Safe scope of practice for medical associate professions
This document sets out a safe scope of practice for MAPs, which NHS employing organisations should adopt to help doctors and other staff to provide safe, high-quality care. These safe practice parameters reflect the BMA’s view that MAP qualifications are appropriate for working in an assistant role under the direct supervision of a doctor – they should not make independent treatment decisions and must not see undifferentiated patients.
The guidance is designed to set out the BMA’s recommendations in relation to safety - NHS employers are encouraged to adopt this safe scope of practice immediately. For the avoidance of doubt, this guidance should not be treated as advice to members on their current interactions with MAPs in relation to issues such as supervision. The BMA is in the process of developing specific guidance in relation to this, which will be published shortly.
Guidance for the supervision of MAPs
This supervision guidance for doctors sets out the BMA’s recommendations on working safely with physician associates (PAs), anaesthesia associates (AAs) and surgical care practitioners (SCPs). It aims to standardise practice and avoid variation in what MAPs are expected to undertake, and should be read alongside our MAPs scope of practice guidance.
Doctors who supervise and work alongside MAPs need to be able to assure the safety of the patients they are clinically responsible for at all times. These recommendations have been chosen to provide assurance to patients that a safe level of working is being undertaken that allows MAPs to contribute to high quality patient care.
Physician associates in general practice
This guidance has been produced to help standardise practice and reduce variation in how physician associates (PAs) work within the general practice setting. It aims to provide a framework to support physician associates to work safely in general practice, for patients, their employers, and GP supervisors. It has been designed to complement the scope of practice and supervision guidance linked above and should also be read in conjunction with GPC England’s Focus on MAPs in general practice.
BMA MAPs Portal
If you have any concerns about the current working arrangements for MAPs in your place of work, please do let us know. We want to learn more about any patient safety incidents that may have taken place, occasions when MAPs have replaced or are replacing doctors on rotas, and examples of doctor or medical student education and training opportunities being impacted.
Please use this portal to share your experiences without identifying any other healthcare professional or patient. We may use submissions to inform and assist local engagement with employers by BMA staff and BMA local or regional representatives. We may also use or summarise your submission in media work, the BMA's own publications and/or lobbying on behalf of our members. Your personal information will be anonymised.
All submissions will be seen by the relevant local BMA team, but if you wish to raise a concern that requires a response, please make sure to raise it with a BMA advisor.
MAPs survey
In response to concerns raised across the profession, the BMA conducted a comprehensive survey to inform its position on physician and anaesthesia associates. The survey findings have been used in our ongoing engagement with central and devolved nation governments, NHS England and devolved nation health departments, the GMC, and other key stakeholders.
Amongst its findings, the survey found that:
- 55% of doctors have found that PAs increase their workloads, even though they were sold as a way of reducing them.
- 87% of doctors who took part said the way PAs and AAs currently work in the NHS was always or sometimes a risk to patient safety.
- Nearly 80% of doctors stated that they were occasionally or frequently concerned that a PA or AA they worked alongside was working beyond their competence.
- 86% of doctors reported that they felt patients were not aware of the difference between these roles and those of fully qualified doctors, showing the immense scope for patient confusion about the level of care they are receiving.
- 72% of doctors do not support the future regulation of PAs and AAs by the GMC.
- 80% of doctors felt that PAs and AAs would be more appropriately named ‘assistants’ than ‘associates’, as they were in the past.
The BMA's view
MAPs can play an important role in the wider healthcare system, but they are not a substitute for a doctor who undergoes years of medical training to provide complex, highly skilled care to their patients. There must be no blurring of the lines between MAPs and doctors. Patient confusion about which type of clinician has treated them has tragically led to at least 3 deaths. We are calling for urgent changes to prevent this blurring of the professions and ensure patient safety:
- The job title “physician assistant,” should be reintroduced. This is what physician associates were called until 2014. We believe it’s a clearer title that better reflects the role, and crucially, reduces any confusion for patients. AAs should be called physician assistants (Anaesthesia) – as they were previously- or anaesthesia assistants.
- All recruitment of new MAPs must be halted until there is clarity and material assurances around their scope of practice.
- The BMA has produced a safe scope of practice for the medical associate professions, which NHS employing organisations should adopt to help doctors and other staff to provide safe, high-quality care. You can read the document here.
- MAPs should be regulated by the Health and Care Professions Council (HCPC), not by the GMC. The GMC has only ever regulated doctors and this change worryingly and unnecessarily undermines the distinctions between the professions.
- MAPs must never, in person or on social media, describe themselves as doctors GPs or medical consultants.
- MAPs cannot replace the expertise offered by a medically qualified practitioner, and this must be recognised in pay scales. All health professionals working in the NHS should be paid properly, but it is clearly wrong that a newly qualified doctor entering postgraduate training is paid over £11,000 less per year than a newly qualified PA, while the doctor’s role, remit and professional responsibility is far greater. We estimate that this is a 35% differential, which is manifestly unjust. We will continue our fight for fair pay for all doctors working in the NHS.
The BMA’s September 2023 position statement can be read here.
The BMA Cymru Wales December 2023 position on MAPs can be read here.
The BMA Scotland statement on PAs and AAs from December 2023 can be read here.
GMC consultation on regulating PAs and AAs: proposed rules, standards and guidance
With regulation of PAs and AAs set to come into force in December 2024, the GMC is now consulting on proposed rules, standards, and guidance. The BMA campaigned vociferously for the GMC not to be the regular of PAs and AA as we believe this blurs the lines between doctors and roles which are not medically qualified in ways which may be confusing and dangerous. However the legislation confirming the GMC as the regulator has now passed and this consultation is a largely technical exercise focussing on how PA and AA regulation will work.
The consultation is open to the public and we have produced a short guide which can be used by clinicians and patients who are keen to provide views. The guide includes some of the wider MAPs context that we have raised in our campaigning and in our Safe Scope of Practice guide, which respondents can use to help inform their answers. The consultation does not specifically call for input on the broader areas of concern that the profession has about the introduction of PAs and AAs, so please be aware that the GMC may not count answers that stray from the questions they have asked or fall outside the narrowly defined scope.
The BMA will be submitting a formal response, led by the Professional Regulation Committee with input from across the association. This response remains in development and the guide should not be seen as a definitive indication of what our final submission will contain.
What are MAPs?
The following three professions are part of the medical associate professions (MAPs) grouping. Other roles such as nurse practitioners, radiographer and advanced practitioners are not MAPs.
1. Physician associates (PAs)
The Faulty of PAs describes PAs as “healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor (a General Medical Council registered consultant or general practitioner), providing care to patients in primary, secondary and community care environments.”
There are currently around 3250 PAs working in the NHS.
2. Anaesthesia associates (AAs) – known as physician assistants (anaesthesia) prior to 2019
The Royal College of Anaesthetists (RCoA) describes AAs as “trained, skilled practitioners that work within the anaesthetic team under the supervision of an autonomously practicing anaesthetist, such as a consultant or SAS doctor.”
There are currently around 150 AAs working in the NHS.
3. Surgical care practitioners (SCPs)
The Royal College of Surgeons of England (RCSEng) describes SCPs as registered non-medical healthcare professionals who have extended the scope of their practice by completing an accredited training programme. They work as members of the surgical team and perform surgical interventions and pre-operative and post-operative care under the supervision of a senior surgeon.
There are currently around 600 SCPs working in the NHS.
Advanced Critical Practitioners withdrew from the programme in April 2022 – read their statement.
The decision to group the professions as MAPs and the career framework
The move to bring the professions under a single umbrella began with HEE (Health Education England) in 2014, with the intention to work ‘towards a common education and training programme to support a route to statutory regulation’. This originally applied to PAs, AAs, and SCPs with ACCPs added later (with ACCPs having withdrawn since).
HEE created a MAPs oversight board and invited the BMA to send a representative to its Career Framework & Quality subgroup along with representatives from employers, royal colleges, and the devolved nations.
The group’s task was ‘to describe quality management, training and a career framework for MAPs, so that a clear professional identity is developed which supports arrangements for statutory regulation.’ The work of the subgroup has now been subsumed into HEE’s MAPs oversight board, on which the BMA is represented.
MAPs differ in crucial ways; in terms of the tasks they perform, the ways that they train and their entry requirements. These differences mean that developing a single career framework is challenging.
NHS England recently consulted on a proposed MAPs career framework. In our response we called for the development of the framework to be paused until such time that MAPs are working to a safe and effective scope of practice. You can read our response to that consultation here.
Reasons for the introduction of MAPs
The appearance of MAPs in UK healthcare reflects a trend towards the development of multi-disciplinary teams as well as ensuring that there is sufficient workforce to meet demand in the NHS.
PAs are seen by the UK government as one of the ways in which workforce pressures in the NHS can be alleviated. In June 2015, the then secretary of state for health, Jeremy Hunt, announced that 1,000 PAs would be introduced into general practice in England to assist in tackling GP workload pressures (as of August 2022 the number stands at 621).
The devolved governments have also identified PAs as a potential way to address pressures.
Alongside increasing the number of doctors by 60,000 by 2036/37, as part of its Long-Term Workforce Plan, the government in England plans to increase the number of physician associates (PAs) from approximately 3,250 to 10,000 (an increase of over 300%); and anaesthesia associates (AAs) from approximately 180 to 2,000.
Regulatory status
None of the MAPs are currently regulated specifically for their role as MAPs, however surgical care practitioners and advanced critical care practitioners are subject to statutory regulation through previous roles.
Unlike PAs and AAs, SCP roles can only be taken up by individuals who are already registered healthcare professionals.
Currently, physician associates and anaesthesia associates are not subject to any form of statutory regulation, however following a 2017 consultation, PAs and AAs the UK government decided that the GMC should be their regulator. The government has introduced secondary legislation via The Anaesthesia Associates and Physician Associates Order 2024 (AAPAO) to provide for the regulation of PAs and AAs by the GMC. The legislation has successfully passed through both house of parliament.
BMA response to the consultation
The BMA response to the consultation argued that all of the medical associate professions should be regulated and that HCPC (Health & Care Professions Council) should take responsibility for regulation, rather than the GMC.
The choice of GMC as regulator
The GMC are to take on the role of regulator for PAs and AAs, with regulation set to begin towards the end of 2024.
The DHSC (Department of Health and Social Care) provided the following reasons for their choice.
- The need to be assured that the chosen regulator will be best able to ensure effective public protection. Based on the independent assessment made by the PSA (Professional Standards Authority) on an annual basis, the HCPC has failed 6 out of 10 of the fitness to practice standards set by the PSA for the last two years. In contrast, the GMC continues to meet all of the PSA standards.
- PAs and AAs are both trained to the medical model and work closely with medical practitioners. Regulation by the GMC will mean that the organisation will have responsibility and oversight of all three professions allowing them to take a holistic approach to the education, training and standards of the roles.
- The majority of respondents to the consultation were in favour of the GMC taking on regulation, including the professional bodies representing the two roles and medical royal colleges (59% for GMC, 20% for HCPC from 3063 total responses).
The decision to only regulate PAs and AAs
The government response to the MAPs consultation (published in February 2019) did not rule out the future regulation of SCPs and ACCPs.
PAs and AAs must hold an undergraduate degree, usually biomedical sciences, or a health-related science. To become a PA or an AA there is no requirement to be a registered healthcare professional. These roles are described as ‘direct entry’ roles and currently they are not subject to any form of statutory regulation.
To become a ACCP or an SCP, it is necessary to already be a registered healthcare professional. These roles, therefore, do not have direct entry and practitioners will be subject to statutory regulation through their background role.
It was decided to prioritise the two professions that are currently not subject to any form of statutory regulation.
Decisions on regulation and the career framework will apply across the UK.
Can MAPs prescribe?
Currently, MAPs are not given prescribing rights as a result of being a MAP. However, prescribing is a part of the role for both SCPs. Candidates for SCP roles must already be registered healthcare professionals, meaning that they are eligible to take a qualification in non-medical prescribing.
AAs and PAs are currently not permitted to prescribe or request ionising radiation. Unlike SCPs, AAs and PAs do not need to be registered healthcare professionals from a previous role. However, a small number of PAs have previously held prescribing roles and are registered health care professionals, and this means that they personally retain those prescribing rights.
We believe that this is potentially confusing for patients, clinicians and employers and in 2019 the BMA endorsed a statement from the Royal College of Physicians and the Faculty of Physician Associates which recommended that no PA should prescribe until all PAs are able to do so.
The consultation on regulation of MAPs included questions about the prescribing rights for MAPs, but in their response, the government stated that prescribing would be treated as a separate question and that a separate consultation would follow.
A statement on MAPs prescribing by the Resident Doctors Committee and GP Registrars Committee can be read here.
Professional indemnity coverage
Types of medical indemnity
Read the summary of types of indemnity and an overview of what each cover.
As with other members of staff, any MAPs working for an NHS trust are covered by the DHSC clinical negligence scheme for trusts.
In primary care, physician associates working in England are now covered by the clinical negligence scheme for general practice (CNSGP) and in Wales by the general medical practice indemnity scheme (GMPI). Practices in England in Wales no longer need to secure indemnity coverage for their clinical staff.
In Scotland and Northern Ireland practices will need to ensure that their practice indemnity coverage includes physician associates along with their other clinical staff.
MAPs working in any part of the NHS may also choose to have their own personal professional negligence insurance from one of the medical defence organisations.