Canada

Canada’s PA profession, still in its early stages, has a solid foundation and is expected to continue to grow throughout the Canadian health care system. As of June 2016, there are about 500 Canadian Certified Physician Assistants (CCPAs) who were trained through either Canadian or American programs. (U.S. PAs are eligible to take the Canadian Certification Exam, but unfortunately, Canadian-trained PAs do not yet have access to the National Commission on Certification of Physician Assistants [NCCPA] exam.)

Canadian PAs are health care clinicians academically and nationally qualified to provide medical services to patients in a wide range of settings and in a variety of roles. All PAs work in collaboration with a physician; the scope of practice is determined by observations and comfort levels and in the negotiated role required of the physician practice and PA qualification. The scope of practice is summarized as duties authorized by a physician that the physician is qualified to perform and is comfortable delegating. A PA can collect a history, order appropriate diagnostics, reach a differential diagnosis, and prescribe appropriate treatment.

The Canadian PA model was developed in the military during the Korean War as an advanced medical technician called a medical assistant . The training transitioned to the present PA concept in 1984 and was further revised in 2002. The Canadian Forces program is taught at the Canadian Armed Forces Health Services Training Center and is restricted to serving members of the Canadian Forces. Three, soon to be four, civilian university programs are located at the University of Manitoba (2008) and in Ontario (McMaster University, 2008) and the Consortium for PA Education (2010). The Consortium is housed in the Department of Family Medicine at the University of Toronto’s School of Medicine and includes partnerships with the Northern Ontario School of Medicine and the Michner Institute for Applied Health Professions. Alberta’s University of Calgary has a program in development potentially starting in September 2016. All programs are 24 to 25 months in duration and deliver curricula that support the Canadian Association of Physician Assistants’ (CAPA) scope of practice statement and Canadian Medical Education Directives for Specialists (CanMEDS) PA competencies. In 2003, the Canadian Medical Association (CMA) Board of Directors approved an application from the Canadian Association of Physician Assistants (CAPA) to include PAs within the CMA accreditation. The CMA first accredited the PA program delivered by the Canadian Forces Medical Services School in 2004.

The Physician Assistant Certification Council of Canada (PACCC) administers and oversees certification for PAs in Canada and provides quality assurance for the entry-to-practice examination. The CCPA designation is recognized as the national standard process (CMA Accreditation Report). As part of the professional recognition requirements, CAPA structured the PACCC to establish an independent national certification examination and registry. The first national examination was held in 2005. In 2009, CAPA refined its National Competency Profile and PA Scope of Practice. The national competency profile (NCP) defines the core competencies that a generalist PA should possess on graduation and is the accepted standard in Canada.

Each province and territory has its own medical act that further delineates the degree of delegation and supervisory requirements. For example, Manitoba first introduced PAs in 1999 under the title of Clinical Associate. In 2009, those regulations were amended to permit practice under the title of PA. Also in 2009, the College of Physicians and Surgeons of New Brunswick amended the New Brunswick Medical Act (1981) to include PAs. Alberta is the only Canadian province with a voluntary PA (nonregulated) registry that is held by the College of Physicians and Surgeons of Alberta. Efforts are currently under way to regulate PAs in Ontario, where they currently practice under the supervision of a physician and are only able to perform controlled acts under delegation. Other provinces are in various stages of considering the PA career as an appropriate clinician for their governmentally controlled health systems.

The highest concentration of PAs (50%) in Canada is found in Ontario. What started as the first emergency medicine projects in 2007 has since expanded to include various demonstration projects in family medicine and community health teams, medical and surgical specialties, and long-term care facilities. New Brunswick has introduced PAs into emergency departments. Alberta has several pilot projects introducing PAs into occupational industrial medicine.

Canada’s certified PAs report working in 32 medical or surgical subspecialties. It is estimated that 38% are in primary care roles, 13% are in internal medicine specialties, 18% are involved in surgical practice, and 19% are in emergency medicine. Just fewer than 50% of Canada’s PAs report serving communities of less than 250,000, with 34.5% in populations under 50,000 (CAPA 2014 National Survey).

A significant advance for Canadian military PAs came in 2016 when PAs transitioned from their status as senior enlisted noncommissioned members and warrant officers to the newly identified officer occupation within the Canadian Armed Forces.

United Kingdom

The first PAs to work in the United Kingdom were two Americans who in 2003 were recruited for primary care posts. They worked in the Black Country, so called from its days as an industrial hub but now an economically distressed and medically underserved area of England’s West Midlands; this area encompasses Birmingham, England’s second largest metropolitan area. A larger scale demonstration project followed in Scotland from 2006 to 2008, with 20 experienced American PAs deployed across a number of specialties. It was from these projects that the U.K. PAs, UK Association of Physician Assistants (UKAPA), the first professional body, was created by expatriate American PAs to provide necessary continuing medical education and to encourage advancement of the PA profession.

Initial efforts by the British at “growing their own” PAs started in 2002 with pilot training programs for what were then called health care practitioners (HCPs), precursors to the PA role, at St. George’s University of London and Kingston University. The HCP model then evolved into the medical care practitioner (MCP) and then to the PA, with the University of Wolverhampton as the first to identify its curriculum as a PA program in 2004. The first substantive programs, as defined by class size with cohorts of 10 or more, were launched in 2008 when the University of Birmingham and University of Wolverhampton and then as St. George’s in London relaunched with a similar sized cohort in 2009. Notably, the St. George’s program was the only one to be led by a U.S.-trained PA. These programs followed a national curriculum and were taught at the postgraduate diploma (PgDip) level.

Despite the emphasis on the creation of PA programs, there was initially significantly less effort devoted to the broad types of advocacy required to create a new health profession. These include (1) role development and gaining the broad support of doctors; (2) the development of a national regulatory processes and the authorization of clinical privileges such as prescribing; (3) the creation of other forms of professional recognition such as certification, recertification, and credentialing at the health systems level; and (4) the authorization of a reimbursement structure to pay for the services of PAs.

A setback to the British PA movement was the closure of the PA program at the University of Birmingham in 2011, the consequence of loss of the original champions within the university’s hierarchy and opposition from certain quarters within the local National Health Service (NHS). The University of Wolverhampton’s program was also suspended at the same time. Meanwhile, on a much more positive note, the St. George’s program in London had doubled its entry cohort number, and a new program was launched at the University of Aberdeen, Scotland, in October 2011.

The transition of the title of “physician assistant” to “physician associate” came upon the recommendation of the NHS’s Health Education England (HEE). Within the NHS structure, the “assistant” role denotes lesser qualified, less trained individuals with lesser academic credentials and reflects lower pay scales. It also was intended to clarify the role from those informally trained “physician assistants” (“medical assistants” in U.S. terminology) who were working in some NHS hospitals.

After a couple of years of the United Kingdom’s PA profession languishing in the doldrums of governmental apathy, the winds of change slowly started to build. A renewed interest in PAs came from cities and regions across the whole of the country, especially as hospitals were feeling the strain of the work hour restrictions on their house officers and doctors in training. First to reclaim their status was the program at the University of Birmingham with a relaunch in January 2014. They continued the momentum of making up for lost time by increasing their cohorts to two intakes per year, which they have since continued to this time, the only U.K. program to do so. The University of Wolverhampton restarted in September 2014, and the University of Worcester joined the effort at the same time. Only a few months later, the sixth program was up and running at the University of Plymouth. This dramatic shift in fortunes was helped along with additional support by the first national strategic PA workforce conference, hosted by HEE, on Physician Associates in the Workplace held in Birmingham in October 2014. This was followed in 2015 when growing support for the PA profession came from the United Kingdom’s Minister of Health and was manifest in a demand for 1000 PAs for the primary care workforce alone by 2020. To meet this demand, the number of universities offering PA programs tripled from just 5 in 2015 to 15 in 2016 and is expected to double again by 2017. Also of significance is that although the number of English and Scottish programs has since increased exponentially, there are now new programs being established in Wales and Northern Ireland, where previously there were none.

Another milestone was achieved in April 2016 when the First Annual Physician Associate Educators Conference was held at the University of Worcester. With the recent explosion of PA programs across the United Kingdom, it was thought that it was time for a renewed vision of increased cooperation and collaboration on setting academic standards among the current and new program.

U.K.-trained PAs were originally expected to work in primary care, which at the time was anticipating a significant shortage of workers in underserved areas. Accordingly, the Competency and Curriculum Framework developed by the Department of Health was focused on primary care. However, implementation of the European Working Time Directive, which significantly limited work hours for doctors in training to less than 48 hours per week, has increased the demand for PAs to work in hospital and specialty practices; fewer are working in general practice (outpatient medicine). Revisions to the CCF are presently under way to reflect the shift to a broader approach, including hospital-based practice.

Unfortunately, despite more than a decade of scores of PAs working in the NHS, there is still no official recognition by the U.K. government or by the nongovernmental medical licensing bodies such as the General Medical Council. The original professional organization UKAPA has since transformed into the Faculty of Physician Associates (FPA) of the Royal College of Physicians. As such, the FPA holds a “managed voluntary register” as a means of identifying the PA workforce; it provides the necessary continuing education U.K. PAs need to maintain their qualification. Until officially recognized, U.K. PAs face the hardships of not having prescriptive practice or being able to order diagnostic imaging, thus limiting their overall effectiveness. Despite these challenges, demand for PAs continues to increase. As of June 2016, there are about 300 PAs in the United Kingdom, including about 20 Americans.

Newly graduated PAs will have an initial qualifying examination, modeled after the Physician Assistant National Certifying Exam (PANCE) in the United States. The United Kingdom’s version is a two-part process, a 200-question multiple-choice examination and a 12-station Objective Structured Clinical Examination (OSCE). Of potential interest to American PAs is that at present, PAs who are already currently NCCPA certified are able to apply to become a member of the Managed Voluntary Register (MVR) without first having to undergo the UK examination process.

A novel idea to further use American PAs in advancing the UK’s PA role in the NHS was the creation of the National Physician Associate Expansion Program (NPAEP) ( http://npaep.com ). This program was intended to recruit more than 200 American PAs to go to the United Kingdom for a period of 2 years, effectively doubling the existing PA workforce. The overall goal of the program was to expand the use of PAs across a number of sites in the NHS. However the projected faced many obstacles including meeting the desired recruitment numbers. The project was implemented in mid-2016.

The Netherlands

Around the turn of the millennium, the Netherlands government predicted upcoming shortages in the medical workforce. To address the imbalance between the demands and supply of Dutch medical care providers, the PA role was first introduced in 2001. Since then five Master Physician Assistant (MPA) programs have been started at universities of applied sciences. The first MPA program started at the University of Applied Sciences Utrecht in 2001 followed by the HAN University of Applied Sciences located in Nijmegen in 2003. Then in 2005, three more MPA programs opened at the Inholland Graduate School in Amsterdam; the Hanze University of Applied Sciences, Groningen; and the Rotterdam University, University of Applied Sciences. With reference to this last MPA program, it should be mentioned that from 2005 to 2009, the program had a primary focus on clinical midwifery. However, since 2009, Rotterdam University also developed a traditional generic MPA program and maintained the midwifery program. In total, the five Dutch MPA programs have an annual enrollment of approximately 125 students. These enrolling students must meet the admission criteria of (1) being a holder of a bachelor’s degree in either nursing or paramedicine and (2) having a minimum of 2 years of relevant professional, clinical experience after their undergraduate training.

In the Netherlands the MPA program is a 30-month curriculum, based on the National Training and Competency Profile MPA. This profile is tailored to the professional roles of the CanMEDS, including (1) medical expert, (2) communicator, (3) manager, (4) collaborator, (5) scholar, (6) health advocate, and the overarching role of (7) professional. These seven professional roles are described by a definition, delineation, and related competencies. Each of these professional roles is linked to the task areas as defined within the Professional Profile Physician Assistant by the Dutch Association of Physician Assistants (NAPA). According to the Framework for Qualifications of the European Higher Education Area, the MPA programs in the Netherlands are designated as second-cycle programs and entail a total study load of 150 European Credits, equal to 4200 clock hours. PA training in the Netherlands differs from other traditional international PA models in the integration of their didactic and clinical education, known as a dual program . At the day of enrollment to the MPA programs, the students are also employed as paid PA trainees. While students on campus (1 day per week) are learning the core knowledge and skills required for all PAs, each student simultaneously receives additional clinical expertise in a designated medical specialty by actually learning in that area the rest of the working week. Students are contracted through a “training and employment contract” with a minimum of 32 hours per working week. On top of this, students are expected to engage in self-study. As a result, PA students have both didactic (to acquire generic competencies, modeled to the medical curriculum) and clinical days (to acquire specialty competencies, analogues to that of training medical residents) interspersed throughout the duration of their training. Fully qualified PAs are known as MPAs. Dutch PAs work across all areas of medicine, including general practice, and because of their unique approach to their training, are found in subspecialty areas in greater numbers than PAs elsewhere.

In the past 15 years, the Dutch PA profession has grown to more than 1000 clinicians. Under the leadership of the NAPA, the Dutch PA profession has made significant advances. The most substantial professional milestone as reached in 2012: PAs are enabled by law to practice medicine autonomously, albeit at all times in collaboration with a medical doctor. Granting this independent practice is a result of a change in the Individual Health Care Professional Act and involves authorization to perform medical procedures, including prescription of medications, which formerly belonged within the realm of physicians only. This assigned professional autonomy is anchored in a temporary legislative change and will be evaluated in the year 2017.

At the time of graduation, PAs can voluntary enroll in NAPA’s Quality Register. The Quality Register contributes to ensuring the quality of professional practice by keeping track of developments in the profession (i.e., by means of continuing medical education [CME]). Being enlisted into the Quality Register indicates the PA to be a graduate of a Dutch Flemish Accreditation Organization–accredited MPA program and is clinically active at time of registration. The registration period covers a term of 5 years after which a re-registration is required. Only those who have been practicing as PAs with a minimum of 16 hours per working week and have followed CME totaling 200 hours (40 hours per year) in the last registration period of 5 years are considered for re-registration.