Ten interns commenced the two cohorts. At evaluation end: eight had completed the internship, one left the SPAI early for a primary care job elsewhere and one was on maternity leave. Eight interns were new PAs. Among the other two, one had been working in primary care for a few months and another on a respiratory ward. One practice hosted an intern in both cohorts. Overall, data were collected from all interns at baseline (seven gave data at every time-point), eight practices at baseline (six gave data at every time-point), and 165 patients from five practices. Key themes relating to the acceptability of interns in primary care are described below.
Conceptualisations of interns
While individual interns integrated as well-liked team members, both interns and practices lacked clarity about what a PA is, let alone an intern, and/or how best to communicate this to patients and colleagues. Three common conceptualisations of interns were: what they were not (e.g. not a doctor or a nurse); what they were similar to (e.g. salaried or trainee GPs, medical student); or what they could not do (e.g. they cannot prescribe). Conceptualisations of what they were, and positive statements about their role, were lacking.
Receptionists’ misunderstanding about interns caused inefficiencies; the ‘wrong type’ of patients being allocated to interns. Dissatisfaction arose if practices had greater expectations of autonomy (e.g. interns are similar to a trainee GP). Although on reflection, these expectations were recognised as being unrealistic, practices highlighted existing literature outlining potential roles of (experienced) PAs[13] as contributing to these perceptions. Patients valued consultations with interns but lacked clarity about the professional they had seen. Interns recognised this. Forty-seven (29%) responding patients reported that they did not know they were seeing a PA.
Interns considered themselves most similar to GPs, although recognised they were not GP replacements. GPs agreed that interns adopted a similar approach to patient assessment and presentation, but thought interns had less depth of understanding and reduced ability to diagnose and consistently manage complex conditions.
Whilst interns had some gaps in their capabilities, compared with trained GPs (the lack of prescribing capability was mentioned repeatedly), their flexibility to perform elements of different healthcare professionals’ roles was valued by GPs and practice managers. Overall, interns were perceived as a hybrid of multiple primary care roles.
Box 1 Quotes illustrating views regarding the conceptualisations of interns
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“No ‘cause if we say…Physician’s Associate. And what’s one of them? [laugh]… isn’t a doctor…isn’t a nurse...in-between but he can do most things.” (Practice Manager)
“I see [the PA]…Half-way between a nurse which is looking at pure clinical…whereas a GP…is…more holistic with a bit of social care added in there” (Practice Manager)
“… [the PA is] not working as a registrar. [the PA is] working as a medical student…” (Practice Manager)
“Like that hypothetical deductive model?...No I don’t think [the PA is] there. I think [the PA is] taught a bit like a third year medical student…these are the questions you ask about chest pain. . .” (General Practitioner)
“…I really like…the flexibility of a PA. There’s nothing they can’t really do, obviously there’s the prescribing bit, but actually can they visit? Yes…Could they see children? Well yes they can in time...There’s been no resistance. [the PA has] just – well show me what to do and I’ll do it.” (General Practitioner)
“…it said physician associate on the door and not doctor…have you not got all your stripes yet?…they keep calling you doctor and you keep saying just stop there.” (PA intern)
“The doctor was easy to listen to and explained everything well, easy to understand, very pleased with the doctor” (Patient)
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Perceptions of the PA role in primary care
The lack of a clear, realistic description of the primary care roles that interns were equipped to undertake caused uncertainty and confusion amongst some practices and patients. Practices often relied on interns to outline their own professional boundaries. Confusion over PAs being independent or dependent practitioners emerged. Practices often recognised that interns were dependent on GPs for supervision, but lacked clarity about the wider implications of this (e.g. the process for administration of influenza vaccinations). Some practices described uncertainty among existing staff about the role(s) an intern would occupy. However, despite lack of role clarity, host-practices saw the subsidised internship as an opportunity to explore something ‘different’. Practices adapted to supervision requirements through a dynamic approach to intern tasks, generally increasing the proportion of time interns undertook patient reviews and non-clinical activities. By internship end, practices were developing conceptualisations of future, higher-level implementation of a PA.
Box 2 Quotes illustrating perceptions of the PA role in primary care
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“Am I utilising him correctly as the Internship is expecting us to do?” (Practice Manager)
‘there’s sort of no singular PA job description…There’s a broad range of things that they can do but it’s making sure that the person…can do what you want them to do and they’re happy to do it.’ (Practice Manager)
“I think they bring something different… they really sit between somewhere like a nurse practitioner and a junior doctor…when you get a very experienced PA, then they certainly are going to be like a good junior doctor.” (Practice Manager)
“…there’s lots of things that they can assist us with…things like phoning patients on our behalf…rather than just seeing their own patients – helping us with our patients…” (General Practitioner)
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Preparedness of interns for primary care: the expectation-preparedness gap
This evaluation uncovered a significant expectation-preparedness gap. All interns expected to undertake book-on-day (BOD) appointments in primary care, though only 44% came into the internship with this experience. Similarly, 89% of interns had expected to do long-term condition reviews but only 22% had prior experience (Table 1). Interns were under-equipped on internship commencement to manage primary care patients with undifferentiated, complex, multi-morbidity.
Table 1: Expected and actual roles compared to previous experience in primary care – the expectation-preparedness gap
Acceptability of the intern among the primary care team
Upon internship completion, most host-practices were overwhelmingly positive about their intern; they demonstrated good clinical skills and performed well in a variety of scenarios. Acceptability of interns grew as initial reservations from some primary care team members eased. Reservations often arose from nursing staff and were related to potential implications of unclear role boundaries. Other concerns, from GPs, included issues regarding prescribing, accountability and supervision time pressures. Practices with previous experience of PAs (usually as students), felt that this enhanced acceptability of the intern amongst staff. Intern acceptability among practices was not always driven by increased clinical contact capacity. Pressure in GPs’ working days includes the ‘silent workload’; the administrative workload undertaken around full clinics, often unseen by patients and some staff. Introduction of the intern, and resultant increased requirement for supervision and blocked appointments, provided some additional time for GPs to undertake this workload. Further, the interns undertook some of the GPs’ silent workload.
Box 3 Quotes illustrating views regarding the acceptability of the intern among the primary care team
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“…I actually sat watching [the PA] do a couple of quite challenging learning disability reviews which I would never have the patience to do the way [the PA] did…[the PA] was very good and I was thinking…I’d be racing through this so the patient probably had a better deal.” (General Practitioner)
“That’s what our nurse was asking as well. What is it [the PA] will do? And I couldn’t answer that question. I said time will answer I think” (General Practitioner)
“I don’t think the nurses were keen….And I still don’t think they’re keen. I think they feel slightly threatened…and perhaps they feel [they] are better qualified…but, it’s another skill mix isn’t it?” (Practice Manager)
“I mean [the GP] and myself often refer to the silent workload…GP’s have got a silent workload of the prescribing…the referrals, etc….there’s a huge silent workload for the practice…all these clinical audits and stuff that requires clinical input but not particularly a GP…that’s where [the PA has] been so useful” (Practice Manager)
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Acceptability of supervising the intern
Intern supervision, and the related issue of trust, were important topics to practices and interns. High-intensity, close supervision was necessary for responsible GPs to build trust in the interns’ capabilities. Perceptions of acceptable supervision levels appeared to be individual GP and/or practice-specific. A single salaried GP in a host-practice refused to provide clinical supervision for the intern due to perceived risks. Some GPs reviewed all intern patients for an extended period but felt over-burdened by this. Conversely, after a short induction period (a few weeks), other GPs allowed supervision to be determined by the intern and case complexity. Whilst training practices were more likely to find the supervision demands acceptable, they often had multiple dependent practitioners/trainees concurrently requiring GP support. The intern was the tipping point in some practices, who adapted their working day (e.g. reducing booked appointments) to accommodate this. Notably, multiple people requiring support from one GP created delays for some interns. Smaller practices struggled most to provide ‘blocked-out’ appointments to accommodate ‘just-in-time’ supervision, due to the relative impact on appointment capacity. The consequences of this were that interns sometimes rescheduled patients with another clinician to complete the management plan and/or felt less supported. Practices that had invested a lot of high-level supervision early on appeared more satisfied at internship end. Over the year, GP face-to-face reviews reduced, and practices and interns developed efficient and sustainable supervision and support methods which, in turn, increased acceptability of supervision. For example, protocolising care for common conditions; utilising electronic prescribing systems (sending electronic prescription requests) if no advice was needed; use of medical record screen messaging systems for brief advice; joint debrief sessions with other dependent professionals/trainees; and catch-up meetings. A mismatch in perceptions of appropriate supervision emerged: some interns felt over-observed and others under-supported.
Box 4 Quotes illustrating the acceptability of supervising PA interns
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“at the moment, it’s not really working for the GPs because so much of their time is going in training…At the moment it’s more work. . .” (Practice Manager)
“…what I think would be more effective is if all the GP practices had one on-call doctor that wasn’t seeing any patients so PAs could go to that doctor ‘cause I think waiting round outside doors, knocking the doors, waiting for patients to leave – it takes consultation time and it also saves us waiting around and feeling awkward…” (PA intern)
“From my perspective it’s definitely been manageable. I think there’s a strong argument that [the PA intern] should get more input than [they get] really.” (General Practitioner)
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Fit of the interns with existing primary care services
The fit within the primary care team was challenged by imprecision in the interns’ roles and conceptualisations. However, intern role-flexibility overcame this. Interns (and practice staff) recognised that their activities were a hybrid of GP and nursing roles and the interns’ flexibility was highly valued and nurtured in many practices. However, in one practice it prevented identification of a specific role for the PA post-internship: “So I can’t say we’ve had a bad experience but I can’t say yes, we really want one, we can’t do without one. I don’t think we’ve found that role to fit [the PA] in.”
The inability of interns to prescribe was a commonly cited barrier to integration and certainty of the relative benefit of interns/PAs compared with other professional groups (e.g. Nurse Practitioners). One practice felt that regular contact with GPs through prescription signing, slowed the intern’s progression towards autonomy.
While the SPAI team provided guidance about target appointment lengths, in reality this was predominantly led by the interns’ preferences. Interns were over-optimistic at the outset about the rate at which their appointments would reduce in length (Table 2). Persistence of longer appointment times was attributed to lack of patient and intern knowledge about PA appointment time norms, the need for interns to seek GP input for prescriptions, the undifferentiated nature of primary care patients, being managed in non-protocol-driven ways, and the need for longer appointments for certain activities/reviews. Despite this, GPs perceived a pressure to reduce appointment lengths to demonstrate acceptable value for money beyond the internship.
Some interns enhanced care by improving outreach to housebound patients, for example, when host-practice nurses did not do home visits, interns did long-term condition reviews at home, and proactive reviews and clerking of nursing/care home admissions. These host-practices noted better or easier attainment of incentivised targets.
Table 2
PA intern actual and predicted appointment lengths
Appointment length
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Baseline
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Baseline prediction of appointment length at 3 months
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Midpoint
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Endpoint
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PA interns responding
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10
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10
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7
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7
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30 minute
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8
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2
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0
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1
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20 minute
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2
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2
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7
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4
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15 minute
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0
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6
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0
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2
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10 minute
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0
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0
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0
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0
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Acceptability of interns to patients
Most patients had confidence and trust in their intern (Table 3); positivity stemmed from the intern:
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Having protracted appointment length
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Demonstrating a caring and listening approach
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Seeking second opinions when needed
Patient acceptability was also indirectly indicated through repeat appointments with interns. One patient was dissatisfied by being care-navigated to the intern, but this related to the patient’s preference for a GP rather than the care provided by the intern per se. Some practices noted the value of proactive intern promotion of patient acceptance: engaging the patient participation group (PPG) and developing a leaflet. PPG members needed reassurance about the origins of the internship (i.e. workforce development), rather than a practice-level cost-cutting exercise. Some large teaching host-practices believed that patients generally accepted that they may see a variety of professionals.
Table 3
Patient feedback regarding the care they experience from PA interns
Aspect of care
(no. of respondents)
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(Very) good
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Neither good nor poor
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(Very) poor
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Overall, how would you describe your experience with the PA? (n = 160)
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158 (99%)
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1 (< 1%)
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1 (< 1%)
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How good was the PA at…
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…giving you enough time? (n = 160)
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160 (100%)
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0
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0
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…treating you with care and concern? (n = 160)
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158 (99%)
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1 (< 1%)
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1 (< 1%)
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…listening to you? (n = 160)
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157 (98%)
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3 (2%)
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0
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…explaining tests and treatments? (n = 158)
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155 (98%)
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2 (1%)
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1 (< 1%)
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…involving you in decisions about your care? (n = 159)
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154 (97%)
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4 (3%)
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1 (< 1%)
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Solutions offered to improve acceptability of interns
Host-practices saw interns as an acceptable addition to the primary care workforce. They stressed that, to optimise the primary care PA value and acceptability, a continued commitment from NHSE and HEE and accurate, realistic information for practices was needed. This should include recognition of, and support for, high-intensity GP supervision for new PAs. A commitment to a national scheme was requested, to provide standardised education, practical and financial support to make the integration of PAs into primary care a success. This was felt to be necessary for at least a few years, until a critical mass of experienced primary care PAs is realised. Host-practices wanted a collaborative network to develop a shared understanding and standardised approaches to supporting their interns.
Box 5 Quotes illustrating solutions offered by practices to improve acceptability of PAs interns
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“NHS England need to stop looking short-term. If they’re gonna make a PA a proper role, and why wouldn’t they, then they need to build that into their kind of workforce modelling and look at five or 10 years not 18 month rolling.” (General Practitioner)
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