Physician assistants in Australia

FigureFigurePhysician assistants (PAs) are making inroads in Australia. Medical extension is an idea whose time has finally come. As the familiar demand-side triad of population aging, wants, and technology collides with workforce and financial constraint, change for Australia will be a necessity, not an option. With 3.3 physicians for every 1,000 of its population, Australia actually has quite a reasonable supply of doctors. In comparison, the United States has 2.5 per 1,000, Canada 2.4, and the United Kingdom 2.8.1 The real reasons for the equally real shortages of physicians are the problems of urban concentration, the imbalance between clinical generalists and subspecialists, and tasks being performed by physicians that might be more efficiently done by others. Because of the latter, Aussies will require more primary care providers. National modeling predicts a grim outlook for nursing workforce supply, even for existing nursing roles.2 For this and other reasons, valuable nursing reforms (including the introduction of the nurse practitioner model) cannot be the whole answer. This is where PAs come in, as a solution for medical care that is flexible and responsive to context and community need. The now-familiar international pattern of skepticism and profession resistance to the PA concept is giving way to formal consideration in national health policy, and in growing support from the medical profession, notably among rural physicians.3,4 As acceptance of new ideas goes, the proposition for PAs in Australia has probably made it past three of J.S. Haldane's phases: nonsense, perverse-but-interesting, and true-but-unimportant. We hope we are well on the way to I've always said so! Australia has a good universal-access health system arranged through a public and private mix of healthcare services and insurance. The national insurance arrangements cover most (if not all) of the fees charged by private family physicians and offers free public hospital care and subsidized medicines. Supplementary private health coverage, incentivized through taxation, pays for other services, including private hospital care. Healthcare spending as a percentage of gross domestic product (GDP) was 9.5% in 2011–2012, a little above the average among developed OECD economies and with good healthcare outcomes.5 By comparison, the United States spends an heroic 18% of GDP on healthcare with results that are less than super (the United States ranks fourth from last among OECD countries in potential years of life lost).1 That said, strains in the Australian system are very real and are set to worsen, particularly given softening economic conditions. Healthcare is already the largest area of growth in government spending—increasing 74% in real terms over the past decade, almost as much as the increase in welfare and education expenditure combined.6 As in many countries, Australia has a rural and a social gradient in access to healthcare and in healthcare outcomes. Australians living in outer regional and remote areas have access to one full-time equivalent physician for every 411 people, compared to a 1:231 ratio in major cities.7 Australia is coming to the realization that a blunt “more doctors” answer is no solution. We need teamwork and a better geographic and medical specialty balance. What is the state of play for the Aussie PA? Two Australian states, Queensland and South Australia, have undertaken PA pilots. Unsurprisingly, both reported positive outcomes in terms of patient and professional acceptance and quality of care.3 Queensland has a useful legacy of legislative change to cover prescribing of medicines, and the government has published a clinical governance guideline for PA practice.8 Two universities have established PA programs, with James Cook University in the rural tropical north continuing after the University of Queensland program was discontinued. Two graduating cohorts to date will be joined by the first James Cook University group this year. Other universities are exploring options. The establishment of the Australian Society of Physician Assistants (ASPA) represents a growing maturity in the Australian PA movement. The 35 Aussie-trained PAs, their US-trained colleagues, and the PA students on the way, are pioneers who have embraced a new career path and an innovative response to meeting community healthcare needs. Australian PA graduates and students bring an average of 15 years of previous career experience to the role from backgrounds that include paramedic practice, pharmacy, podiatry, physiotherapy, nursing, and the army medical corps. Most PA graduates and students continue to be engaged under their old occupational titles as they await expanded opportunities for formal employment as PAs. Employment in the private sector is possible, although generating the revenue to underwrite a salary can be a challenge. Employment opportunities for PAs in government health systems are limited at present but there are encouraging signs, particularly with greater regional autonomy under national reforms. National licensing of the PA profession will ultimately underpin the highest standards of care and protect the title. In Australia, as in the United States, this will likely follow, not precede, acceptance of PAs in the workplace and the community. In the meantime, alliances with physician groups; a focus on meeting priority healthcare needs; and greater flexibility in workforce, employment, and revenue generation will get things established. All Australians, especially those in rural and remote areas, deserve access to affordable, timely, efficient, and effective healthcare. The PAs of Australia are trained and experienced professionals awaiting the opportunity to play their part.

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