The debate around the clinical responsibilities of physician associates

 In the second part of our analysis of the role of physician associates within general practice, Eliza Parr looks at what clinical responsibilities they are being given, and the potential risks in their practice

A handful of high-profile, tragic cases involving physician associates have caught public attention over the last year. Emily Chesterton, a 30-year-old patient at a GP practice in North London, died at the end of 2022 after seeing a PA. She had suffered a pulmonary embolism, and the coroner concluded that poor quality of care provided by the PA contributed to her death. Worryingly, her family revealed that Ms Chesterton believed she had been seeing a doctor.

It’s no surprise that tragedies like this make it into the national consciousness. And the case of Ms Chesterton has raised awareness about PAs among the public and across the political spectrum, with several politicians citing it in Parliament when debating the regulation of these professionals.

Singular cases like this cannot be used to extrapolate across all PAs – many may be working safely and effectively in GP practices. But the speed of their rollout, paired with gaps in guidelines and regulation, has led to deep concern among the medical profession.

Prescribing rights

Critics of the PA rollout often cite the extent of their education and training when compared with doctors. To be accepted onto a postgraduate PA training course, most applicants will need a bioscience-related undergraduate degree.

The two-year postgraduate training course then ‘involves many aspects of an undergraduate or postgraduate medical degree’ and focuses mainly on general practice and general adult medicine in hospitals, according to the NHS careers website. Following this, trainees must pass the PA national examination, which allows them entry onto the Faculty of Physician Associates (FPA) voluntary managed register.

Doctors’ Association UK (DAUK) GP spokesperson Dr Steve Taylor warns the course is ‘trying to squeeze a medical degree into two years’. And when compared with GP training – a three-year programme which follows a five-year medical degree and two years as a foundation doctor – he says there is ‘just no comparison’.

The one concrete differentiating feature in how PAs work is that legislation does not allow PAs to write prescriptions or request ionising radiation. Yet despite the current ban on prescribing, one recent job advert for a PCN in Ipswich said the role will ‘involve independent prescribing within the scope of professional practice’. And, a job advert for an Operose GP practice had previously suggested that physician associates can prescribe medication – the company told Pulse it will ‘revise’ this wording for future adverts to avoid confusion.

Perhaps confusion like this prompted NHS England to clarify its stance on prescribing, with new guidance in March emphasising the importance of GP practices having a policy to prevent PA access to prescribing. The guidance urged GPs to provide assurance that ‘clinicians are not able to undertake activities falling outside their role’s scope of practice’. One suggestion was providing PAs with smart cards loaded with system role profiles that do not permit access to prescribing activities.

But prescribing rights are on the horizon. The Government has said that regulation of PAs, which the GMC will soon take on, ‘paves the way’ for broadening their scope of practice, including the possibility of being able to prescribe. NHS England has previously committed to launching a consultation on prescribing rights for PAs ‘within 24 months of their regulation’.

It’s likely that any consultation would receive strong opposition from doctors’ groups. Dr Shamit Shah, a GP partner in Hampshire and Wessex LMC member, warns that the PA curriculum as it stands ‘does not do pharmacology properly… I’d be very worried about safety if they got prescribing rights – and many PAs will tell you the same thing,’ he says. But whether the Government takes heed of these concerns is uncertain, given that criticism from doctors has so far failed to sway policymakers.

In the meantime, NHS England has stated that while PAs still can’t issue prescriptions, they can ‘prepare prescriptions for GPs to sign’.

Undifferentiated patients

The other main source of contention in PAs’ practice is whether they can see ‘undifferentiated’ patients. NHS England currently describes PAs as ‘medically trained generalist healthcare professionals’, who work alongside doctors to provide ‘medical care’ as part of the multidisciplinary team.

Despite the disparity in training length and depth, NHS England encourages, and in some ways mandates, that physician associates see undifferentiated patients in primary care. The PCN contract, which dictates how Additional Roles Reimbursement Scheme (ARRS) staff must be used, had said PAs must ‘provide first point of contact care for patients presenting with undifferentiated, undiagnosed problems’. It was amended for the 2024/25 contract to add: ‘where their named GP supervisor is satisfied that adequate supervision, supporting governance and systems are in place’.

In contrast to this, the BMA’s recently published scope of practice for physician associates stipulates that they should never see undifferentiated patients in a GP setting. Adhering to the union’s guidance is not mandatory, but this contradiction with NHS England may leave many GP partners confused and unsure how to maintain safe patient care. In response to the BMA’s guidance, the FPA – the PA professional body – expressed ‘serious concerns’ about its development, and claimed it was an ‘inaccurate reflection’ of the PA workforce.

Even more confusingly, the GP contract for 2024/25 explicitly states that ‘non-GP doctors’ – for example, staff and associate specialist (SAS) doctors – working in primary care ‘should not see undifferentiated patients’. This misalignment with guidance on PAs suggests that professionals straight out of a two-year postgraduate course can manage risk better than SAS doctors who could have a decade of medical experience.

Passions were high at the UK LMCs Conference last month. Dr Chris Morris, from the GP registrars committee, said: ‘Physician associates are a threat to health professionals, GPs and doctors… This is devaluing our worth as expert generalists. How can it be acceptable that non-medical practitioners can work in general practice and see undifferentiated and differentiated patients with just two years of training?

‘PAs working in general practice and seeing these patients make a mockery of our extensive training and CCT. This is an attack on doctors and patients, and is a short-sighted poor investment in the future. If this experiment continues, we’ll be left with a two-tier healthcare.’

‘Scope of practice’

All this feeds into a far broader discussion: the need for a clearer ‘scope of practice’ – the term increasingly used in the debate.

Professor Azeem Majeed, professor of primary care and public health at Imperial College London, worries that ‘very often’ PAs end up doing ‘very similar work’ to GPs, and are therefore ‘seen as substitutes’. A clear scope would help prevent this: ‘That’s what our main concern is, around that scope of practice – I think the key question is really to define this scope of practice at a national level’.

Some GPs may be waiting on GMC regulation, which is expected to encompass PAs by the end of this year. But the regulator has been clear that the standards it sets for PAs, which it recently consulted on, will not determine scope of practice ‘beyond initial qualification competences’.

Instead, it seems to be the royal colleges that are taking on, or being given, responsibility for determining the scope of practice.  

In the guidance issued in March, NHS England said: ‘The Faculty of Physician Associates (professional body) is collaboratively working with the Royal College of Physicians to generate additional supportive guidance around the supervision and scope of practice of PAs.’ Meanwhile, the RCGP has recently consulted on the role of PAs in general practice, asking GPs, as supervisors, how the role ‘could be best deployed going forwards’.

There is still disagreement on who is best to regulate PAs. The RCGP Council recently passed a motion saying it should be a different body to the GMC, a stance supported by East London GP partner Dr Selvaseelan Selvarajah. He says: ‘The GMC was primarily set up to regulate doctors and avoid the confusion for patients about who is treating them. The GMC needs to make it clear that doctors and PAs do not fall under a single category of medical professionals as the roles are different.’

Yet Professor Majeed says it should be up to the GMC and NHS England to fully determine the scope to ‘ensure patient safety’. He adds. ‘They are the two organisations best equipped to establish and maintain the scope of practice for physician associates. A national approach to establishing the scope of practice of physician associates would ensure a standardised and consistent approach across the NHS in England.’

How practices are using PAs

With this lack of guidance and regulations, GPs are having to decide how to use PAs in general practice, and each is taking its own route. A Pulse analysis of job adverts reveals the general tasks they are expected to take on (see box).

GP partner Dr Dean Eggitt says the PA at his practice in Doncaster – who is employed though the ARRS – tends to do nursing home rounds, giving all patients at the home a ‘holistic review’. After this, she will see a ‘handful’ of ‘non-triaged’ patients back at the practice. She sees undifferentiated patients, or in other words, those ‘who have not been filtered other than through care navigators at the reception desk’.