Faculty of Physician Associates – ensuring safe and effective integration of physician associates into the clinical workforce

Recent communications from NHS England regarding the safe and effective integration of physician associates (PAs) into the NHS clinical workforce provide useful guidance for clinicians, managers, employers and the wider healthcare team.

The Faculty of Physician Associates (FPA), the professional membership body for PAs in the UK, wants to build on recent communications to support FPA members, supervisors, other doctors, healthcare managers and employers.

Clinical supervision

Physician associates (PAs) are healthcare professionals who work as part of a multidisciplinary team under the supervision of a named senior doctor. PAs are not doctors and all clinical work they undertake is overseen by a supervising senior doctor. In primary care, PAs should always be supervised by a General Medical Council (GMC)-registered general practitioner (GP), and in secondary care PAs should be supervised by a GMC-registered consultant.

There is no ‘one-size-fits-all’ approach to supervision. The level of supervision and debriefing of patients is the responsibility of the supervising senior doctor and the employer. This should be clearly defined within an employer’s governance framework. The GMC has published advice for PAs and doctors who supervise them and NHS England has also published supervision guidance for primary care networks.

Newly qualified PAs will require more supervision than more experienced PAs. Some PAs may require ongoing closer direct supervision depending on the area in which they work or the relationship with their clinical supervisor, while others may work within employer-approved governance frameworks that have clear protocols for escalation and discussion.

Core competencies at qualification

PAs can assess, diagnose and treat patients in primary, secondary and community care environments under the supervision of a named senior doctor and must work within their agreed scope of practice.

To become a qualified physician associate (PA) in the UK and be registered on the FPA Managed Voluntary Register (MVR), the FPA requires all student PAs who have completed a UK PA programme to take the Physician Associate National Examination (PANE). The PANE is developed and delivered by the Assessment Unit on behalf of the Royal College of Physicians (RCP) and is independent of the higher education institution from which the student PA trained.

PAs registered on the MVR who enrolled in a programme of study before September 2023 were trained in line with the Competency and Curriculum Framework (2006, revised 2012). It sets out the minimum competencies required of anyone who has qualified as a physician associate.

Students who enrolled on a programme of study from September 2023 are being trained in line with the Physician Associate Curriculum, which aligns to the General Medical Council’s pre-qualification education framework for PAs.

PAs are required to maintain their breadth of knowledge and competence throughout their professional career. Individual PAs will acquire additional experience and expertise in particular fields, through experience or further training, which should build on their pre-registration training. A portfolio of evidence should be collated and maintained to demonstrate enhancing knowledge, skillset and competency in practice.

Additional Roles Reimbursement Scheme

The Additional Roles Reimbursement Scheme (ARRS), introduced by NHS England in 2019, is part of the government’s commitment to improve access to general practice services in England. Through the scheme, primary care networks (PCNs) can expand the general practice capacity.

PAs are designed to expand access to care for patients and are one of 17 roles that form part of ARRS. Further information on the key roles and responsibilities of PAs employed under the ARRS can be found on the NHS England website. As with all healthcare professionals, employers of PAs have a responsibility to ensure that appropriate governance is in place to support the safe implementation, utilisation and development of the role to ensure safe patient care.

The network contract directed enhanced services (DES) contract specification clearly outlines that PAs must only work under the supervision of a medical doctor and that their named supervisor must be a general practitioner (GP). Through adequate supervision by a GP, PAs may provide the first point of contact care for patients presenting with undifferentiated, undiagnosed problems.

Only PAs registered with the FPA may be employed under ARRS. Employers, supervisors, patients and others can check the registration status of PAs who are listed on the MVR via the FPA website.

Delegation, teamworking and accountability

The GMC’s professional standards for doctors delegation guidance states that ‘delegation involves asking a colleague to take responsibility for providing care or treatment on your behalf’ and ‘accountability for safe delegation is shared between the colleague delegating and the colleague to whom care or treatment is delegated.

A doctor can delegate roles and responsibilities to another colleague. The GMC states that the doctor ‘must be confident that the colleague [they] delegate to has the necessary knowledge, skills, and training to carry out the task, or that they will be adequately supervised to ensure safe care.

The GMC makes it clear that when doctors delegate care in line with their guidance, the doctor is ‘not accountable to the GMC for the actions (or omissions) of those to whom [they] delegate care.’ Doctors are responsible for the ‘decision to delegate care’ and the ‘overall management of a patient if [they’re] the responsible consultant or clinician.

Until statutory regulation is in place, PAs can join the MVR. This should reassure doctors and employers that the PA has met the core competencies expected at the point of qualification.

PAs and prescribing activities

PAs are not legally able to prescribe medicines.

As part of a PA’s pre-qualification training, all student PAs are expected to learn how to ‘determine and propose appropriate therapeutic interventions from the full range of available prescription medications’ and ‘write accurate and legible prescriptions in out-patient, in-patient and primary care setting for review and signature by a supervising clinician.

Electronic patient care record systems should ensure that PAs on the MVR can propose medications to a prescriber. Systems should not entitle PAs to be able to authorise or prescribe medicines.

The GMC has clear guidance for doctors around prescribing at the recommendation of a colleague. Doctors ‘must be satisfied that the prescription is needed, appropriate for the patient and within the limits of [their] competence’. Doctors may ‘delegate the assessment of a patient’s suitability for a medicine’, but that they must be ‘satisfied that the person you delegate to has the qualifications, experience, knowledge and skills to make the assessment. The doctor ‘will be responsible for any prescription [they] sign.

Registration on the MVR provides employers, supervisors, other doctors and patients with the reassurance that a PA has met the core competencies at the point of qualification. The FPA regularly writes to employers for them to check the ongoing registration status of a PA to ensure they remain listed on the MVR and in good standing with the FPA, demonstrating ongoing compliance with our standards, including agreeing to the FPA code of conduct and continuing professional development (CPD) guidance.

The FPA recommends that people who are qualified to supply or prescribe medicines gained from a previous healthcare professional role (eg registered nurse or paramedic with independent prescriber status) do not use these responsibilities when practising as a PA.

Important references

April 2024