MEDEV

School of Medical Sciences Education Development

Introduction

The NHS was inspired and created in the 1940s, but needs have changed as have advances in healthcare technology and delivery, and patient expectations.The paper, The NHS Plan for England proposed ways in which the NHS might deliver a more patient-led service. Health Resources in the NHS Plan recommended less rigid boundaries between respective health professions for skills delivery, to allow flexibility and accessibility of career pathways, to support staff achieving their true potential.

In the early 1990s, there were discussions between the Royal Colleges, US and UK healthcare and education providers on introducing a generic healthcare professional equivalent to the US-Physician Assistants (US-PAs). The US-PAs have been an integral part of their healthcare delivery since the 1960s, but for other countries including the UK, Australia and Canada, physician assistants are an exciting development. Inevitably, a new profession is viewed with caution, but key players in the US have emphasised how US-PAs are part of the medical team, along side doctors and nurse practitioners (Hutchinson et al., 2001; Mittman et al., 2002).

Physician assistants for the UK's NHS?

US-PAs are so successfully working in the UK that they have already formed the UK Association of Physician Assistants (see www.ukapa.org.uk). US-PAs were recruited to general practice and accident and emergency within the UK to support areas with skills shortages - and the scheme has been a real success for NHS staff and for improving patient access and care (Walton; 2004; Woodin et al., 2005). Moreover, for the majority of patients attending the GP surgery notice no difference between the GP and the US-PAs, other than the fact they are American!

For our own home-grown PAs, however, the use of the title, physician assistant, has been intensely debated, (Heath, 2004; Child 2005), owing to, at least in part, differences in the perceptions of the word physician within the UK and USA health systems. Therefore, the working title for the UK-equivalent is, at present, medical care practitioner (MCP) - the final name has yet to be agreed. It is expected that the US-PA will be mentors and role models for MCP students, as well as facilitators for integration of MCPs into healthcare teams. Nonetheless, the key issue is the NHS clinical governance arrangements for US-PA as a profession in the UK to have appropriate regulatory status (Woodin et al., 2005).

Curriculum and training of MCPs in the UK

The Universities Board for MCP Programmes (Birmingham, Hertfordshire, London-South Bank University, Kingston and St. GeorgeÕs; Surrey, Warwick - in collaboration with Coventry - and Wolverhampton) has worked with the National Competence and Curriculum Framework Development Steering Group (that includes Department of Health, representation from Royal College of Physicians & Royal College of General Practitioners, the NHS stakeholders and US-PAs) to agree the core curriculum and skills competences. The rationale for such a document is to assure a consistent level of knowledge, skills competence and professional behaviours for accredited degrees, to facilitate national transferability of the final award.

Curriculum planning and content

As MCPs will be working to a medical model, the nature of the knowledge and skills have been informed by both the curricula for US-PA degrees and the medical curriculum (GMC 2003) with respect to:

• the disciplines for core scientific and clinical knowledge and skills competences and their assessment
• competence of the clinical mentors and supervisors
• establishing the recognised route for registration and professional identity.

Generally, the applicants for MCP programmes will be post-graduates, (like their US counterparts) and the time frame for the degree is expected to be equivalent to 3 academic years. As the breadth of curriculum is vast, the Universities Board for MCP Programmes have taken advice from others, including the US Accreditation Review Commission for Education of Physician Assistants with respect to the breadth and depth of curriculum content and the nature of the clinical placements. For MCPs, a minimum number of hours and types of clinical placements are specified within the competence and curriculum framework document.

Learning within the clinical setting

Expertise is available within the university hospital sector for clinical teaching, supervision, and mentorship of medical, MCP and other healthcare students. But obviously there will be a capacity issue with respect to clinical placements, and potential competition between education providers of MCPs and other trainee health professional groups. Therefore systems will need to be established for quality assuring the clinical placements, as well as innovative approaches to provision and scheduling.

Assessment of MCP degrees

The general view is that the type and frequency of assessment should remain the responsibility of the university awarding the accredited MCP degree. But with this new professional emerging, the Universities Board for MCP Programmes endorse the introduction of a national accreditation examination as a pre-requisite for professional registration to assure fitness to practise of MCPs to all - colleagues, patients, and the MCPs themselves. In following the US model, it means that MCPs are the only UK healthcare professional required to jump such a hurdle in order to register to practice. (It is noteworthy that there are discussions within the GMC on the appropriateness of national examinations for medical students.)

The team involved in developing the national accreditation examination have taken advice from assessors of the Postgraduate Medical Education and Training Board and undergraduate medicine with respect to the guiding principles for the assessments (Southgate & Grant 2004). Knowledge and skills will be tested by written examinations and OSCEs respectively; these will be jointly set and agreed between the HEIs. Blueprinting of the core curriculum for question and OSCE station preparation, and standard-setting techniques will be applied, as with the UK medical programmes and the National Commission on Certification of Physician Assistants in the USA.

Regulation of MCPs

Discussions with regulatory bodies are on-going to clarify the mechanism for the regulation of MCPs. Thus the finally agreed title of the role will be protected, i.e. set by the regulator and adopted by employers, assuring a nationally agreed minimum standard of practice. Currently, the trainee MCPs and US-trained PAs in the UK work under a delegation and referral clause of the GMCÕs document Good Medical Practice (GMC, 2001) so are not independent, but have negotiated performance autonomy (Mittman et al., 2002), and may apply to become associates of the Royal College of Physicians.

Conclusions

The US has led the way for the training of PAs, but it is acknowledged that locally developed education and appropriate resources for this new role in the UK are essential for their successful introduction into the medical team, to assuage concerns of the existing professions and patients. Nationally agreed NHS policies and guidelines, together with the education of the present workforce are essential for the success of this new profession. If MCPs follow a similar pathway for success as their US counterparts, they will assist in improving capacity and facilitate the NHS to respond more effectively to patient needs.

Acknowledgements:

To the Universities Board for MCP Programmes (Guy Dean, Barry Hunt, Di Jackson, Hilary Paniagua, Janice Forbes-Burford, Jim Parle, Nick Ross, Ed Peile, Neil Johnson) and the members of the National MCP Team (part of the National Practitioner Programme).