronic conditions or unique health care needs.²⁵ It also encourages GPs to take up leadership roles within larger multidisciplinary healthcare teams. This gives GPs the opportunity to engage in more other important activities such as professional development courses and research, allowing them to better address the evolving healthcare needs of a growing and ageing population.²⁵

Supervising GPs, who are ultimately responsible for coordinating and managing patient care, may face unwanted liability in the event of an adverse clinical error when delegating clinical responsibilities to PAs. Pursuant to section 72 of the Health and Disability Commissioner Act 1994 (HDCA) of New Zealand, the actions of a practitioner who is an employee, member, or agent of another health care provider are treated as having been done by the employing authority as well as the practitioner who committed the act.²⁶ Given that PAs work under a licensed medical doctor’s supervision, they are legally considered agents of the supervising doctor. Thus, under section 72, clinical mistakes made by a PA may also result in liability for the supervising doctor. The recent Supreme Court decision in Ryan v HDC shows that the application of section 72 has a very broad reach meaning that a doctor may be held liable for the actions of their agents even if they had nothing to do with the incident.²⁷ The implications of section 72 in our context would mean that for GPs to minimise their legal liability risks when employing and supervising PAs, they would need to scrupulously evaluate all of the PA’s clinical examinations, diagnoses, and treatment plans and actively be aware of what the PA is doing. However, achieving such a feat would be extremely time consuming and costly. It raises the question: What is the point of employing a PA when the GP could have directly examined the patient themselves without having to incur the additional cost of supervision? The prospect of legal liability under agency law is likely to discourage GPs from hiring PAs.

Nevertheless, the role of PAs extends to more than just a mere relationship with the supervising doctor. PAs are integral members of a larger multidisciplinary health care team, collaborating with professionals like nurses, health care assistants, and other allied health professionals. For the PA role to thrive and reach its full potential, it necessitates mutual respect, trust, and support from other health care professionals. Given the relative inexperience of the New Zealand health workforce in understanding what the PA role entails or what their clinical responsibilities are, collaboration with various health professional regulatory bodies (such as the Medical Council of New Zealand, Nursing Council, among others) and specialist medical colleges (such as The Royal New Zealand College of General Practitioners) is essential for providing guidance to healthcare providers on how these new clinical roles can be integrated into existing primary care teams. It is also important to inform the public about the implications of these changes, particularly in relation to the impact on the care that they receive.

Continuing to have an unregulated medical profession practicing in New Zealand poses a potential threat to the integrity of our health care system, with a genuine risk of compromising patients’ life and health. Regulating the PA profession would yield various advantages, providing assurance to the public that PAs are clinically competent and fit to practice as well as ensuring that registered practitioners are culturally safe and ethically competent.

Conclusion

In conclusion, the prospect of regulating the PA profession marks an exciting development with the genuine potential for PAs to work alongside other health care professionals, thereby alleviating rising workloads and enhancing the expertise of doctors. This, in turn, holds promise for improving the delivery of primary care services in New Zealand.