In this study, we explored physician associate students’ perceptions of financial support whilst studying. Our findings highlight that the majority of PA students worried about finances, and most agreed that this negatively impacted their studies. PA students perceived the costs associated with the course to be excessive, and funding to be insufficient for them to thrive whilst studying. These concerns were heightened for those with dependents and/or disabilities. We observed that concerns about finances had detrimental impacts on the health of PA students.
A considerable proportion of the target population offered their data for inclusion, allowing for representative establishment of demographic data. Our sample comprised approximately 15–20% of all current PA students – as estimated from cohort numbers collated via FPA student representatives. Therefore, the sample representativeness is one of the greatest strengths of this research. The population was highly similar when compared to the national PA census14 with respect to gender, age, and ethnicity. The sample was predominantly white, female, and had similar levels of educational experience. This highlights other areas of diversity associated with advantageous socioeconomic status17 which could be explored in further research.
A key theme was that studying to be a PA incurs excessive and potentially unexpected costs. The majority of respondents used the HEE grant to fund tuition over other costs, despite its original usage being targeted towards travel and placement – which is enforced in some regions, such as the North West18. The vast majority of respondents were worried about finances, particularly maintenance costs such as travel and rent. These concerns appeared to negatively impact respondents’ education, highlighting the necessity of greater financial support for PA students so that they can study effectively to join the workforce. Enacting financial provision such as increasing postgraduate loans, implementing bursaries for those with dependents, or subsidising accommodation for long-distance placements; may help to alleviate prohibitive financial worry among student cohorts. These issues were pertinent during the COVID-19 pandemic and will continue to be amidst the current cost of living crisis, exacerbating detrimental impacts on student experiences 19. The NHS Business Services Authority runs a ‘Practice Placement Expenses’ scheme20 for those eligible for the NHS Student Bursary21, which PAs are currently excluded from – highlighting more avenues through which PA students could be better supported. A notable frustration among respondents was unexpected expenditure, such as the rise in mandatory national exam fees12, or ‘hidden’ costs associated with the course such as unreasonable travel incurrences. We recommend that universities ensure to advertise course-related costs as transparently as possible, including the potential for these costs to increase. Further to financial stressors, Brown et al22 suggested that limiting PA travel to placement might also benefit individual sense of identity; though the rates of PA course expansion are inherently likely to challenge the practicalities of implementing reduced travel from educational institutions.
Our survey showed that many students worked paid jobs alongside their full-time studies, with 71.2% of these participants disagreeing that they would continue to do so if in receipt of greater funding. This highlights the paradoxical relationship of paid work being detrimental, and yet necessary, to sustain PA studies for many students. Respondents articulated the toll that concurrent paid work had on their studies and personal lives. This further emphasises the importance of sufficient funding for PA students to support their educational development and personal wellbeing. It is worth noting that during this study, proposals for a Physician Associate apprenticeship scheme were finalised23. This aims to employ students via NHS trusts, delivering the PA programme alongside transferrable paid roles, over a longer period of time than the conventional two years24 with the employer covering tuition. These schemes are not widely available options, with few trusts having taken them up. It remains to be seen whether the apprenticeship concept can be scaled up to provide well established routes into qualification, or will adequately and ethically prepare students for the PA national exams. This could be a target for future research.
It was evident that respondents’ financial concerns were inextricably linked to wellbeing and mental health. This mirrors research showing clear relationships between financial difficulties and mental health16. Our findings come amidst a zeitgeist of increasing staff burnout and worrisome mental health of NHS workers25–27. It would seem to apply that those who experienced declining mental health due to financial stressors would be less productive, and find it more difficult to study or hold down additional work particularly amidst the context of a pandemic28, compounding the negative feedback loop of working for money and time for study. A considerable number of respondents (16.5%) had financial dependents, and these respondents found the structure and cost of the course to be oftentimes at odds with caring responsibilities, with 77.4% disagreeing or strongly disagreeing that they were well-supported financially in caring for their dependents. The prevailing format of PA courses appears to risk excluding people with caring duties from the workforce. It would be progressive for universities to consider offering alternative structures for PA courses, such as part-time or 3-year courses, to be more amenable to continuing paid work and juggling family life. This would also likely necessitate increased government loans, but might attract applicants from a greater pool of diversity and talent.
Respondents were additionally worried about the future of Physician Associate careers, with financial accessibility to the career a chief concern among some. A considerable portion of respondents discussed concerns about others, including students present, prospective, and future. Some related accessibility to historic issues regarding socioeconomic diversity in medicine6,8, and other healthcare courses9. All participants who spoke of ‘closed-shop’ issues implied this was bad for the profession, with the overarching concern being that wealthier PA students would not correlate to better PAs than those from poorer backgrounds.
Limitations
To our knowledge, this is the first study to engage with the financial perspectives of PA students, thus constituting a valuable and novel contribution to the field. However, it is subject to some limitations. Firstly, the survey took place during a global pandemic – a novel context in which financial experiences were altered for many. It remains unclear to what extent the experiences reported in this study translate to other contexts. In addition, there was also potential for responder bias in this study, whereby those who participated may have had stronger feelings on the subject matter than the general PA student population. The population was also comprised entirely of current students, where there might be some benefit to exploring the perceptions of prospective students in relation to prohibitive costs or concerns. Finally, whilst many respondents produced rich responses to the survey, the research design did not allow for follow-up on potentially salient lines of enquiry. These issues could be addressed in future research, in which qualitative interviews could be conducted with student PAs to further explore their experiences and identify innovative solutions that effectively support student PAs to join the workforce.