title: Physician associates in primary health care in England: A challenge to professional boundaries?
abstract: Like other health care systems, the National Health Service (NHS) in England has looked to new staffing configurations faced with medical staff shortages and rising costs. One solution has been to employ physician associates (PAs). PAs are trained in the medical model to assess, diagnose and commence treatment under the supervision of a physician. This paper explores the perceived effects on professional boundaries and relationships of introducing this completely new professional group. It draws on data from a study, completed in 2014, which examined the contribution of PAs working in general practice. Data were gathered at macro, meso and micro levels of the health care system. At the macro and meso level data were from policy documents, interviews with civil servants, senior members of national medical and nursing organisations, as well as regional level NHS managers (n = 25). At the micro level data came from interviews with General Practitioners, nurse practitioners and practice staff (n = 30) as well as observation of clinical and professional meetings. Analysis was both inductive and also framed by the existing theories of a dynamic system of professions. It is argued that professional boundaries become malleable and subject to negotiation at the micro level of service delivery. Stratification within professional groups created differing responses between those working at macro, meso and micro levels of the system; from acceptance to hostility in the face of a new and potentially competing, occupational group. Overarching this state agency was the requirement to underpin legislatively the shifts in jurisdictional boundaries, such as prescribing required for vertical substitution for some of the work of doctors.
authors.affiliation: Faculty of Health, Social Care and Education, Kingston University and St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK. Electronic address: v.drennan@sgul.kingston.ac.uk.
authors.forename: Vari M
authors.initials: VM
authors.lastname: Drennan
authors.affiliation: Centre for Criminology & Sociology, Royal Holloway, University of London, Egham Hill, Egham Surrey, TW20 0EX, UK. Electronic address: j.gabe@rhul.ac.uk.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Gabe
authors.affiliation: Faculty of Health, Social Care and Education, Kingston University and St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK. Electronic address: maryhalter@sgul.kingston.ac.uk.
authors.forename: Mary
authors.initials: M
authors.lastname: Halter
authors.affiliation: Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, GU2 7PX, UK. Electronic address: s.lusignan@surrey.ac.uk.
authors.forename: Simon
authors.initials: S
authors.lastname: de Lusignan
authors.affiliation: Independent Researcher, London, UK. Electronic address: roslevenson@gmail.com.
authors.forename: Ros
authors.initials: R
authors.lastname: Levenson
mesh_terms: D004739:England; D006801:Humans; D009722:Nurse Practitioners / Q000592:standards / Q000706:statistics & numerical data; D010823:Physician Assistants / Q000592:standards* / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000191:economics / Q000379:methods; D024382:Professional Role; D000068616:Professionalism / Q000592:standards*; D036301:Qualitative Research; D013222:State Medicine / Q000458:organization & administration; D000078329:Workforce
keywords: England; Health professions; Physician assistants; Physician associates; Primary care; Professional boundaries