PHYSICIAN ASSOCIATES IN RURAL PRIMARY CARE FROM THE FARMHOUSE TO THE ROUNDHOUSE (1) AND INTERNSHIPS Alex Strivens-Joyce PA - Montgomery Medical Practice, Powys PA Ambassador - (Shropshire & Staffs) - HEE-WM -Clinical Tutor - North Staffs PA Internship Programme Dr Simon Currin Managing Partner - Montgomery Medical Practice
PHYSICIAN ASSOCIATES IN RURAL PRACTICE US PAs in rurality; greater scope of practice, autonomy & likelihood of being principal care provider (2)(3) Rural UK practices finding it harder to recruit GPs (4) (smaller lists, funding & location (5) ) Montgomery Medical Practice (MMP): 7,158 Patients, 4 GP Partners, 2 PAs, 2 NPs, 3.5 PNs, 1.5 HCAs Rurality: Large practice area, few community services, distant secondary care (=>1/24 from DGH) additional services PA role: Clinical, medical support, enhanced services, management, teaching, continuity (6) Why rural GP? Community, cost of living, clinical opportunities, diverging governance (NHS-Wales)
OUTCOMES AT MMP Patient feedback: Good Recognition: 2016 Steve Hugh Award for innovation in primary care (7) Training: PA students/interns, medical students, training practice Capacity: Visiting, appointments, mental health, enhanced services, access, less locums Recruitment: Two GP partners, 2 nd PA Services: Minor surgery, minor injuries, care homes, anti-coagulation, secondments, sustainability funding, community hospital Virtual Ward (hospital avoidance): Medical link: community health & social services Data: Admissions, prescribing
SUBSTITUTION MODELS IN PRIMARY CARE The Roundhouse (1) : GPs sitting as Consultant primary care physicians (CPCP) overseeing a skill mixed MDT within a bespoke clinical architecture MMP: model slowly evolved; GPs deliver care via skill mixed team: On-call GP sits as floating CPCP (1) supervising a team of PN s, DN s, NPs & PAs Urgent appointments filled by nurse telephone triage Routine appointments booked directly PA s provide urgent, routine & MH appointments, visiting & manage all clinical results/ post Supported by upskilled admin team & HCAs Advanced Practitioners: non-doctor clinicians of varied aetiologies, can integrate into skill-mixed MDTs & redistribute primary care workload (1)(10) Figure 1. The Roundhouse building (1) MMP
ROUTINE APPOINTMENT SIGNPOSTING SYSTEM (RASS) 10 : Evolution of existing model: PA triage of routine appointments though capture of presenting complaints (PCs) at booking 11/17: 12 month audit cycle (incremental rollout of RASS) Access: Phone, Practice, Online (EMIS: E-consult): Same day resolution of suitable PCs by phone consultation or clinical admin, signposting or referral (Care Navigation (15) +) Urgent PCs transferred to urgent triage system Remaining PCs allocated appt. : HCA, PN, DN, NP, PA, GP Waiting interval set by severity: 2-3/7, 1/52, 2/52 Objective: increased access to routine appointments
EXPERIENCE OF A CLINICAL SUPERVISOR Dr Simon Currin, Managing Partner, Montgomery Medical Practice Why did we choose the PA route? How did we integrate the role into our team? What were the challenges? How have we benefitted? What does the future hold?
HEE-WM: PA AMBASSADORS (PRIMARY CARE) Primary Care: a prime generalist specialty but only 15% (12) of NQPAs are choosing it, why? DH: 1000 Primary Care PAs (England) by 2021 (13), 2017:~75 (12) (UK) 2016 FPARCP Census: 31 (14) HEE-WM : Two ambassadors: Shropshire & Staffs (AS-J), Hertfordshire (CS-W) Objectives: 1. Facilitating PA student placement 2. GP Engagement (PA agenda, recruitment & retention) 3. PA Internships / Preceptorships Current Snapshot: Shropshire & Staffs Feb 2017 : 1 PA in primary care, Oct 2017: 8, Feb 2018: 15 North Staffs PA Internship Programme (Primary Care) Two additional HEIs starting PA courses in the next 18/12
NORTH STAFFORDSHIRE PA INTERNSHIP PROGRAMME (PRIMARY CARE) Designed to provide a broad clinical base & preceptorship for NQPAs in their 1 st year 2 days: Secondary care, 2.5 days: GP, 0.5 days: Teaching Mid Band 6: One year training post - SSSNHSFT host trust 1st cohort: Oct 2017(5), 2 nd : Feb 2018 (7), 3 rd : Oct 2018 (6) and 4 th : Feb 2019 (6) GP and Consultant clinical supervisors HEE-WM pilot project: GP-FV funding 50% GP salary costs, indemnity & teaching Desired outcome: PA-interns recruited substantively by host practices 5 GP Practices 3 Secondary Care Trusts: SSSNHSFT - OP Psych BHNHSFT - EM UHNMNHST EM & T+O
NORTH STAFFORDSHIRE PA INTERNSHIP PROGRAMME EDUCATION COMPONENT Teaching: case based learning lead by GP trainer & PA tutor: 46 taught sessions, rolling 12 month syllabus Curriculum: based on RCGP learning outcomes for GPSTs (16) allied to 1 st hand experience & NQPA/student feedback Educational package: Peer/pastoral support, books/online resources, weekly teaching, support for practice/firm, secondary care courses Assessment : Case based reflective portfolio, observation(mini- CEXs/video analysis), CBDs, grand rounds, termly practice visits
NORTH STAFFORDSHIRE PA INTERNSHIP PROGRAMME FUTURE Short term: working towards accreditation with a medical school for award of a PGCert in Primary Care Medicine (PA) on completion Medium term: A tailored internship for PAs looking transfer from secondary care To establish a Staffordshire PA Academy for career long CPD, mentorship, research opportunities & academic certification
THANK YOU AND QUESTIONS
BIBLIOGRAPHY: (1) Lewis DM, Naidoo C, Perry J, Watkins J. The Roundhouse: an alternative model for primary care. Br J Gen Pract 2016-04-28 16:05:24;66(646):e364. (2) Sawyer BT, Ginde AA. Scope of practice and autonomy of physician assistants in rural versus urban emergency departments.. Acad Emerg Med. 2014-05-21(5):520-5. doi: 10.1111/acem.12367. (3) KE Martin. A rural-urban comparison of patterns of physician assistant practice. JAAPA. 2000 Jul;13(7):49-50, 56, 59. (4) Rural GP surgeries in crisis say senior doctors. 2015; Available at: http://www.bbc.co.uk/news/av/health- 34125942/rural-gp-surgeries-in-crisis-say-senior-doctors. Accessed 17/9/2017. (5) British Medical Association: Rural GP Practices Face Financial Uncertainty. 2016; Available at: https://www.bma.org.uk/news/2014/february/rural-gp-practices-face-financial-uncertainty. Accessed 17/9/, 2017. (6) Parle J, Ennis J. Physician associates: the challenge facing general practice. The British journal of general practice : the journal of the Royal College of General Practitioners 2015 May;65(634):224-225. (7) 2016 Winner of the Steve Hugh Award. 2016; Available at: https://shropdoc.org.uk/news/2016-winner-steve-hughaward. Accessed 17/09/, 2017 (8) Crude Emergency Admission Rates per 1000 - North Cluster - All Specialties - NWIS/SUS APC dataset. Powys Teaching Health Board 2017. (9) Carroll J. QOF Medicines Management Annual Visit- Montgomery. Powys Teaching Health Board 4/7/2017 (10) Primary Care Workforce Commission. The future of primary care: Creating teams for tomorrow. 2015;138(3):230. (11) Strivens-Joyce A. Can Waiting Times for Routine Primary Care Appointments be Reduced by the Triage of Presenting Complaints at Booking to the Appropriate Clinician? [Unpublished research proposal]. Birmingham: University of Birmingham; 2017. (12) HEE Physician Associate Workshop; 15 March 2017. BMA House, London. (13) Health Care Select Committee. Primary care Fourth Report of Session. Primary care Fourth Report of Session 2015-16. (14) Ritsema TS. Faculty of Physician Associates: Census results 2016 FPARCP 2016 (15) Jones C. West Wakefield Care Navigation Tool. 2016. (16) The RCGP Curriculum: Professional & Clinical Modules 2.01 3.21 Curriculum Modules RCGP: London 2016