Background

PAs are clinicians who have often, but not always, completed a two-year post-graduate course, following a 'related degree' – a wide selection including but not limited to physiotherapy, biochemistry, nutrition and psychology, PAs have been utilised in general practice for several years, with their use increasing, particularly following the introduction of the 2019 Primary Care Network Direct Enhanced Service (PCN DES) Additional Roles Reimbursement Scheme (ARRS) in England. 

This workforce ARRS funding can be spent on a selection of staff, although currently to the exclusion of GPs, practice nurses and HCAs. The growth of the PA workforce has coincided with the widening of universities that now offer PA degrees. It is widely acknowledged that PAs are dependent practitioners, i.e. clinicians who cannot work independently and who require ongoing close supervision and oversight.

PAs, as non-regulated clinicians, are not able to prescribe or request ionising radiation. Despite this, their use in GP and hospital settings has increased whilst the supervision and oversight has, in many instances, been relaxed.  Until recently, the PCN DES National Health Service England (NHSE) role specification stated that PAs must see undifferentiated patients, in a similar vein to a GP.  

Following a BMA survey, which made clear the scale of concern in the profession about the ways in which many PAs have been deployed and some very concerning reports of patient harm, the BMA created GP specific and profession-wide guidance on their safe supervision, with several Royal Colleges reviewing their stance on PAs following feedback from their members.   The wording of the PCN DES has been revised following the release of the BMA's MAPs guidance linked above, and now states:

'...where their named GP supervisor is satisfied that adequate supervision, supporting governance and systems are in place, provide first point of contact care for patients presenting with undifferentiated, undiagnosed problems by utilising history-taking, physical examinations and clinical decision-making skills to establish a working diagnosis and management plan in partnership with the patient (and their carers where applicable). The GP supervisor must take into account a Physician Associate’s knowledge, skills and experience gained through their training and development'.

 An important founding principle of engaging PAs in general practice is ensuring the provision of appropriate and accessible GP supervision and oversight to support safe clinical patient care.  We would urge GPs who choose to employ PAs to prioritise the safety of their patients, noting that although the new DES wording suggests PAs may be able to see undifferentiated patients, this now clearly places the onus upon the GP supervisor to ensure appropriate supervision is in place.

The following recommendations have been made to support PAs to work safely and enable them to contribute to high quality patient care, in addition to providing protection to employing practices and supervising GPs. A lack of appropriate level supervision and support may result in increased exposure to regulatory risk and liabilities for employing practices and supervising GPs. 

Other UK nations

In other parts of the UK, the PCN DES and ARRS do not apply. The Welsh GMS contract’s Additional Capacity Fund does not have similar restrictions in terms of what staff cohorts it can be used for. PAs are employed at GP practices and in health care systems across all four nations, and the principles of this guidance will apply.

1. Within each workplace setting, PAs must at all times have access to a clearly identified, and immediately available, named on site GP supervisor. This should be a post-CCT qualified GP and not a doctor in training (i.e. GP Registrar or F2). There should be a readily available register of supervisors at each workplace employing PAs.  Patient safety is of the foremost priority in clinical practice.
   
   
2. Salaried GPs may supervise PAs, should they consent to do so, but must be under no obligation. Should they agree to do so on anything other than an emergency basis, this should form part of their agreed job plan.
   
   
3. Any employed GP providing PA supervision must be given adequate time to safely supervise the PA, with the necessary debrief and supervision time to review patients built into their clinic templates. This would also need to take into account the additional administrative and prescribing workload generated after patient reviews.
   
   
4. As with the supervision of salaried GPs, any partner/contractor GP who takes on supervision responsibilities for a PA must ensure they have appropriate time to safely supervise the PA.
   
   
5. Locum GPs may supervise PAs provided this has been mutually agreed in advance and they are given appropriate time to safely supervise the PA during their clinic templates. All locums should ensure that they are content with the wording of their contract on the supervision of PAs.
   
   
6. Supervision should consist of the GP supervisor being presented with the patient history and examination findings (where relevant). The GP should then review the patient with the PA and any subsequent action should be in line with what the supervising GP deemed appropriate for the safe, effective care of the patient.
   
   
7. Supervision must take place contemporaneously (immediately after the consultation), and prior to the patient leaving the site, in order to permit GP supervisor clarification and re-examination when needed. This must happen for each patient.
   
   
8. For telephone consultations conducted by a PA, it is acceptable for the PA to advise the patient they will be called back, then present to the supervising GP, and then for the GP supervisor to call the patient back.
   
   
9. PAs should not be used to undertake home visits without a supervising GP present. They should not perform tasks for a GP on a care home ward round, unless accompanied by a GP supervisor.
   
   
10. GPs who supervise PAs should familiarise themselves with the above guidance. GP supervisors should only delegate the tasks described in the traffic light tables in the BMA's Safe Scope of Practice for MAPs Recommendations (note that the MAPs grouping includes but is not limited to PAs). This is to minimise risk to patient safety caused by the possibility of PAs working beyond their competence. For example, for simple procedural tasks (e.g. recording blood pressures, performing phlebotomy, recording ECGs, giving flu vaccinations via PGD) a risk assessment should be performed for that specific task or procedure. Depending upon the outcome, this may result in the PA no longer requiring direct supervision and debrief after each contact, as no clinical decision is being made. However, immediate access to a GP supervisor will still be needed for any unexpected issues or queries, as would be expected for other staff members (e.g. Nurses/HCAs) performing such tasks.
    
    
11. GPs providing supervision need to be appropriately indemnified for supervising PAs and should confirm this with their medical defence organisation (MDO). Clinical negligence indemnity may be covered automatically by state-backed NHS indemnity schemes, but this does not cover proceeding at criminal, civil or coronial courts, or for GMC investigations or tribunal hearings). GPs should inform their MDO that they are undertaking such supervision and ensure they have adequate professional cover.

1. You must have a clear understanding of the scope, parameters, competencies, and level of supervision required for PA roles in general and for the specific work PAs undertake whilst under your supervision. You should familiarise yourself with the following guidance.
   
   The ‘Safe scope of practice for MAPs’ document states the BMA’s position on the ceiling of practice for MAPs (including PAs) to enable safe working. When considering delegation of tasks in the amber column of the traffic light tables, the BMA recommends that you should not delegate such tasks unless you have direct observation and experience that the individual has the requisite skills and competencies. The BMA recommends that MAPs should not be supervised to undertake any tasks listed in the red column. Even with GP supervision the BMA does not consider it safe for PAs to conduct these activities.
   
   
2. We recommend that you prioritise the training of doctors and medical students, in order to ensure that these colleagues are suitably equipped with knowledge, skills and competencies for developing the expertise they must acquire to practice independent medicine; this is essential for the development of the future medical and GP workforce.
   
   
3. GP supervisors must regularly familiarise themselves with their GMC and MDO obligations. The MDU has stated that “although PAs remain accountable for their actions, a doctor will retain responsibility for the overall management of the patient and the system of supervision”. Supervisors are likely to be legally responsible for PAs working under their supervision/employment. There may be potential financial, legal, and regulatory ramifications of actions or omissions by a PA you are employing and/or supervising. We strongly advise you to ensure appropriate MDO and trade union membership. For further information see The General Medical Council's advice for PAs, AAs, and doctors who supervise them.
   
   
4. When supervising a PA in general practice (in or out-of-hours), you should be immediately available and easily accessible to review patients with the PA and must delegate supervising responsibility to another consenting GP who agrees to undertake supervision in the instances when you are not available (e.g. visits, teaching, leave). 
   
   At all times, the GP supervisor should be clearly identified and their name and contact details readily available so that they can be contacted with any queries about delegations in place on a particular day or shift. Co–located same site contemporaneous supervision is required for any PA working in any general practice setting. We also refer to the section on delegating safely and appropriately in GMC GMP 2024 which states at paragraphs 66 and 67 that:
   
   "You must be confident that any person you delegate to has the necessary knowledge, skills and training to carry out the task you’re delegating. You must give them clear instructions and encourage them to ask questions and seek support or supervision if they need it. If a task is delegated to you by a colleague but you’re not confident you have the necessary knowledge, skills or training to carry it out safely, you must prioritise patient safety and seek help, even if you’ve already agreed to carry out the task independently."
   
   
5. If for any reason you cease to be able to supervise a PA and are unable to arrange alternative appropriate supervision by a GP colleague, you must instruct the PA that they are unable to continue clinical work until safe supervision can be resumed.

1. If you are working with PAs in general practice, you should treat them civilly and with the same level of professionalism as you would any colleague.
   
   
2. You should know who a PAs named GP supervisor is and how to contact them at all times. 
   
   
3. You should familiarise yourself with the above guidance.
   
   
4. If you are asked to supervise a PA, and are not in a position to do so, you should politely decline and redirect them to their named GP supervisor.
   
   
5. If a PA raises a patient concern to you and you are not the named GP supervisor:
   - If there are immediate safety concerns about a patient, this should prompt an immediate GP assessment and management.
   - If there are no immediate patient safety concerns, then the PA should be redirected to their named GP supervisor for support.
   
   
6. If you have patient safety concerns at any time when you are on duty, you should escalate through your locally agreed mechanisms. Please notify the BMA if you are being instructed to not do this.
   
   
7. If you are concerned about unsafe practice by MAPs specifically within your department or workplace, please raise it here: MAPs reporting portal, as well as raising it within your locally agreed mechanisms, such as Datix/SIRMS. This may include PAs working in an unsafe way beyond their competence or substituting GPs in any way, including providing supervision of doctors (F2/GP Registrars) or medical students.
   
   
8. In general practice, you should escalate concerns to the practice manager, practice partners, or organisation directors in the first instance.)  Should this not resolve the issue, please consider contacting your LMC. Please also raise these concerns with the BMA via the MAPs reporting portal.
   
   
9. If you are concerned about loss of training opportunities for doctors and/or medical students in your workplace, please continue to raise this with the practice, through the MAPs reporting portal, and through any formal exception reporting mechanism available to you. You should escalate your concerns to your educational supervisor and Deanery during formative and summative reviews.

Recommendations for employment of PAs

1. It is the employer’s duty to ensure the safe use of any PAs they employ, whether this is under the ARRS or directly.
   
   
2. We recommend that as with all roles and services, due diligence is carried out, taking into account the clinical and cost effectiveness of overall needs, and factoring in the costs of GP supervisors and supervision time.
   
   
3. Should employers continue to employ or begin to employ PAs, we advise that the above guidance is referred to and provided to all staff working with PAs in their organisations/practices, noting that liability for the PAs work lies with their employers/supervising GPs.
   
   
4. For further advice, the BMA’s Employer Advisory service is available to GP partners who are BMA members.