Regulation of physician associates in Aotearoa New Zealand mitigates a medical practitioner workforce crisis and leads to stronger, diversified healthcare teams

Physician associates (PAs) were introduced in Aotearoa New Zealand in 2010. In 2013, PAs began to fill the demand for healthcare practitioners during a predicted doctor shortage in Aotearoa New Zealand. Approximately 11 years later the shortage is being called a health crisis.^1,2 There are healthcare worker shortages in many countries and predictions reveal this trajectory will not diminish soon. Estimates from the World Health Organization state there will be a global shortage of 10 million healthcare workers by 2030, mostly in low- and low–middle-income countries.³ These shortages and forecasted deficiencies have caught the attention of several countries.

If Aotearoa New Zealand wants to change its trajectory and deliver positive change to the healthcare system, strategic insight and a timely action plan are necessary. Like many countries during the pandemic, our country was tested and stressed with border closings, and an even greater workforce shortage emerged. The economic impact cannot be erased. A step in this timely action plan and a means of expanding the role of medical service delivery is to fill a portion of the workforce gap with the PA profession. The profession was built on doctor shortages in the United States in the late 1960s and it has continued to expand globally. An impressive catalogue of medical workforce studies identifies the PA as a highly trained, cost-effective and patient-satisfying addition to the workforce. Globally, there are over 170,000 physician assistants/associates and 366 training programmes.⁴ This article looks at what the profession offers Aotearoa New Zealand amid a health workforce crisis. The views and information expressed in this report are gathered from two PA workforce demonstration pilots,⁵ combined with research and input from workforce strategists, employers, stakeholders and doctors.

A formalised strategic plan to support doctor shortages began in 2018 with the New Zealand Physician Associate Society (NZPAS) and a few PAs who worked in Aotearoa New Zealand at that time. Expanding the profession with rural placement was a priority. Within 5 years of this initiative, a 10-fold increase in PA employment was realised.⁶ With nearly 50 PAs in the country, many have become residents of Aotearoa New Zealand.⁶ These PAs are employed in general practices, urgent care, dermatology clinics and an emergency department.⁶ However, regulation of the profession is necessary and to delay this will prevent this highly skilled practitioner from becoming a workforce multiplier, as it has been in other countries.

PAs are healthcare professionals trained under the medical model, and they practise medicine with medical practitioner supervision. They offer a unique and flexible role within the healthcare team. Trained in health sciences, along with partaking in clinical rotations, their skill set aligns closely with their supervising doctor(s). The scope of practice and professional autonomy of PAs varies slightly internationally due to different healthcare systems, regulatory frameworks and professional standards.^7,8 The range of medical tasks the PA performs daily includes physical examination, diagnosing and treating illnesses, ordering and interpreting medical tests, assisting in surgery, writing prescriptions and providing preventive healthcare services. All tasks are undertaken within a framework of delegated practice, with the PA located with a doctor on-site or contactable to a doctor at a distance.⁴ The role is flexible and offers crossover into a range of medical specialties. A PA’s scope can move from general practice to a specialty, like orthopaedics or psychology. Those working in primary care cover general practice, paediatrics and women’s health, and work in clinics alongside general practitioners. Due to their unregulated status here, PAs cannot prescribe and everything they do is under the supervising doctor’s registration.⁶

The specialty PA becomes an expert in their chosen area of medicine and can offer relief in under-served areas and areas with critical shortages. Settings can include prisons, in- and outpatient hospital departments, dermatology, geriatrics, nephrology, surgery, orthopaedics, gastroenterology, urology, occupational health and telehealth. This flexibility marks the role as an addition to current teams and not a replacement.⁹ However, lack of regulation stymies what PAs can offer within Health New Zealand – Te Whatu Ora, the public system.¹⁰ Currently, PAs cannot work in hospitals and most specialty practices until the profession is regulated. Private clinics with some government funding do hire PAs because there are not enough doctors in the country and the profession has proven its worth as a role that is able to support shortages.

Employers, staff and doctors working with Aotearoa New Zealand PAs wholeheartedly support regulation.⁶ A central policy that ensures public safety and provides a full scope of practice for the profession is considered essential.^7,8,11 Research that compares the work of PAs and that of doctors assures that if quality of care is maintained, patients trust PAs, and access to and the cost of care improve without compromising safety.^6,12

 One of the strongest arguments that has been made by supporters is that PA regulation will protect the public. Medical practitioners looking after the healthcare of individuals face unwanted liability when they supervise unregulated professionals.⁶ There is a voluntary register for PAs set by NZPAS. However, with the growing numbers of PAs it is unclear what percentage of qualified and practising PAs are on this register. The possibility of a growing group of advanced healthcare providers practising medicine in Aotearoa New Zealand without a national regulatory authority is risky. In addition, concerned parties have questioned the PA profession’s capability and education. Regulation would address this by ensuring that all registrants are competent and fit to practise in New Zealand, with education, professional conduct and practising standards set by the regulatory authority.⁶ A full scope includes prescribing authority rights and ordering testing and imaging under their registration.

The PA profession has expanded internationally and is meeting healthcare demands in over 18 countries with 25 more countries using alternative names for similar roles. The model and international training is becoming more standardised, and regulation is on the increase, most recently progressing in the United Kingdom and Canada.¹¹ PAs are practice-focussed, train within the medical model and have relatively shorter training than doctors. As a result, they can adapt to a broad range of clinical settings and clinical specialties.⁷ They do not seek to practise independently of doctors. Hospitals found that they could substitute about 50–75% of a doctor’s work with one PA. One of the advantages of having PAs working in house officer positions is the continuity of service they offer. They are not rotated as junior medical staff are, and they are trained for a specific role and stay with it. They offer an added teacher for nurses and junior doctors and are invaluable in hospital wards and emergency departments that often get overwhelmed.¹²

As of May 2024, there were 43 PAs practising in Aotearoa New Zealand across 29 clinics in both the North and South Islands, with four more PAs awaiting visas and seven more clinics actively recruiting a PA. There has been a 100% satisfaction rate for clinics who employed a PA, with 11 of the 29 clinics who have hired a PA choosing to hire a second or even third PA.⁶Several clinics await their first PA hires this year. PAs have been shown to decrease burnout and increase job satisfaction among physician teammates.^6,12 PAs already play a crucial and expanding role in providing quality healthcare services to hundreds of thousands of New Zealanders a year, particularly in under-served communities. Quick expansion can help further in the public system and within specialty practices facing workforce shortages. To address existing risk and to make them sustainable and fully integrated into these communities, a centralised regulatory authority is necessary and will provide consistent standards of practice and patient safety.⁷ However, a few members of some of the medical colleges and the Medical Council of New Zealand propose various concerns that regulation can wait, risk can be ignored and regulation is not essential at this time. Unfortunately, these influential individuals are not considering important factors that are essential in terms of supporting their colleagues and the public. Small numbers may seem like a strong argument but for doctors, nurse practitioners and clinic staff working under stress in crisis conditions this is no small matter. They want regulation and prescribing rights for the PAs they are working alongside.⁶ As PAs are relatively new to Aotearoa New Zealand, the country’s inexperience of the PA role is understandable. Realisation that this profession is high risk needs to be clear and the following obstacles accepted as accurate and significant. These obstacles have not been resolved and stakeholders understand there has not been success on these important issues. Indemnity insurance and Accident Compensation Corporation coverage is not set. Prescribing rights and a full scope, which constitute the PA role only, follow regulation. In New Zealand it has been established that no domestic training programme can begin without regulation due to the profession’s partial scope, vulnerability of standards and namesake.⁶ PA training often sits alongside medical schools and allows shared coursework, professors and cost. Medical schools have expressed interest for a training programme after regulation is secured.⁶ Professions need domestic training programmes that allow access to homegrown workers. Aotearoa New Zealand specifically needs individuals from small rural communities, including Māori and Pacific individuals, to train in a tertiary programme and return quickly to the communities to provide high-standard medical care. Policymakers, risk management systems and the Health and Disability Commissioner Act have long set rules and responsibilities for doctors and many medical professionals to abide by many standards of care under regulation. The PA application for regulation has progressed through all the standardised steps the Ministry of Health regulatory body requires, up to and including the health minister review and support.⁶ When the choice for the regulatory body is set, regulation for PAs awaits the final step that will anticipatingly be an enthusiastic and astute supportive vote from Parliament to become law—thus offering the public a regulated, safe, full-scope PA profession to further assist healthcare teams and support a struggling workforce.