Hospital physician assistants: past, present and future [corrected

Expansion of the roles of PAs into the hospital setting has been the most significant recent trend in the healthcare field's use of these professionals. Initially intended to be primary-care providers, PAs have moved into the institutional domain with ease and in large numbers to assume roles as medical and surgical inpatient house-staff and as assistants to specialists and subspecialists. In most instances, they have adapted to these types of roles without formal training beyond the normal two-year educational period. PAs in hospitals have been proven to maintain or improve the existing level of quality and access to medical care, have been shown to be cost-effective in the delivery of inpatient services, and have displayed extensive clinical versatility among the various medical disciplines. Hospitals' use of PAs came about through changing forces in the health-personnel supply pool and mandated adjustments in the patterns of graduate medical education. Employing PAs has permitted hospitals to maintain the required levels of patient care in a cost-effective way, has allowed residency programs to balance the numbers of specialty-trained physicians, and has thereby contributed to a more balanced supply of specialists in overcrowded fields. The use of PAs has also contributed to increasing the continuity of care on hospital services and to measures that enrich the quality of residency education for physicians in training. To accommodate PAs as inpatient providers, medical-staff bylaws have been amended to recognize the education and expertise of PAs and to provide their institutional sanction to perform inpatient duties under the supervision of physicians.(ABSTRACT TRUNCATED AT 250 WORDS)     

Designing and implementing E-health Applications in the UK's National Health Service

Telemedicine/e-health applications have the potential to play an important role in Britain's National Health Service (NHS), including the NHS in Scotland. The Scottish Telemedicine Action Forum (STAF) was established by the Scottish Executive Department of Health in 1999 to take a range of applications, targeted on national priorities, into routine service. In the process it has provided insights into how advanced information and communication technologies (ICTs) can be moved from the research stage into routine service. In this article four of the projects are described and analysed focusing on the key issues that have emerged as critical for carrying projects successfully through to implementation in service as follows: 1. A multisite videoconferencing network linking 15 minor injury units to the main accident and emergency (A&E) centre. 2. A single-site neonatal intensive care "cotside" laptop system to assist communication between parents and clinical staff. 3. A single-site outpatient chronic disease management system. 4. A multisite software audit tool to support the care of cleft lip and palate patients from birth onward.     

New Role, New Country: introducing US physician assistants to Scotland

This paper draws from research commissioned by the Scottish Executive Health Department (SEHD). It provides a case study in the introduction of a new health care worker role into an already well established and "mature" workforce configuration It assesses the role of US style physician assistants (PAs), as a precursor to planned "piloting" of the PA role within the National Health Service (NHS) in Scotland.     

An analysis of job satisfaction among physician assistants in Taiwan

The physician assistant (PA) is a relatively new medical specialty that developed to manage the shortage of resident physicians and to ensure that patients receive high-quality health care in today's increasingly complex and demanding medical environment. PAs in Taiwan are not governed by laws and regulations, and the absence of legislation to define their roles and responsibilities can lead to confusion in the work environment and potential communication barriers with coworkers and supervising physicians. The purpose of this exploratory study was to examine the environmental and sociodemographic factors that influence job satisfaction and job-related communication among PAs in Taiwan. The data source, a self-administered mail survey, was sent to 196 PAs working within medical facilities in northern, central, and southern Taiwan. The response rate to the survey was 71.01%. There was a strong correlation between communication satisfaction and job satisfaction among respondents. The PAs' overall position in the hospital, relationships with coworkers (doctors, nurses, and other medical staff), and ability to perform his or her duties while working with the supervising physician were the major environmental factors that influenced job and communication satisfaction. In addition, the number of working years and marital status were important demographic factors influencing job satisfaction. Demographic and environmental factors influencing job satisfaction are analyzed, and ways in which the roles and responsibilities of PAs can be clarified, strengthened, and improved are discussed in an overall effort to provide management strategies for the current PA system in Taiwan.     

Skill mix: The potential for personal assistants to undertake health‐related tasks for people with personal health budgets

Personal health budgets (PHBs) are being promoted in England as expanding the benefits of choice and control to individuals with healthcare needs. National Health Service (NHS) money is provided to eligible people to use as set out in approved care plans, including direct employment of personal assistants (PAs). The government plans to increase NHS‐funded PHBs and to further introduce integrated personal budgets (IPBs). This potentially creates more demand for directly employed or self‐employed PAs with health‐related skills. The objective of this paper is to report findings from interviews with PAs (n = 105) and key informants (n = 26) from across England, undertaken between October 2016 and August 2017, about the potential for the PA workforce to undertake ‘health‐related’ tasks as facilitated by the introduction of PHBs. PAs were purposefully recruited to ensure the sample included participants from different geographical locations. Key informants were purposefully selected based on their knowledge of policy and community services. Data were analysed quantitatively and qualitatively. This paper focuses on reporting qualitative findings, which are set within the theoretical framework of normalisation process theory to explore implementation challenges of PHBs. The majority (64%) of PAs confirmed that they saw their current roles as congruent with PHBs, were willing to engage with PHBs and undertake health‐related tasks. However, 74% of PAs said they would need additional training if enacting such roles. Key informant interviews appraised the development of PHBs as complex, noting incongruences arising from NHS and social care‐funded PAs carrying out similar roles within different organisational systems. We conclude the current PA workforce is willing to take on PHB work and is likely to interweave this with work funded by PBs and self‐funding care users. Implications include the need for careful consideration of training requirements and delivery for PHB‐funded PAs.     

Designing and Implementing E-health Applications in the UK's National Health Service

ABSTRACT

Telemedicine/e-health applications have the potential to play an important role in Britain's National Health Service (NHS), including the NHS in Scotland. The Scottish Telemedicine Action Forum (STAF) was established by the Scottish Executive Department of Health in 1999 to take a range of applications, targeted on national priorities, into routine service. In the process it has provided insights into how advanced information and communication technologies (ICTs) can be moved from the research stage into routine service. In this article four of the projects are described and analysed focusing on the key issues that have emerged as critical for carrying projects successfully through to implementation in service as follows:

1. A multisite videoconferencing network linking 15 minor injury units to the main accident and emergency (A&E) centre.

2. A single-site neonatal intensive care “cotside” laptop system to assist communication between parents and clinical staff.

3. A single-site outpatient chronic disease management system.

4. A multisite software audit tool to support the care of cleft lip and palate patients from birth onward.

     

Are Dutch patients willing to be seen by a physician assistant instead of a medical doctor?

ABSTRACT: BACKGROUND: The employment of physician assistants (PAs) is a strategy to improve access to care. Since the new millennium, a handful of countries have turned to PAs as a means to bridge the growing gap between the supply and demand of medical services. However, little is known about this new workforce entity from the patient's perspective. The objective of this study was to assess the willingness of Dutch patients to be treated by a PA or a medical doctor (MD) under various time constraints and semi-urgent medical scenarios. METHODS: A total of 450 Dutch adults were recruited to act as surrogate patients. A convenience sample was drawn from patients in a medical office waiting room in a general hospital awaiting their appointments. Each participant was screened to be naive as to what a PA and a nurse practitioner are and then read a definition of a PA and an MD. One of three medical scenarios was assigned to the participants in a patterned 1-2-3 strategy. Patients were required to make a trade-off decision of being seen after 1 hour by a PA or after 4 hours by a doctor. This forced-choice method continued with the same patient two more times with 30 minutes and 4 hours and another one of 2 hours versus 4 hours for the PA and MD, respectively. RESULTS: Surrogate patients chose the PA over the MD 96 % to 98 % of the time (depending on the scenario). No differences emerged when analysed by gender, age, or parenthood status. CONCLUSION: Willingness to be seen by a PA was tested a priori to determine whether surrogate Dutch patients would welcome this new health-care provider. The findings suggest that employing PAs, at least in concept, may be an acceptable strategy for improving access to care with this population.     

NHS occupational health services in England and Wales--a changing picture

AIMS: To establish the extent of doctor input to occupational health (OH) service provision in the UK National Health Service (NHS) in 2001 and to compare this with inputs in 1998. METHOD: A postal questionnaire was used to obtain information from OH medical staff employed by the NHS in England and Wales. RESULTS: The NHS OH service has seen an increase between 1998 and 2001 in the amount of doctor time per employee. Doctors tend to work now for more sessions per week. The proportion of doctors holding specialist qualifications has also increased. An increased number of NHS employees now have access to consultant care for occupational medicine. OH departments increasingly tend to provide services to employees beyond the NHS and are thereby able to generate income to further the development of the service. CONCLUSIONS: Steady progress is being made in improving the provision of OH services within the NHS. However, substantial variation exists in the apparent level of access to such provision. The government policy for all NHS staff to have access to a consultant-led service is not yet met. NHS Plus will impact on this picture and deserves study in the future.     

Who in Brazil has a personal doctor?

Background. Continued medical care (including having a personaldoctor) is regarded as an essential aspect of a good healthservice. Objectives. The objectives of the present study were to investigatethe reasons for not having a personal doctor, and the satisfactionwith the care received by patients with and without a personaldoctor. Methods. We conducted a cross-sectional study with data collectedduring 20 days over 6 months in the Emergency Service of theConceição Hospital, the busiest emergency servicein Porto Alegre. The subjects were 553 patients selected throughsystematic random sampling. The main outcome measure was havinga personal doctor. Patients who reported usually to see thesame doctor and remembered their physician's name were regardedas having a personal doctor. Results. Patients who usually use primary care service represented23% of the sample, and were four times more likely to have apersonal doctor (OR = 3.83, CI 95% = 2.41–6.11). Independent,statistically significant variables associated with having apersonal physician were: usually receiving care from a primaryhealth care service (OR = 3.8, CI 95% = 2.39–6.00) andfrom a physician in the private sector (OR = 2.16, CI 95% =1.15–4.00). Patients who had a personal doctor reportedhigher satisfaction with their access to health care. The personaldoctors' specialties were: internal medicine (37%), cardiologist(17%), gynaecologist-obstetrician (13%), family physician (8%)and pneumologist (6%). Conclusions. For patients who attend emergency services in Brazil,primary health care and private medical care provide betteraccess to continuity of patient care. Patients with personaldoctors report higher satisfaction with access to consultations. Keywords. Continued medical care, personal doctor.     

Patients’ experience with cancer care: A qualitative study in family practice

Abstract

Background: Continuity is an important aspect of cancer care that is often a challenge owing to the movement of patients between family practice, cancer clinics, and hospitals.

Objectives: To investigate the experiences of cancer patients in relation to continuity of care.

Methods: A qualitative study was conducted in a family practice setting. Semi-structured interviews were used for data collection. 10 cancer patients with a wide variation in their disease duration and experiences with medical care were interviewed. Open questions were used to encourage patients to express their personal experiences with cancer care. The interviews were recorded, transcribed and analysed by three researchers using thematic analysis.

Results: Cancer patients experienced a lack of information concerning cancer and its treatment. They also perceived that the cancer treatment made them suffer. In the patients’ opinion, the family doctor has a limited role in cancer care. However, the patients felt that the family doctor should be aware of their health. The patients’ satisfaction with the oncologist's care was high. They considered that their role in cancer care was to mediate an exchange of information between the oncologist and the family doctor.

Conclusion: Cancer patients experience continuity of care in several ways: continuity in cancer care should be implemented by co-ordinating activities, such as regular check-ups, a clear timeframe and provision of adequate information. In addition, communication between the primary and secondary sector could be improved.     

英国NHS体系对我国卫生服务的启示

本文介绍英国NHS体系的特点,包括公平优先、兼顾效率,合理的分级保健体制,健全的医药体制及电子化健康服务,对我国卫生服务启示:动员社会资金投入卫生服务,推行家庭医师制度,推进药物制度建设,加强卫生信息化建设。     

Focus group investigation on expectations of elderly people from health care facilities and physicians

INTRODUCTION: While the elderly are intensive health care users, little is known about their expectations of various medical facilities and physicians. We investigated their views on advAntages and disadvantages of different medical settings. METHODS: We established four focus groups and surveyed elderly people living in a rural area accessible to local practitioner's offices, and community, regional, and university hospitals, The focus groups examined advantages and disadvantages of care from these facilities. A coding scheme was used to organize the data in thematic categories, In a mail survey, participants ranked the importance of specialty care; overall care; triage of patients; gentle personality; listening skills; and explanation skills, The data were analyzed for statistical differences between the various settings. RESULTS: Total of 41 elderly participated in focus groups, and 40 individuals (response rate 98%) returned statistical surveys. Advantages of care from a primary care doctor included continuity and physician accommodation of patients' preferences, while limited medical services and urgent access were disadvantages. Advantages of the community hospital included expanded medical facilities and having doctors easy to talk with, while disadvantages included lack of trust and frequent turnover. Advantages of larger facilities included extensive medical equipment, a broad range of departments and specialists, and more expert care. The survey revealed expectations for expert triage skills and familiarity with a doctor who is easy to talk with, particularly primary care doctor. DISCUSSION: These elderly subjects expect primary care and community doctors to be accessible and to exhibit excellent behavioral and communication skills, They expect more specialized and technical care in larger hospitals.     

Continuity of care: a concept revisited

Continuity of care has been a fundamental principle of general practice over the last fifty years. Historically the notion was clearly rooted in the concept of personalised one-to-one general practitioner to patient care. This arrangement has been linked to benefits in terms of patient satisfaction and therapeutic compliance. The concept of personalised continuity has been gradually eroded by factors that relate chiefly to patient choice and to the increasing complexity of disease management in the light of major medical advances. The components of continuity are considered in the context of the evolution of general practice. The paper explores how far those desirable features can be contained within a medical environment dominated by the need for evidence-based management. The concept of individual doctor/patient continuity has served its time. We must ensure that the benefits historically associated with it are translated into team-based care. Among these, the quality of communication between patient and doctor and the quality and accessibility of the clinical records are uppermost.     

Medical needs and survival of NHS continuing care residents

BACKGROUND AND AIMS: To determine the medical needs and survival of patients admitted to NHS continuing care beds for the frail elderly. METHODS: A retrospective cohort study of admissions during one year to 222 beds in south-east Glasgow. Case-sheet review identified the diagnoses on admission. Medical interventions were allocated to one of six predetermined categories. Mortality data was collected up to four years after admission. RESULTS: One hundred and eighty nine patients (65 male and 133 female) were admitted, 183 (92%) for NHS continuing care. The overall survival at three months was 47.8% and 38.5% at six months. In total 1585 interventions were recorded, 56.3% of admissions required one or more major intervention. Seventy eight (75.7%) of these were managed in the continuing care setting avoiding transfer to an acute hospital bed. CONCLUSIONS: Older people resident in NHS continuing care have a short life expectancy and require frequent medical interventions. Much of this can be provided in the NHS continuing care setting avoiding admission to the acute sector. Shift of care for these patients to private nursing homes may not provide such support.     

UK GPs' and practice nurses' views of continuity of care for patients with type 2 diabetes

BACKGROUND: Continuity of care is widely regarded as a core value of primary care. Type 2 diabetes is a common chronic disease with major health, social and economic impacts. Primary health care professionals in many countries are involved in the management of patients with type 2 diabetes, but their perspectives on continuity remain neglected in research. OBJECTIVE: To explore UK GPs' and nurses' experiences of continuity of care for patients with type 2 diabetes in primary care settings. METHODS: Semi-structured individual interviews were conducted with 16 GPs and 18 practice nurses who manage patients with type 2 diabetes recruited from 20 practices with various organizational structures in Leeds, UK. RESULTS: Three types of continuities were identified: relational continuity from the same health care professional, team continuity from a group of health care professionals and cross-boundary continuity across primary-secondary care settings. Relational continuity was influenced by the quality of the patient-health care professional relationship, policy of the National Health Service (NHS) in the UK (new General Medical Services contract), walk-in centres, the behaviour of receptionists and the structure and systems of the practice. Team and cross-boundary continuities were influenced by the relationship between team members and by effective communication. Relational continuity contributed to more 'personal care', but the usual health care professional might know less about diabetes. Team continuity was important in providing 'physical care', but patients could be confused by conflicting advice from different professionals. Cross-boundary continuity helps to provide 'expert advice', but is dependent upon effective communication. CONCLUSION: GPs and practice nurses dealing with patients with type 2 diabetes identified three types of continuities, each influenced by several factors. Relational continuity deals better with psychosocial care while team continuity promotes better physical care; therefore, imposing one type of continuity may inhibit good diabetic care. Cross-boundary continuity between primary and secondary care is fundamental to contemporary diabetic services and ways should be found to achieve more effective communication.     

Perceptions of good medical practice in the NHS: a survey of senior health professionals.

OBJECTIVES: To categorize senior health professionals' experience with poor medical practice in hospitals and in general practice, to describe perceptions which senior NHS staff have of good medical practice, and to describe how problems of poor medical practice are currently managed. DESIGN: A postal questionnaire survey. The questionnaire sought perceptions of good medical practice, asked participants to characterise deviations from good practice, and to describe experience with managing poor performance at the time of the introduction of the General Medical Council (GMC) performance procedures. SETTING: A range of NHS settings in the UK: hospital trusts, health authorities/boards, local medical committees, community health councils. SUBJECTS: Senior health professionals involved in the management of medical professional performance. MAIN MEASURES: Perceptions of what constitutes good medical practice. RESULTS: Most respondents considered that persistent problems related to clinical practice (diagnosis, management, and outcome and prescribing) would require local management and, possibly, referral to the GMC performance procedures. Informal mechanisms, including informal discussion, education, training, and work shifting, were the most usual means of handling a doctor whose performance was poor. Many took a less serious view of deficiencies in performance on manner and attitude and communication, although consultation skills rather than technical skills comprised the greatest number of complaints about doctors. CONCLUSIONS: Senior NHS professionals seem reluctant to consider persistently poor consultation skills in the same critical light as they do persistently poor technical practice. These attitudes may need to change with the implementation of clinical governance and updated guidance from the GMC on what constitutes good medical practice.     

Healthcare system performance in continuity of care for patients with severe mental illness: A comparison of five European countries

Most healthcare systems struggle to provide continuity of care for people with chronic conditions, such as patients with severe mental illness. In this study, we reviewed how system features in two national health systems (NHS) – England and Veneto (Italy) – and three regulated-market systems (RMS) – Germany, Belgium, and Poland –, were likely to affect continuing care delivery and we empirically assessed system performance. 6418 patients recruited from psychiatric hospitals were followed up one year after admission. We collected data on their use of services and contact with professionals and assessed care continuity using indicators on the gap between hospital discharge and outpatient care, access to services, number of contacts with care professionals, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients’ characteristics. Important differences were found between healthcare systems. NHS countries had more effective longitudinal and cross-sectional care continuity than RMS countries, though Germany had similar results to England. Relational continuity seemed less affected by organisational mechanisms. This study provides straightforward empirical indicators for assessing healthcare system performance in care continuity. Despite systems’ complexity, findings suggest that stronger regulation of care provision and financing at a local level should be considered for effective care continuity.     

Changes in patterns of acute medical receiving in Scotland 1996 to 2001

The purpose of this study was to review changes in working practises of physicians and hospitals from 1996 to 2001 in the light of rising medical admissions and published reports into the organisation of acute admissions. Information was gathered by direct discussion with the appropriate lead doctor for each hospitals acute service in February 2001. The results were compared with a previously published study, which recorded the situation as of October 1996. The hospitals which were studied were the twenty seven Scottish hospitals which admit more than 3000 acute medical patients each year. There has been a 25% increase in number of consultants carrying out receiving duties. Nearly all hospitals now have an acute admission unit. Four hospitals have appointed acute care physicians. Triage of appropriate patients to more specialised ward based care has increased. There has been a rise in geriatricians involvement in acute receiving from four to fifteen hospitals. New developments include early discharge for chronic obstructive airway disease, outpatient management of venous thrombosis, discharge planning and streamlining investigation of chest pain. Two hospitals have specific alcohol support services. There continues to be progress and changes within medical and geriatric services over the last five years stimulated by the continuing rise in number of medical admissions.     

Convenient care clinics: the future of accessible health care.

The need for accessible, affordable, quality health care in the United States has never been greater. In response to this need, convenient care clinics (CCCs) are being launched across the country to help provide care to meet the basic health needs of the public. In CCCs, highly qualified health care providers diagnose and treat common health problems, triage patients to the appropriate level of care, advocate for a medical home for all patients, and reduce unnecessary visits to emergency rooms and Urgent Care Clinics. CCCs have been called a "disruptive innovation" because they are consumer driven. They serve as a response to many patients who are unhappy with the current conventional health care delivery system--a system that is challenged to provide access to basic health care services when people need it the most. CCCs are based in retail stores and pharmacies. They are primarily staffed by nurse practitioners (NPs). Some CCCs are staffed by physician assistants (PAs) and physicians. The authors acknowledge the important roles of both PAs and physicians in CCCs; however, this paper primarily provides education about the role of NPs in CCCs. CCCs have evolved at a time when our health care system is floundering, and the need for accessible, affordable health care is at its greatest. The CCC model provides an accessible, affordable entry point into the health care system for those who previously were restricted access.