Spotlight series – PAs in mental health
In the UK, approximately one-in-four people will experience a mental health problem each year.1 Given the undoubted effect the COVID-19 pandemic has had on increasing the prevalence of mental health problems, even more people than usual are accessing mental health services.
Physician associate (PA) Frances Leach qualified from St George’s University of London in 2014. Frances began working in mental health in April 2020, just as the COVID-19 pandemic began. In her story, she explores the impact the pandemic has had on her patients and how she continues to support them while growing her own skills.
What made you decide to become a PA?
I am not sure where my fascination for medicine came from, but I always wanted to work in this field. At school, I was always the first person to help with first aid for my friends, whether that was treating their cut fingers after cooking class or patching up grazed knees. My interest was compounded by watching medical programmes on TV and wanting to understand exactly what was going on. After finishing school, I went studied biomedical science as my undergraduate degree. Following graduation, I worked in the NHS as a healthcare assistant in theatres. I loved my role, as it allowed me to experience working in a team and to see surgical procedures up close. The highlight was being present during pseudomyxoma peritonei surgery (rare cancer that begins in the appendix). The hospital I worked at in Basingstoke was the only one in the UK that performed the surgery, and we saw patients who have travelled from all over the country. I was fascinated watching the surgeons battle through 18 hours of surgery, but I never got to care for the patient on the other side.
I found it frustrating, as I always wanted to do more. I worked in various NHS roles and did some travelling before focusing on what I wanted to do next. I remember being told about the PA course during my undergraduate degree. When I researched further, it sounded perfect – being able to learn and work in a range of specialties was very appealing. It will be ten years this September since I moved to London to start the PA course, and I don’t regret a single second.
Can you tell us more about your experience of working as a PA in mental health?
When I graduated as a PA in 2014, there weren’t many job opportunities for us because the profession was still so new. I found myself working in general practice, as that was where most jobs were available at the time. This gave me a great opportunity to consolidate my learning and build confidence and knowledge. I saw patients of all ages and demographics, presenting with a variety of concerns, from chronic health complaints to emergencies, as well as those with mental health worries. I remained in primary care for four years before I moved into oncology. Working with those patients reminded me why I loved working in healthcare; they are phenomenal people, and it took my job satisfaction to new levels. However, there was a lot of scepticism about the PA role at that time, and I felt I wasn’t being utilised to my full potential.
While looking around for other job opportunities, I came across a split role working in psychiatry/mental health and as a PA ambassador for south-west London. I thought it would be a perfect fit for me, and being an ambassador would help me to get the passion back for my role as a PA.
I started my role just as the COVID-19 pandemic began and really threw myself in at the deep end. Initially, my role was to support patients with eating disorders but, due to the pandemic, an emergency mental health unit was set up and that was the team I joined. It has been the best experience and I’ve learned so much working alongside the psychiatry trainee doctors and nurses. Our skills complement each other well: I focus on the physical health of the patient while working closely with the trainee doctor on the patient’s mental health needs. It has been a learning curve, as I’m the first PA they have had on the team. I’m proud of the skills I’ve developed in performing in-depth psychiatric assessments on vulnerable and (at times) aggressive patients.
What diagnostic/investigation/procedural skills have you gained?
Before I joined the specialty, I didn’t appreciate how detailed a mental health assessment was. I have years of experience as a PA taking a patient’s medical history, but developing a mental health assessment is an entirely new skill. We must dig deep and consider the previous traumas the patient may have suffered. This can include childhood trauma or abuse, which may not feel relevant when taking a history, but this can impact and contribute to how a patient is feeling in the present day. I feel like a detective, as I piece together their experiences and feelings to best understand what therapy will help address their concerns.
The way I communicate with patients has changed, too. For example, when supporting psychotic patients (who hear voices) it is important to be aware of cues that show they are getting agitated. This can indicate that they are listening to the voices and will start to get anxious, or on occasions aggressive. In these situations, it is key to break down communication into bite-sized chunks to help me understand what my patient is experiencing, and to support the patient in the best way possible. It’s also important to be aware of the details of a case before approaching the patient and to plan how best to communicate in advance. For example, when treating a patient experiencing domestic violence, the choice of language is key. We wouldn’t want to use accusative language, eg ‘How did you get that black eye?’ But more: ‘Who did this to you?’ as this can be seen as exposing the perpetrator.
I treat a range of patients of all ages and with varying mental health concerns. There is one case that will always remain with me – a young patient I saw during my first week. They were very distressed, wanting to end their life, and if we turned our backs for a second, they would harm themselves. They were experiencing a level of distress that I had never seen before. I continued with the physical examination, and gradually the patient became calmer. It helped massively that – for a few short minutes – we weren’t focused on their mental health but more on other, everyday topics. Being present with someone who is feeling suicidal to that degree, getting to help them gradually focus on other things, and being able to reduce their distress is a real honour.
How would you describe the impact your role as a PA has had?
The mental health emergency unit was set up in response to COVID-19, and to relieve pressure from the GP surgeries, A&E, and the ambulance service. The service was closed due to a lack of funding, but the need for us very much remained, as more people sought mental health care. We now provide community-based mental health care and visit patients at home to take the pressure off existing healthcare services. This can help them feel relaxed and comfortable as they remain in their own environment. Having the service available also means that we’re able to start their treatment straight away, and there isn’t a need for any delays. Prior to having a PA on the team, the patient would be asked to attend their GP for an ECG and blood tests before starting medication. Now I can perform the ECG and blood tests, and my consultant will commence their treatment immediately. This also helps with patient engagement with other teams moving forward.
My role offers a level of support to the mental health nurses too, and our skills and knowledge are very complementary. Mental health nurses don’t have as much physical health training, and as a PA new to mental health, I was picking up invaluable mental health knowledge from them. I aimed to assist them in understanding more about the physical health of patients, advising on what key signs to look out for that could mean a patient’s physical health is deteriorating. For example, I help to provide training on various topics, including the vital signs of alcohol withdrawal and seizures. In turn, they have helped to support me with my mental health assessment skills.
We’re also able to reduce the need to refer patients to A&E for medical optimisation (ie to rule out infection). I’m able to assess patients in the clinic and do some investigations. Prior to my joining the team, the patient would be sent to A&E to rule out organic causes, which put pressure on services. The A&E environment can be very intimidating for mentally unwell patients. If I have any immediate concerns, I can ask an A&E consultant for additional advice, using the link that has been set up between us and the local acute hospital. This helps to reduce the level of pressure placed on other healthcare services.
What do you find most enjoyable and rewarding about being a PA?
Building relationships with my patients and being able to go the extra mile to care for and support them. Working in mental health is so rewarding when you’ve helped a patient during one of the most difficult and scary times of their lives. Finding out that they are better and receiving feedback is so rewarding. I enjoy that I get to learn something new every day. My knowledge continues to grow, and I feel rewarded and validated in my role.
Being part of only the fifth cohort of PAs to qualify, it has been humbling to see how our profession has grown, and I look forward to seeing it continue to grow in the future. PAs are so supportive of each other and are genuinely interested in how their roles are personally going, which is fantastic. This community is a special one and I’m proud to be part of it.
What challenges do you face as a PA working in mental health?
The beauty of the PA role is that we’re able to enter new specialties and expand our knowledge and skillset, but that doesn’t make entering a new role and team any less daunting. I felt this particularly keenly when I began working in mental health. However, I was lucky, as the service was newly set up and my new colleagues were all in the same position, so our mutual support and team spirit helped massively. Despite that, joining a new specialty at the beginning of COVID-19 was always going to be difficult. For example, wearing full PPE to assess a patient who was paranoid or suicidal was a new territory to navigate.
It was, and still can be, a learning curve when it comes to the range of medications in psychiatry. Monitoring patients receiving antipsychotics is a new experience for me, along with the level of investigation that comes with that. I had confidence in my ability to monitor a patient’s physical health, and over time I’ve built up the same level of confidence to support their mental health too, which I’m proud of, as I never thought I would be able to get to this level.
What does the future look like for you as a PA?
I’m thoroughly enjoying my role in mental health and want to remain here and continue to build my skills and knowledge. When we become a regulated profession, I’m hopeful this will open even more doors for me in the specialty. I will begin a new role as a lead PA in urgent care psychiatry this month. I will also be managing an addition PA who is joining the team. My next challenge will be learning the leadership and management skills to improve my management of this person, and I’m very much looking forward to this.
There is a lot of interest from our trust to employ additional PAs, which is fantastic. My current role was initially planned to be filled by a core trainee doctor, but my consultant fought for a PA to join the team. I’m hopeful that we will have more PAs joining us in the future.
What advice would you give to a PA looking to work in mental health?
My main piece of advice is to jump in head first! In the first instance, mental health can seem daunting, given what we’re taught on the PA course, but you will know more than you think you do. Looking back, I felt as though I hit the ground running a lot more than I thought I would. A big portion of the role is a patient’s physical health – what we’re good at. I have also found mental health teams to be the most supportive people who really champion the PA role. You’ll be fully supported and learn so much along the way. Jump in, don’t feel daunted, and I promise you won’t look back.
We’re always looking for qualified PAs who are FPA members to share their stories. If you’re interested in sharing yours, get in touch using the contact details below. If you’re thinking of a career as a PA, you can learn more about how to begin your journey here.
Get in touch to share your PA story:
Jenna Donaldson – FPA communications officer