How might Physician Associates help (or not) address the workforce crisis in the NHS

Research summary

Our overall research question is: How might Physician Associates help (or not) address the workforce crisis in the NHS and more particularly are they part of the solution in NHS hospitals? This will be a multiple methods study including five activities. • Activity a: Secondary NHS workforce database analysis where we analyse secondary data analysis from publicly available database,Electronic Staff Records (ESR) and NHS trust and health board HR database Our main objectives for activity A are to (1) explore available administrative statistics from four UK nations to understand historical and current trends and geographical distribution of PAs in secondary care,and to (2) explore “our local partners” (NHS Trusts/Health boards) workforce data to analyse changes in local demand for health professionals. We would therefore use quantitative analysis of secondary NHS workforce data at the national and local levels,the latter based only on data of NHS Hospital Boards/Trusts participating in this study. The main outcomes are (1) Data structure and framework made available to organisations responsible for NHS workforce planning and statistics and professional bodies; (2) Illustrative cases from eight selected NHS study sites on numbers of posts and vacancies for PAs and related health professionals that help deepen our understanding on current trends and future PAs’ hospital roles. Data sources and data management For the regional and national level data,NHS statistical agencies and professional bodies will be approached for their permission for data access. At the participating NHS study site level,we will collaborate with the Human Resource (HR) and Research Governance team in each organisation for essential data access. Only aggregated data that strip personal data of sufficient elements to identify any individual will be presented in our case studies report. The research team will not keep or process any personal identifiable data outside the data framework used by these partner organisations. Data analysis will be done using statistical programmes such as STATA or R. Summary statistics will be presented and visualised into diagrams and maps,then analysed together with existing theories and frameworks. • Activity b: Longitudinal cohort studies and discrete choice experiment of physician associate students,who are studying in their final years of the PA programme of participating schools at the time of the survey in 2024. Our main objectives are to: 1. Develop and employ survey tools that help to better understand the experiences and career aspirations of qualifying PAs to inform NHS workforce planning 2. Identify improvements required for the routine administrative data and design the system for cohort studies of comparable quality to the UK medical education database (UKMED) We would achieve these through co-designing the exit survey and DCE with key stakeholders and then collaborate with PA training schools,regulators,and professional bodies to lay out recommendations to establish and mainstream long-term longitudinal database strategies for PAs. DCEs are survey-based relying on what respondents say they will choose or prefer between hypothetical options. One of the key strengths of a DCE is its ability to set-up hypothetical jobs with attributes,e.g. salary ranges or career opportunities,that do not currently exist but could potentially influence choice of job and inform human resources policy. Sampling All PA training programmes will be invited to participate in the survey through contacts and network of the PA Schools Council,a body representing Physician Associate schools across the UK. All PA students satisfying the inclusion criteria in these universities will receive an email invitation from their institution to join the study. Although we strive to recruit as many included PA students as possible,we anticipate that 300-600 students (out of around 1,300 eligible students from the whole UK) will participate in the survey. We will conduct an online survey with PA students meeting the inclusion criteria,who have given their informed consent to participate in the study by clicking on the "agree" button before beginning the survey. The survey consists of a simple online questionnaire (the exit survey) followed by the DCE task at the end of it. The online survey will be collected and managed by the programme REDCap without IP address information. The collected data will be stored in a local secured server by the research team in Oxford. We plan to recruit the participants by asking participating PA training programmes (with the support of the PA Schools council) to share the survey link via their existing databases or communication channels. Hence,the research team will not have a direct access to participants’ contact information at recruitment Exit Survey (Online Questionnaire) The research will occur online where respondents can participate through a device of their choice,i.e. PC,tablet,or smartphone. Participants will answer survey questions before completing the Discrete Choice Experiment. The survey questions consist of demographic information (age-group,gender and ethnic groups where participants can choose to answer ‘prefer not to say’),institution name,training experiences,work intentions,expectations,challenges encountered,workload,well-being,and longer-term career plans. To maximise response rates and avoid ‘survey fatigue’ from repeated questions with other existing surveys,we will engage with collaborators from PA training programmes through co-design meetings to finalise the exit survey. We also aim to ensure that the survey including the DCE will be completed within 22-30 minutes. Discrete Choice Experiment (DCE) In the DCE,participants will be asked to complete 12 choice questions. For each choice question,they will be shown descriptions of two hypothetical PA posts,asked to select their preferred option and asked if they will consider taking that post after graduating. Each post will be described in terms of several attributes,which will be derived from a review of the literature,discussion with the PPI group,and co-design meeting(s) with stakeholders from PA training programmes and professional organisations. The combinations of the levels of these attributes will be different in each choice question. We plan to conduct a pilot study involving 30-40 participants,who are in their first year of their PA training,where some extra questions will be asked at the end of the survey to gauge participants’ understanding and engagement with the process. In addition,an open-ended question at the end allows participants,amongst other things,to note anything that they found uncomfortable or upsetting,and we will be able to adjust the final survey if any such issues arise. Establishing longitudinal database In addition to our collaboration with stakeholders to recommend potential solution(s) to establish and mainstream long-term longitudinal database for PAs,we will also collect personal data from the participants in the exit survey for a possibility of conducting a follow-up survey in 2025/26. We plan to collect the participants’ email address and phone number. These questions will be optional and asked as an opt in option ‘to be contacted next year as part of the longitudinal surveys’ at the end of the whole online questionnaire (after the DCE). This contact information will be kept in a separate file per Oxford University and GDPR data protection regulation and only newly assigned study ID will be attached to the main survey data. Data analysis We will use statistical programmes such as STATA or R to produce descriptive statistics. Choice models will be estimated from the DCE and survey data. We will employ extensive specification and statistical testing,including testing of internal validity. We will also publish appendices providing in-depth details of our data and methods to ensure reproducibility of our results in published articles. • Activity c: NHS trust interviews and focus group discussions,at participating NHS Trusts and Health Boards,with senior trust managers and divisional directors,people in the clinical team (PAs,Consultants,nursing staff,junior doctors,non-clinical support staff),and patients with experience of interaction with PAs Activity C will include a set of qualitative researches of the roles and integration of PAs through case studies of NHS Health Boards/Trusts across the United Kingdom. The aim would be to explore (1) at the Trust and health board level,the range of roles and to what degree NHS Boards/Trusts employ PAs,AAs,SCPs,and ANPs and explore their employment intentions,as well as their current practice,appraisal,clinical governance,job description,scope of practice,line management structure,and (2) at the clinical team level,the integration of PAs into different hospital care teams. We would hope to understand the perspectives of key stakeholders involved in the recruitment,training and integration of PAs into secondary care in the NHS to inform practical recommendations on optimising recruitment,retention and role satisfaction of PAs,as well as an in-depth understanding of the scope of work of PAs across a range of secondary care contexts,in order to share learning & highlight successful and unsuccessful examples of PA deployment & integration across different NHS Trusts. We will conduct semi-structured,in-depth interviews (IDIs) and focus group discussions (FGDs) with key stakeholders meeting the inclusion criteria,who have given their written informed consent to participate in the study in each of the participating NHS Trusts. Senior trust managers,consultants will be interviewed at the time of their convenience,and PAs,junior doctors,nursing staff and other clinical and non-clinical team staff will be asked for their preference for taking part in in-depth interviews (IDIs) or focus group discussions (FGDs). IDIs and FGDs will be audio recorded using an encrypted voice recorder and transcribed with Oxford-approved professional transcriber or digital transcription services with participant consent. In-depth interviews Semi-structured in-depth interviews will be held face-to-face (where able) or online through Microsoft Teams with senior trust managers and/or divisional directors,Consultants,and patients seen by PAs. Participants will be invited to discuss their experiences of PAs,their knowledge of PA practice in healthcare delivery in their NHS Trusts,and their understanding of the long-term career prospects and roles of PAs within the NHS. Patients will be invited to discuss their experiences with PAs and their understanding of their role within the healthcare team (in the forms of either interviews or focus group discussions depending on availability). We will continue the interviews until data reach theoretical saturation across sites,likely start with a total of 15 interviews including with 5 senior managers,5 consultants and 5 patients conducted at the first few study sites. We would then tailor recruitment as we progress across sites aiming to capture a variety of voices and fill potential gaps in our understanding. Together with the focus group discussion below,we imagine we would have up to a maximum total of 150 NHS Trust and Health Board staff (20 senior managers,20 consultants,40 PAs,20 junior doctors,20 nursing staff and 10 other clinical team staff,20 patients) across eight sites or until data reach theoretical saturation. Focus / Small Group Discussions Focus / small group discussions with between 4-8 participants depending on availability will be held face-to-face (where able) or online through online meeting platforms fully compliant with GDPR if any restrictions to meeting in-person,with i) PAs,ii) nursing staff,iii) junior doctors,and iv) patients. Group discussions with different staff and patient groups will be conducted separately due to the potential power dynamics and professional hierarchies,which may otherwise prevent participants from expressing their views freely. Similar to the interviews we will continue with group discussions until we seem to be learning little new but expect to conduct 5 focus groups with PAs,nursing staff,junior doctors and other clinical team members and 3 to 5 focus group with patients across study sites. Together with the interviews described above,we aim to involve up to a maximum total of 150 NHS Trust and Health Board staff (20 senior managers,20 consultants,40 PAs,20 junior doctors,20 nursing staff and 10 other clinical team staff,20 patients) across all sites or until data reach theoretical saturation. Data collected through IDIs and FGDs will be transcribed by Oxford approved digital transcription software or service provider,saved with study identifiers instead of actual names. This will articulate how and why PAs are being introduced into hospital Trusts and contextual factors explaining,for example,why Trusts or hospital departments are early or late adopters of PAs within their workforce. • Activity d: Participatory video through creating a short film with physician associate representatives Participatory Video is a methodology used to enable individuals and groups to explore aspects of their lives and voice their experiences,perceptions,feelings and ideas through creating a short film which can be shown to different audiences. It has been used as a tool for community development,health promotion,programme evaluation and in conjunction with participant observation,as a research tool. We plan to work with a group of 4-8 PAs in a 1-day collaborative film-making workshop. During this facilitated workshop,PAs will be encouraged to share and reflect on their roles,experiences,aspirations and issues which they prioritise as important to share and discuss with broader audiences. Working with a facilitator and a film-maker,the group will: a) Prioritise content for the video through discussion b) Storyboard ideas and discussion points/interview questions on flipcharts c) Gather media interviews including film recording d) Conduct a rough edit as a group The participatory nature of the video-making process and the subsequent content of final video(s) produced,will largely be determined by the participants,however we anticipate that videos will help express some of the key knowledge generated across all three research objectives: to explore PA roles; to learn about aspects of integration; and to highlight successful and unsuccessful examples of PAs work. We anticipate that the video(s) produced will be used in a range of ways including: to stimulate discussion in stakeholder and patient engagement (activity E); raising public awareness through posting on a public-facing website; communicating study findings and issues to policy-makers; highlighting important issues in scientific presentations; and in educational settings. Prior to sharing the final video,participants will be asked to approve the video,or decline use of their contribution,and sign an Oxford University media release form. When declining their footage will be removed from the video. • Activity e: Collective sensemaking workshops with national-level stakeholders In addition to negotiation of roles within Trusts,integration of PAs into the NHS workforce is also determined by regulators,professional associations and public perception of their competence and professional identity. We use the term “collective sensemaking” in line with current discourses in participatory practices and research co-production as a guide to our work. In practice,this would take place in the format of stakeholder workshops and patient focus group discussions. During the stakeholder engagement workshops,we will deliberately convene regulators,leaders of professional associations,Trust managers and staff using the visual material produced to promote reflective engagement with the topic of PAs and their work in secondary care. We will keep notes during these meetings and may record these meetings to help with note-taking only if the participants consent to this. Recorded meetings will be deleted within 2 weeks of recording. For collective-sensemaking with patient groups,we will share illustrative descriptions and videos of PA roles to focus group members,and then will gather patients’ views and feedback on PAs noting whether they have previously engaged with PAs directly. Participants will be provided with information regarding the study and their participation will be voluntary,with no negative impact for those who choose not to participate or drop-out. Data collected from patient groups will be thematically analysed and fed into stakeholder workshops,which will be conducted separately,so there are “safe spaces” for patient engagement. Similarly,we will keep notes during these meetings and may record these meetings only if the participants consent to this. Recorded meetings will be deleted within 2 weeks of recording. All meeting recordings will be transcribed and meeting notes will be entered into NVIVO.

Principal Investigator

Dr Elaine Hill

Contact us

Email: cushla.cooper@ouh.nhs.uk

IRAS number

334923