MBA Healthcare management Research proposal

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Exploring a new identity:

A qualitative study investigating

the experiences of Physician’s

Associate’s in respect to being

regulated by the General Medical

Council.

MODULE NUMBER: MOD001774

STUDENT ID: 1922012

Abstract

The General Medical Council (GMC) believes that it should regulate the Physician’s

Associates (PA), as long as it didn’t increase the fees of the doctors. Physicians

Associates have now become an integral part of the medical workforce, and are found

in every specialty possible. It also said that the long-term regulation of Medical

Physicians Associates (MAP’s) needed to be financially sustainable. "Doctors cannot

be expected to incur additional costs through their annual retention fees for the

ongoing regulation of MAPs," the GMC said. (1)

The thought of regulation stems from the issue that people often misunderstand

Physician’s Associates, and a lot of people are unaware of their role specifically.

Physicians are unable to prescribe medication, so the regulation of this body by the

GMC would help relieve the burden from medical professionals, and would give them

the authority to prescribe. It would further provide credibility and competence to the

PA’s so that their skills are effectively utilized. Regulation will ideally help to reduce

the gap that seems to exist between PA’s and doctors. (2)

The study would involve a qualitative methodology using loosely structured

interviews. The interviews will then be recorded and transcribed verbatim. The

transcripts will then be coded using Framework Analysis techniques. Interviews will

be undertaken with PA’s in different clinical settings. Including the views and

perceptions of the PA’s into the GMC’s decision-making process of the absorption of

the FPA will have a positive impact on them. It will lead to reduction in workload of

the doctors, and benefit the healthcare system as a whole, in the process of

combating the problem of understaffing. It will also improve the efficacy of PA’s in

the NHS as a whole.

Aim :

To gain insights into the perceptions of PA’s into their views of the GMC regulating

the FPA, so as to incorporate their views into the laws and regulations regarding

PA’s.This will ensure a smooth transition into the GMC, and establish trust between

the PA’s and the GMC.

Objectives :

To explore PA’s general perception of the GMC’s decision to regulate the Faculty of

Physicians Associates, to get an insight into their mindset and how it might affect

them.

Key Words: Physicians Associates, General Medical Council, Hospital, Faculty of Physician Associates, Perception

Abbreviation:

GMC - General Medical Council

PA - Physician’s Associates

UKAPA - UK Association of Physician Associates

NHS - National Health Services

DH - Department of Health

TABLE OF CONTENTS :

1. INTRODUCTION

2. LITERATURE REVIEW :

2.1 Role of physician associates within the medical workforce

2.2 Hierarchy

2.3 Governance

2.4 Uncertainties in the Profession

2.5 Strengths

3. RESEARCH METHODS :

3.1 Collection of Data and Analysis 3.2 Data Analysis 3.3 Strengths of this study

3.4 Limitations of the study

3.5 Truthfulness

4. Ethical Implications

5. Potential Implications for Policy and Practice

6. References

Introduction :

“Behind every good doctor, is a great Physician’s Associate.” -Unknown

The concept of the “Physician Associate” profession is still relatively new in the UK.

They were officially introduced in the UK in the year 2003. This role of the PA was

first introduced in the United States, in the 1960’s, and similar roles to this exist in

all healthcare systems around the world. In 2005, the UK Association of Physician

Associates (UKAPA) was established, which acted as the sole body to supervise as a

professional body for PA. (3)

Source: Watkins, J., Straughton, K. and King, N., 2019. There is no ‘I’ in team but there may be a PA. Future Healthcare Journal, 6(3), pp.177-180.

A PA is a healthcare professional who, while not a doctor, works to the medical

model, with the attitudes, skills and knowledge base to deliver holistic care and

treatment within the general and/or general practice team under defined levels of

supervision. PAs work in conjunction with and under the supervision of a consultant

or GP. PA’s are able to practice medicine in the UK as a result of a clause within the

GMC’s guidance on Good Medical Practice. A PA is a “new type of healthcare

professional who, while not a doctor, works to the medical model, with the skill and

knowledge base to deliver holistic care and treatment under defined levels of

supervision.” (4)

The concept of “team-based healthcare is not a new concept in the UK. A “doctor -

centric” service delivery was the rule back in the 1920’s. Healthcare has transformed

over the years, and now medical teams work collaboratively with other members of a

“multi - disciplinary” team. The NHS has been battling the issue of understaffing for

quite a few years now.

In addition to this, the NHS is currently dealing with inequalities in healthcare and

increasing pressures from an ageing population. Thus, during this time of crisis,

effective teamwork is essential to improve quality of care, and patient outcomes. By

2020, it is estimated that there will be over 3000 PA’s employed in the Uk medical

system. PA’s are employed across a wide variety of medical specialties, and are found

in almost every department. (5)

PA is a brand-new line in the medical field which has the capacity to bring about a

positive change to the healthcare system in the UK. However, it is often

misunderstood by both, the medical professionals and the patients. A very important

aspect of the PA was a shortage of medical staff on hand. PA’s were found to be

acceptable, and an appropriate add on to doctors, surgeons and nurses. They were

found to positively contribute to continuity within the medical/surgical team, patient

experience. (6)

The healthcare sector is now the most integral and the fastest growing segment

amongst all the industry sectors. Like most other services, healthcare needs to be

upgraded constantly, and it needs to keep up with the times in every aspect possible.

Patient needs and expectations are increasing every day. And any good healthcare

setup will only achieve success if it can cater to its patient’s needs. In a multispecialty

clinical workforce, the PA has an integral part to play, as a clinician and a medical

practitioner. This field is rapidly expanding as the need for medical professionals is

increasing exponentially. The PA profession is expected to influence the NHS and its

challenges positively. (5)

Physicians associates have the knowledge base, skills and attitudes to deliver a

holistic type of care and treatment under consultant supervision. Their skills to

support the physical health care of patients in mental health settings bring important

benefits to mental health services and they have the potential to help consultants

work to the top of their skill set, meaning that productivity is improved. While

trainee doctors and surgeons rotate through different specialties, PAs offer continuity

and stability both for patients and for the team in which they work. (3)

The Royal College of Physicians has openly welcomed the decision of the GMC being

chosen as the regulator for the FPA. “Achieving statutory regulation for PAs has been

an important policy priority for the RCP and the Faculty of Physician Associates. This

will allow PAs to fulfil their potential and continue to support the wider NHS

workforce and maintain high standards of patient care. Once regulation has been

officially introduced, the next priority for the government should be to consult on

prescribing rights for this vital profession.” (3)

‘The GMC has a long history and wealth of experience in regulating doctors, and

understands the standards required both educationally and professionally to deliver

safe, competent high-quality medical care to patients.” (Pulse, 2017)

The main goal of this study is to give us an insight into the perceptions of PA’s.

Previous studies have explored patient experience of consultations with PA’s in

primary care, but data regarding the PA's personal experiences are rare.

2.Literature review:

2.1 Role of physician associates within the medical workforce:

a. In the words of a physician, PA is “a new healthcare professional who, while not a

doctor, works to the medical model, with the attitudes, skills and knowledge base to

deliver holistic care and treatment within the general medical and/or general

practice team under defined levels of supervision” (7)

b. PA’s are ideally trained as medical generalists. Currently a lack of statutory

regulation and prescribing power is restricting the PA’s from an equal opportunity of

practice, but the government has a plan to regulate this profession. It includes

further work and consultation on prescribing authority. The positive aspect of this is

that it is a team effort, which improves patient safety and outcomes. PA’s are

professionally accountable for their practice, however the primary responsibility for

the patient lies with the consultant or GP who supervises them. Although they are not

currently regulated (they are going to be regulated by the GMC), the FPA holds a

names of all qualified PA’s. (4)

c. Although PA’s are unable to prescribe, they see patients according to their own appointment slots and formulate a differential diagnosis. Their responsibilities

include reviewing diagnostic test results such as blood tests and imaging reports,

reviewing correspondence from secondary care, and referring patients on an urgent

or non-urgent basis to the emergency department, assessment unit, or secondary

care specialties. With a greater emphasis on disease prevention in an ever - growing elderly population in the UK coupled with reduced staff availability in primary care,

PA’s were incorporated into the medical system to tackle these issues. (8) The physician associate is a relatively new and upcoming profession in the UK. Numbers

are growing with over 3000 graduates are said to increase by 2020. (9)

2.2 Hierarchy :

Source: Malik, B., Krishnaswamy, R., Khan, S., Gupta, D. and Rutkofsky, I., 2019. Are Physician Associates Less-Defined Force Multipliers? Comparative Role

Definition of Physician Associates Within The Hierarchy Of Medical Professionals.

a. This figure explains hierarchy in a medical profession. There is a degree of

consensus amongst healthcare staff with regard to the roles and responsibilities

especially in the UK. There seems to be a lack of clarity with regards to the PA’s roles

and responsibilities. There have always been apprehensions surrounding the role of

PA’s, and their authority to practice medicine, since they do not fall into a

characteristic category of a medical professional. (10)

2.3 Governance :

In 2017, the DH went out to public consultation on proposals regarding the

regulation of PA’s. The consultation proposed was: to introduce statutory regulation

for PA’s. The reasons for this public consultation have been cited as “rising demands

for medical treatment and advances in clinical care,” creating a need for a

synchronized approach and a better skill mix in the NHS healthcare teams. If the

regulation is approved, the PA’s could be regulated within 2 years or so, which would

remove the “glass ceiling” preventing their more cost - effective use. PAs are certainly

not the answer to the mismatch between workload and demand, but they can be a

part of the solution. (11)

b. The debate has always been which healthcare regulatory body would be the most

appropriate to regulate PA’s. Given this, the GMC or the Health and Care Professions

Council (HCPC) seemed to be the most suitable options considering their current

registrar bases.In previous studies, research was done to ascertain the most potential

set - up costs to Government and ongoing fees to registrants as well as further

consideration of which regulator would be “best suited” for this profession. (9)

c. In the UK, the Health Select Committee report has suggested that PA’s should be

included in regulatory processes as a matter of utmost urgency, with the objective of

allowing prescribing rights to be addressed. (12)

d. In the most recent update by the DH, it has been announced that there is a strong

possibility that PA’s will be able to prescribe medications and request for

investigations involving ionizing radiations which would be a ground-breaking

development for the medical workforce and may turn out to be a blessing for the

healthcare systems in the UK, as well as other countries, ensuring higher standards

of care provision, training and patient safety. (10)

2.4 Uncertainties in the Profession :

a. A general unfamiliarity and uncertainty have always been associated with the role

of PA’s, and whether they are able to operate in a general practice setting or even a

multi-specialty hospital. GP’s and other associated members of the medical

workforce have had mixed opinions about the capabilities of PA’s to practice

holistically. Concerns were raised about their ability to help with managing complex

cases and the risk associated. (12)

b. The diversity of the understanding of this profession has ranged from “certain and

accurate”, through “uncertain” to “certain and inaccurate”, as previous studies have

depicted in primary care. Confidence and trust in the PA’s were found to be linked.

There seemed to be an element of risk regarding the competence and intentions of

the PA’s by patients. Different forms of information were used by General Practices

to explain the role of PA’s thoroughly, so that the patients understood the nature of

this role substituting for the doctor. (12)

2.5 Strengths :

A strength of this role is that the PA’s work under the supervision of doctors. Both

the PA and the consultant work together as a team. Through supervision the PA’s

skills are further developed and focused on the needs of the patients. (13)

PA’s are an integral part of the healthcare system in terms of continuity of patient

care, improved patient outcomes, redistribution of the medical workload and

increased training and development opportunities for all team members. The key to

mutually beneficial and supportive working arrangements based on skill. For PA’s to

work effectively, organisations and medical teams need to be prepared to integrate,

support and progress the PA, enabling them to practice to their full potential. (13)

3. Research Methods:

The role of PA’s is fairly new in the UK. There has been a rapid expansion by the NHS

due to combat the issue of understaffing. The Department of Health recently revealed

its plans for the General Medical Council to regulate PA’s. Given such a new change

and the newness of their role, PA’s are still establishing their identity in the

healthcare workplace. This qualitative study will analyze the perceptions of PA’s

about the decision to be regulated by the GMC. This work will undertake inductive

qualitative study. The methodology selected for use is a constructivist grounded

theory. This study will be conducted objectively, and it will not involve the opinion of

the researcher. It will be based on the studies conducted previously and the

interviews taken during this study.

3.1 Collection of Data and Analysis :

1. The 30 participants will be chosen on the basis of experience. Given this, all PA’s

with more than 5 years of experience will be made a part of the study. Participation is

voluntary and consenting PA’s would get in touch with the gatekeeper from each of

the two hospitals chosen, and set a day and time for the interview.

2. Each interview would last for about 45-50 minutes. The study will take place in 2

hospitals in Essex. The interviews will then be recorded and transcribed verbatim.

The views put forward by respondents will feed into this work.

3. The participants will also be divided equally on the basis of gender, to rule out any

gender bias. The chosen age group for this study is 30-45 years.

4. The study will last for 3 months.

INCLUSION CRITERIA >5 years of experience

EXCLUSION CRITERIA <5 years of experience

Males (30-50 years)

Females (30-50 years) 15

Total 30

2. The hospitals chosen are:

a) Basildon and Thurrock University Hospitals NHS Foundation Trust

b) Colchester Hospital University NHS Foundation Trust

3. The tools used to asses will be:

One on One Interviews 10

Phone Interviews (Skype,

Facetime)

Group interviews A group of 5 from each

hospital from different

specialties (10)

Total 30

4. Since PA’s are involved in all departments of a hospital, they will be picked from 4

different settings.

SETTINGS :

Hospital IPD 5

GP 5

Specialties (Cardiology,

Gynaecology, Anesthesia,

etc)

A&E 5

Clinic Setting 5

Total 30

3.2 Data Analysis :

1. Data will be collected through loosely structured interviews with open ended

questions. Participants will be contacted via phone or face to face, for a one on one

interview. Prior to the start of the interview each participant will be briefed about the

protocol, and confidentiality.

2. Researchers will engage in discussion throughout the research process to

determine when no new thematic categories were required and saturation reached.

These discussions would conclude that all interviews will represent an adequate

sample size that both answered the research questions of this study and allowed for

transferability of the results to other contexts.

3. Framework Analysis coding in iterative cycles with constant comparison will be conducted by all members of the research team, ensuring each transcript is coded by

at least two researchers to deepen analysis, and get rid of any bias.

4. An inductive, qualitative approach will be used where the researchers will seek to

understand the experiences and perspectives of the participant PA’s in dealing with

this new change of being regulated by the GMC. The interview discussion will cover

their experiences as a PA, their anxieties and insecurities with their profession. All

participants will be encouraged to contribute their experiences and insights about the

topic of this study.

5. The audio tapes of all interviews will be coded verbatim and reviewed for accuracy

prior to their analysis. The transcripts will be examined and coded independently by authors, who will then meet to compare and review their interpretations.

6. In accordance with qualitative analysis, the transcripts from each author will be

the initial focus for a holistic analysis. Each author will independently code and

develop his own codes and themes, for an unbiased interpretation. This will then be

compared to ensure reliability.

3.3 Strengths of this study :

1. Qualitative research relies on unstructured data, or data that is non- numerical.

The data may be collected in the form of interviews, audio, documents of various

kinds, or even material artefacts. In this case, a qualitative approach is most

appropriate because it will give us an insight into the minds of the PA’s. Qualitative

research eliminates the bias that tends to come through collected data, in an attempt

to answer all of the questions that are put forth by the researcher. Participants can be

themselves and express how they really feel, and the data is more accurate.

2. It doesn’t have a rigid structure. It is based on emotional responses. PA’s have

always had a very uncertain stance in the medical field with regards to their position

and stature in the medical workforce. This research will be able to shed light upon

their insecurities, and their mental status as a whole, and give us an insight into their

thinking and their honest viewpoint about this whole process.

3. Some PA’s may have a similar viewpoint, and the evidence gathered will have a

predictive quality, so as to identify with other people who have the same stance or

viewpoint.

4. It allows for detail-oriented data to be collected through open ended questions.

Other forms of research have a lot of restrictions, to obtain results in a short amount

of time. It focuses on details. It is within those intricate details, that the insights are

found.

5. The qualitative research process deals with a smaller sample size as compared to

other methods. This is due to the fact that a substantial amount of information is

gained from each participant, since the questions are open ended. Thus, this makes

qualitative research more cost effective, and also produces faster results, while being

authentic and reliable. (14)

3.4 Limitations of this study :

1. Data obtained through the qualitative approach does not provide statistical

representation. It provides data from the perspective of the participants, and

responses cannot be measured in any form. Only comparable data is available, which

gets repetitive over time.

2. The data obtained through qualitative research is dependent upon the experience

of the researchers in the process. Any field specific data must be collected by

someone who is familiar with that field.

3. It requires a great deal of trust between the researcher and the participant, which

may be difficult in this case. Some participants may withdraw or be hesitant, or may

not trust the fact that the data collected will be confidential.

4. PA’s lead busy lives and they may not have the amount of time that is required per

participant. In that case, a greater follow up sample will be required which will create

more costs ahead.

5. Because qualitative research is based on perspectives, their perspectives may

change, which may affect the study. This makes the data difficult to verify, and the

conclusions may be debatable. Another important factor is researcher’s bias, which

may influence the study. (14)

3.5 Truthfulness :

Trustworthiness or rigor of a study refers to the degree of confidence in data,

interpretation, and methods used to ensure the quality of a study (Pilot & Beck,

2014).Truth in qualitative research is using all the necessary means to arrive at a

deeper understanding of the participant’s perceptions of it and the meanings they

attribute to the elements of their world. Trustworthiness is often defined in terms of

establishing credibility, transferability, confirmability and dependability. This study

ensures all four criteria.

a. Credibility: Triangulation of data in qualitative research is one of the key determinants of improving the methodology for conducting qualitative research. The

findings in this study (obtained through interpretation of transcripts from

interviews) will be consistent with the findings of previous studies. This ensures

credibility.

b. Transferability: This study and its findings can be used in other studies, with similar populations, and in similar settings and will be applicable to other contexts

and similar circumstances.

c. Confirmability: To ensure confirmability, we will involve more than one researcher who will then interpret each of the transcripts independently, and then it will be

compared with the interpretations of the other researchers who will be a part of this

study, to get rid of any bias or personal motivations of the researchers. An audit trail

will be provided, which highlights every step of data analysis that will be made in

order to provide a reason for the decisions made in the process of this study. This will

help to establish the research study’s findings and will accurately portray

participants’ responses.

d. Dependability: This means that the study could be repeated by other researchers and that the findings would be consistent. An inquiry audit will be used in order to

establish dependability, which will require an outsider to review and re- examine the

research process and the data analysis in order to ensure that the findings are

consistent and could be repeated by other researchers. (15)

4. Ethical implications :

1. Funding : this project will not require any funding, as it is purely interview based.

2. Conflicts of interest : a. If any researcher has any personal gain from this study, this might prove to be

conflict of interest. In that case, the researcher will be removed from the study

b. If any researcher has any personal bias, they will remove themselves from the

study.

3. Gaining access to potential participants :

a. The gatekeeper will offer participation in the study to all PA’s that fit into the

inclusion criteria. If the PA’s are not available on that day, a record of the PA’s will be

checked and they will be contacted personally by the supervisor and offered to be

made a part of the study.

b. One supervisor of the PA’s, from each of the two hospitals (Basildon and

Colchester) will be requested to act as a gatekeeper for the duration of this study. He

will obtain consent from the PA’s for the interviews and pick them anonymously.

c. The consent will state that the data will not be shared with any third party, and will

remain with the researcher. A confidentiality form will be signed by both parties

prior to beginning the interview.

4. Application to an ethical committee : All data used in this research will be approved by a Universal Ethics Committee at Anglia Ruskin University, Chelmsford,

United Kingdom.

5. Consent for participation : The authors will certify that they have obtained participant consent forms. In the form, the participants would have given consent for

their perspectives and thoughts to be shared in the journal. The participants

understand that their names and initials will not be published and due efforts will be

made to conceal their identity, but total anonymity cannot be guaranteed.

6. GDPR : Data storing and sharing statement: Individual data that underlines the results which are reported in this study after deidentification (interviews, transcripts,

list of names and perceptions), the consent and study protocol will be available right

after publication without an end date. Results will be communicated through

meetings and/or by publication in a peer - reviewed journal article. Transcripts of the

interviews will be available permanently with Anglia Ruskin University, Chelmsford.

5. Potential implications for policy and practice

a. Impact of the proposed research: The proposed study is aimed to understand and explore the perceptions of PA’s. Given this, it may be included in the GMC’s decision

of regulating the FPA and implementing their views into the rules and regulations, so

as to make this transition as smooth as possible.

b. Having flexible medical professionals, and clinical practitioners trained in the

medical model, who can share the burden of work and reduce tensions between

increasing demands, training requirements and budget cuts, and help to mitigate

other damages. PA’s can provide a continuity not provided by junior doctors, who

frequently rotate to other departments. Many patients and doctors value consistency

in this setting. However, PA’s potential in the hospital setting is unlikely to be fully

utilized without a suitable level of regulation with the proper authority to prescribe

medicines and order ionizing radiation within their purview of practice. (12)

REFERENCES :

1. Rimmer, A., 2017. GMC Says That It Should Regulate Physician Associates.

2. Rimmer, A., 2018. Physician Associates Will Be Regulated Along Same Lines As

Doctors And Nurses.

3. Fparcp.co.uk. About FPA | Faculty Of Physician Associates - Quality Health Care

Across The NHS. [online] Available at: <https://www.fparcp.co.uk/about-fpa>

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line-Weir.pdf>

5. Watkins, J., Straughton, K. and King, N., 2019. There is no ‘I’ in team but there may be a PA. Future Healthcare Journal, 6(3), pp.177-180.

6. Drennan, V., Halter, M., Wheeler, C., Nice, L., Brearley, S., Ennis, J., Gabe, J., Gage, H., Levenson, R., de Lusignan, S., Begg, P. and Parle, J., 2020. What is the

contribution of physician associates in hospital care in England? A mixed methods,

multiple case study. BMJ Open, 9(1), p.e027012.

7. de Lusignan, S., McGovern, A., Tahir, M., Hassan, S., Jones, S., Halter, M., Joly,

L. and Drennan, V., 2016. Physician Associate and General Practitioner

Consultations: A Comparative Observational Video Study. PLOS ONE, 11(8),

p.e0160902.

8. Curran, A. and Parle, J., 2018. Physician associates in general practice: what is their role?. British Journal of General Practice, 68(672), pp.310-311.

9. 2019. Physician associates appear to make a positive contribution to inpatient

care.

10. Malik, B., Krishnaswamy, R., Khan, S., Gupta, D. and Rutkofsky, I., 2019. Are Physician Associates Less-Defined Force Multipliers? Comparative Role Definition

Of Physician Associates Within The Hierarchy Of Medical Professionals.

11. Assets.publishing.service.gov.uk. 2019. [online] Available at:

<https://assets.publishing.service.gov.uk/government/uploads/system/uploads/at

tachment_data/file/777130/maps-consultation-report.pdf>

12. Halter, M., Drennan, V., Joly, L., Gabe, J., Gage, H. and de Lusignan, S., 2017. Patients’ Experiences Of Consultations With Physician Associates In Primary Care

In England: A Qualitative Study.

13. Williams, L. and Ritsema, T., 2014. Satisfaction of doctors with the role of physician associates. Clinical Medicine, 14(2), pp.113-116.

14. Gaille, B., 2018. 25 Advantages And Disadvantages Of Qualitative Research.

[online] BrandonGaille.com. Available at:

<https://brandongaille.com/25-advantages-disadvantages-qualitative-research/>

15. Cousins, C., 2002. Australian Journal Of Adult Learning - Getting To The

'Truth': Issues In Contemporary Qualitative Research. (APAFT) - Informit.