We’re about to get our first crop of physician assistants. But what’s holding them back?

At the recent national rural health conference in Perth, one of the priority recommendations from the floor was for a “a review of health professional scopes of practice and, informed by this evidence, a re-design of the rural and remote health workforce”.

The recommendation continued: “This will mean additional professionals working in models of care not based on fee-for-service, and a greater number of positions in public and private sectors for members of the so-called ‘newer’ professions such as Aboriginal Health Workers, Nurse Practitioners and Physician Assistants. This workforce re-design will require new funding models for integrated inter-professional primary care teams which will include the resources required to assist existing services adapt to the new paradigm.”

Today Croakey kicks off a series of articles examining the potential for physician assistants to contribute to health care, particularly in under-served areas, and what’s holding them back…

How medical and nursing unions are blocking a rural health solution

Melissa Sweet writes:

In a few months’ time, the University of Queensland will graduate the country’s first crop of home-grown physician assistants (PAs). But, in a telling comment on the state of health workforce reform, it is far from clear whether they will find jobs, although we hear so much about the shortages of health workers, especially in rural and remote areas.

PAs, for those who haven’t been following this fascinating study in how vested interests rather than community need so often drives health policy**, are a health profession that developed in the US in the 1960s with the aim of supporting doctors and ensuring health services in under-served areas.

The US has more than 74,000 PAs working in all areas of medicine, with an estimated 35 to 40 per cent based in primary care, and they are now also found in many other countries.

Some senior health policy and medical leaders have been agitating for years for their introduction to Australia, which eventually persuaded health authorities in Queensland and SA to trial some PAs from the US in diverse settings during 2008 and 2009. Evaluations of both trials, completed almost a year ago, reached remarkably positive conclusions.

What’s happened since, during a time when we’ve been hearing so much about health reform?

Not much, largely because health ministers and bureaucrats appear to lack the grit to take on an unholy alliance of interests: that of the medical and nursing lobbies (the only development that could top this irony would be if some perceived shared threat put the AMA and Pharmacy Guild in bed).

Medical groups are worried that PAs will reduce medical student and junior doctors’ access to clinical training, while nursing groups are concerned PAs will be a threat to nurse practitioner roles.

Yet the evaluations suggest such concerns are much over-stated. For example, the Queensland evaluators were told the PAs had helped medical teaching by easing the clinical burden on doctors, allowing them more time for teaching.

For this recent Australian Rural Doctor story, I spoke with Dr Nikki Williams, a GP at Innisfail in north Queensland, who described the enormous benefits to her practice of having a student PA on clinical placement there as part of her UQ training. The student, a paramedic with 13 years experience, was able to take on a range of responsibilities, and was warmly received by patients.

Williams had only positive views about the potential of PAs to help overstretched rural doctors and services – so long as funding and infrastructure issues are addressed. She said opposition to PAs was “ridiculous”, given the need for more health workers.

“If my experience is any indicator, this is a very valuable tool towards increasing the capacity and the complexity of general practice,” Dr Williams said.  “It could solve a lot of the workforce issues in quite a reasonable way. I think general practitioners need to take it on board and not be threatened by it.”

In this article in the latest Australian Journal of Primary Health, the authors of the Queensland evaluation ran through the history of PAs, and concluded that “it now remains for the state and Commonwealth governments, in consultation with the relevant professional bodies, to determine whether the role has a future in Australia”.

Or perhaps not.

In the absence of strong leadership from professional bodies and policymakers, perhaps the push to introduce PAs will be led by grass-roots doctors like Nikki Williams who can see the potential benefits, not only to their workloads but to the communities they serve.

Perhaps bottom-up innovation is less susceptible to the muscle-flexing of medical and nursing unions.

** Don’t take my word for it; a draft background paper on health workforce innovation and reform now in circulation from Health Workforce Australia says:

“…the pace of reform of health professional roles and service delivery models has been slower in Australia than in many other comparable OECD countries. New roles such as nurse practitioners, physician assistants, and lay health workers that are long established in other developed (and developing) countries have often faced barriers in Australia and continue to be the subject of debate, despite evidence of the effectiveness of these roles in achieving the same or improved patient outcomes.  Protection of professional boundaries and the continued reliance on models of health service delivery and health education that is based on existing professional roles are seen by many as being largely responsible for this slow pace of reform.”

• The next post in this series will report on why Edith Cowan University is developing a PA program.