GP mythbuster 82: Physician associates in general practice

This guidance clarifies the role of the physician associate (PA) in general practice.

The role of the physician associate in general practice

Physician associates (PAs) are generalist healthcare professionals who are trained to the medical model. They work alongside doctors and provide medical care as an integral part of the multidisciplinary team.

As practitioners, physician associates work under the supervision of doctors. They can practise independently and make independent decisions while receiving effective supervision, appropriate collaboration and supportive working relationships with their clinical supervisors.

Physician associates can supplement and complement but not replace GPs, nursing staff and other members of the practice team. Governance obligations for physician associates are the same as for other staff employed (or deployed) in the practice. They apply where roles involve independent complex clinical decision-making.

Studies on physician associates in primary care in England and physician associates working in primary care and other NHS services in Scotland show physician associates to be safe, effective and liked by patients. They are named as one of the 12 healthcare professionals (HCP) able to be recruited under the Additional Roles Reimbursement Scheme (ARRS), which is part of the Primary Care Network Designated Enhanced Service.

Read guidance from the British Medical Association (section 7) on roles included in ARRS.

Qualifications and registration

To enter the profession, all physician associates must have both a:

• relevant degree or masters degree, for example, bioscience or healthcare-related
• postgraduate diploma that takes 2 years of full-time study to complete.

Physician associate courses in the UK follow a national curriculum and competence framework. This can include multiple choice questions (MCQs) and objective structured clinical examinations (OSCEs) to test knowledge and comprehension and to evaluate clinical skills and competency.

The Faculty of Physician Associates (FPA) is the national membership body representing physician associates in the UK. The profession is moving closer to being regulated by the General Medical Council (GMC). This means that there are changes to the way in which physician associates will be required to evidence their ongoing competency and up-to-date knowledge in practice.

See:

• Requirements to remain on the Physician Associate Managed Voluntary Register.
• Physician Associate National Examination.

Providers should be able to show how they assure themselves of the governance and ongoing competence of physician associates.

Regulation and indemnity

Physician associates are not currently regulated. However, the General Medical Council (GMC) will become the professional regulator.

See PA and AA regulation.

The Faculty of Physician Associates (FPA) at the Royal College of Physicians maintains a Physician Associate Managed Voluntary Register (PAMVR). This acts like a GMC or Nursing and Midwifery Council register, but it not statutory.

Practices should only employ physician associates who are on this register. All physician associates are currently required to fulfil continuous professional development (CPD) requirements to remain on the register. This is audited by the Faculty of Physician Associates (FPA) and the Royal College of Physicians using a CPD diary.

The register gives assurance that physician associates:

• have qualified from an appropriate UK or US programme
• have passed the national exams (and re-certification exam if appropriate)
• maintain their continuing professional development (50 hours a year)
• do not have any code of conduct, scope of professional practice, or fitness to practise concerns.

Physician associates work under the 'delegation clause'.

Governance arrangements should take account of the fact that these professionals are trained and registered on the basis that they should always work under supervision.

Organisations should identify an individual at GP partnership/integrated care board level who is responsible for the supervision and oversight of PAs. 

It is important to establish local processes to govern how these professionals are deployed and supervised. This is to ensure safe, high-quality care, and to support effective multi-disciplinary working. 

Practices should also make sure that: 

• the supervisor is easily accessible 
• staff know who the supervising member of staff is 
• staff have enough time to supervise. 

The GMC’s guidance on delegation and referral states that doctors can delegate tasks to non-clinicians. However, they must be sure that the person is capable and available and be aware that, as the doctor, they retain the responsibility. 

Physician associates are indemnified under the General Practice Clinical Negligence Indemnity scheme in the same way as the rest of the practice team.

See the GMC’s effective clinical governance handbook.

Supervision and oversight

Providers must make sure staff are competent, and they must provide appropriate supervision and oversight. A senior medical member of the clinical primary care team should provide day-to-day supervision of all clinical staff under their direction and control.

The consensus statement from the Academy of Royal Colleges states that this should be a senior doctor.

See:

• High level principles concerning physician associates
• Ensuring safe and effective integration of physician associates into general practice teams through good practice.

The Royal College of General Practitioners (RCGP) stipulates that:

• Physician associates working in general practice must always work under the supervision of qualified GPs.
•  Physician associates must be considered additional members of the team, rather than substitutes for GPs.
• Physician associates do not replace GPs or mitigate the need to urgently address the shortage of GPs.

See:

• RCGP ‘red lines’ on Physician Associates working in general practice.

See also:

• GMC professional standards for doctors delegation and referral.

Supervision can be:

• Clinic/practice supervision: day-to-day support for issues arising in the practice.
• Clinical/professional supervision: regular support to promote high clinical standards and develop professional expertise. This does not always need to be a GP.
• Educational supervision: supports learning and enables learners to achieve proficiency.

The amount of supervision needed depends on the person’s knowledge, skills, and experience.

The physician associate is responsible for their own actions and decisions. However, the consultant/GP is the clinician who is ultimately responsible for the patient.

Employers of newly qualified physician associates, or of those who have just moved to a new specialty, may wish to offer a 1-year internship or preceptorship so that the physician associate is able to consolidate their core knowledge and skills, and demonstrate their competence in practice.

During this period, they should be able to:

• access supervision
• maintain a portfolio of cases and case discussions with clinicians. This may also be reviewed with their clinical supervisor.

Prescribing and referral for other investigations

Physician associates can plan and suggest ongoing treatment, but they will be restricted in what they can do. For example, they are not able to request diagnostic tests using ionising radiation (for instance, X rays or CT scans). Any suggestions for further investigations would be discussed with and authorised by the accountable GP.

Physician associates can recommend prescriptions for signing by a GP, but the prescriber remains responsible and accountable for the prescription they issue. They need to be assured of the appropriateness of the consultation and the medicine being prescribed.

See GMC guidance on this.

Physician associates cannot prescribe or issue medicines using Patient Group Directions (PGDs). They can administer medicines by a Patient Specific Direction (PSD).

There should be a standard operating procedure (SOP) in place to show how the prescription/PSD is raised and monitored. This would be considered best practice.

What we look at

We use these regulations when we assess if a practice is safe, effective, caring, responsive and well-led. The role of physician associates relates to:

• Regulation 17: Good governance
• Regulation 18: Staffing
• Regulation 19: Fit and proper persons employed

We will assess how providers ensure the following.

• They complete safe recruitment processes.
• There are enough qualified, skilled, and experienced people, who receive appropriate and effective support, supervision, and development.
• These staff work together effectively to provide safe care that meets people’s individual needs.
• There are clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.
• Information about risk, performance and outcomes is managed and shared securely with others when appropriate.
• They value diversity in the workforce and work towards an inclusive and fair culture by improving equality and equity for people.

Further information

• Ensuring safe and effective integration of physician associates into departmental multidisciplinary teams through good practice (NHS England)
• RCGP templates, guides and advice for employers and supervisors of physician associates (Faculty of Physician Associates)
• Health and Care Professions Council supervision guidance (Health and Care Professions Council)
• Employing Physician Associates in general practice (Faculty of Physician Associates)
• Workplace supervision for advanced clinical practice (NHS England)
• Care in advanced serious illness and end of life (CQC)
• Supervision guidance for primary care network multidisciplinary teams (NHS England)
• Professional standards for doctors and delegation and referral (General Medical Council)