New RCGP guidance sets clear limits on Physician Associate roles

Jan 1, 2025

Both the Royal College of GPs (RCGP) and the British Medical Association (BMA) recently voted to phase out Physician Associate (PA) roles on grounds of patient safety. However, around 2,000 PAs already work in general practice.

In recognition of this reality and the need for clarity around PA roles, the RCGP issued new guidance in October, covering induction and preceptorship, supervision and the scope of practice of PAs. It sets a ‘deliberately narrow’ scope of practice to protect patient safety and to reflect the limited evidence base.

Echoing previous BMA recommendations published in March, the RCGP guidance makes clear that PAs should not see undifferentiated patients. With the General Medical Council (GMC) preparing to regulate PAs from December, it is essential that GPs, practices and PAs are familiar with the guidelines and maintain a clear distinction between GP and PA roles.

PA preceptorship, induction and supervision

The RCGP guidance defines PAs as ‘dependent healthcare professionals’ working in the multidisciplinary team with ‘supervision from a named GP Clinical Supervisor’. The GP Clinical Supervisor oversees the work of the PA and retains overall clinical responsibility for the patients the PA sees.

The guidance says that PAs should also have an Educational Supervisor to oversee educational and professional development during a preceptorship period, normally 12 months long. A learning needs assessment, performed by both supervisors together with the PA, will form the basis of a job plan, setting out the PA’s role.

Furthermore, PAs must have a minimum induction period of two weeks, full-time equivalent, when they begin a new role. During this time, the practice should ensure that the PA and other staff understand the PA role, lines of accountability, and how the PA should be introduced to patients – transparency is key.

Job plans must include protected time for daily supervision and regular review meetings, with frequency dependent on the experience and competence of the PA.

What can PAs do?

Despite the restrictions, the RCGP guidance sets out responsibilities that are in scope for a PA. For example, PAs can be the first point of contact for patients over 16 years with suspected minor conditions that have clear clinical pathways and escalation processes. The RCGP proposes starting with the seven common minor illnesses in the Pharmacy First programme.

While PAs can ‘take a history, complete a physical examination, and construct an appropriate diagnostic and management plan’, they must share the plan and all patient notes for approval by their GP Clinical Supervisor.

• PAs may also perform tasks including annual NHS health checks and assisting in making referrals as agreed with a GP. They may also support or lead practice clinical audits, learning events, research and service development and other practice initiatives.
• However, there are strict limits on the PA’s role with regards to clinical procedures, tests, prescriptions, and patient forms. Only PAs with further training may take on a wider scope of practice, if agreed with their GP Clinical Supervisor, such as providing contraceptive advice, vaccinations, performing certain clinical tests and reviews, and additional administrative tasks.

PAs must follow clinical protocols

PAs must always use the GP practice clinical guidelines and protocols, and document all patient encounters, including advice given by the GP Clinical Supervisor. Practices should ensure they have a protocol for safe prescribing for patients seen by the PA.

Importantly, PAs must always introduce themselves to the patient and make it clear in communications with patients and other staff that they are not a doctor. Practices must also inform team members about the PA role and ensure that patients are told when they are seen by a PA.

PAs have a limited scope of practice and must not see undifferentiated patients

The GP Clinical Supervisor will determine the PA’s scope of practice at the start of their employment, based on their clinical competencies, and the PA must always work within this, and within the scope of practice of their GP Clinical Supervisor.

In particular, the RCGP guidance states that ‘PAs must not see patients who have not been triaged by a GP and only undertake work delegated to them by, and agreed with, their GP Clinical Supervisor’.

Notably, this contrasts with wording in the updated network contract directed enhanced service  published in September, which indicates that PAs can see undifferentiated patients if their ‘named GP supervisor is satisfied that adequate supervision, supporting governance and systems are in place’.

The RCGP guidance provides a list of patients that should not be triaged to PAs, including those with potentially serious, complex or rare conditions, suspected mental illness, pregnant or post-natal women, and children under 16.

GMC to regulate PA roles from December

From 13 December 2024, the GMC will begin to regulate PAs, setting expected standards of practice, education and training.

Although PAs will not be legally required to register until December 2026, they will be encouraged to apply as soon as possible. PAs on existing voluntary registers will be invited to sign up by the end of January 2025 and employers will be asked to promote this. Once registered, PAs will be required to follow ‘Good medical practice’ and participate in annual appraisals to support future revalidation.

GP practice responsibilities

GP practices should check that PAs are listed on the Physician Associate Managed Voluntary Register or, once GMC regulation begins, the GMC’s Register of PAs. Further advice on governance considerations is summarised in the RCGP guidance, including advice from the GMC and from NHS Resolution for doctors who supervise PAs.

Importantly, although RCGP cannot enforce its new rules, employers are responsible for handling of PA contracts, and the guidance may be ‘taken into account by NHS Resolution and medical defence organisations in a case of alleged negligence or clinical or professional mistakes’.

Employers must ensure that adequate professional indemnity insurance is in place for the PA. If you would like further advice about this, or have other questions about PA roles, please contact us at Medical Defense Society.