Guidance for the supervision of Medical Associate Professions (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).

Location: UK
Audience: All doctors
Updated: Wednesday 22 May 2024
NHS Structure Article Illustration

This guidance 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.

The following 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.*


Recommendations for supervision of MAPs

1.  In each healthcare setting (private or public), MAPs must have an immediately available, named supervisor. Consultants, GPs and autonomously practising SAS doctors are all suitable as MAPs’ supervisors. There should be a readily available register of supervisors.

2.  The BMA considers that locally employed doctors, specialty doctors who do not practise autonomously, or doctors in training are not suitable to provide supervision and must not be put into a position where they are asked to do so.

3.  We recommend that consultants, GPs and autonomously practising SAS doctors who supervise MAPs delegate only the tasks described in the traffic light tables in our Safe Scope of Practice for MAPs Recommendations to their MAPs in order to minimise risk to patient safety caused by the possibility of dependent practitioners working beyond their competence.

4.  Employers should ensure that where MAPs are employed there is adequate time allocated each working day for every patient to be fully discussed with the supervising doctor and reviewed in person by the supervising doctor if necessary.

5.  Consultants, GPs and autonomously practising SAS doctors will need to be appropriately indemnified for supervising MAPs (clinical negligence indemnity may be covered automatically by state-backed NHS indemnity schemes). Consultants, GPs and autonomously practising SAS doctors should notify their medical defence organisation that they are undertaking such supervision and ensure they have adequate professional cover, noting the requirement to double check patient symptoms, clinical signs and test results before agreeing to any management plan of a MAP they have agreed to supervise.


Recommendations for doctors supervising MAPs

1.  You must have a clear understanding of the scope parameters, competencies, and level of supervision required for MAPs roles in general and for the specific work MAPs undertake while under your supervision.

The BMA Safe Scope of Practice for MAPs Recommendations are the BMA’s position, as your trade union and professional body, on the ceiling of practice for MAPs to enable safe working. When considering delegation of tasks in the amber column of the traffic light tables in the Safe Scope of Practice for MAPs Recommendations, the BMA recommends that you should not delegate such tasks unless you have direct observation and experience that the MAP 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 supervision the BMA does not consider these activities to be safe.

2.  We recommend that you prioritise the training of doctors, particularly resident doctors (trainees) and medical students, in order to ensure that doctors are suitably equipped with knowledge, skills and competencies for developing the expertise they must acquire to practice medicine.

3.  You must be aware of the consequences of delegating tasks beyond recommended traffic light tables in the Safe Scope of Practice for MAPs Recommendations. The MDU has stated that “although AAs and PAs remain accountable for their actions, a doctor will retain responsibility for the overall management of the patient and the system of supervision”. Supervisors may be legally responsible for MAPs. You should be aware of the potential financial, legal, and regulatory  ramifications of actions/omissions by a MAP. 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 on a shift, or general practice session, you should be immediately available to review patients with the MAP and you must delegate your supervising responsibility to another appropriate consultant, GP, or autonomously practising SAS doctor who agrees to undertake supervision when you cannot be present (clinics, theatre, teaching, leave). At all times, the name of a MAP’s supervisor should be readily available so that they can be contacted with any queries about delegations in place on a particular day or shift. Physically closer supervision will be required for any MAP working in a critical care or urgent care setting. The BMA recommends that you should not delegate supervision to a doctor who is not a consultant, GP or autonomously practising SAS doctor. 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.  The BMA would like to hear from you if your department or Trust/Board is making it difficult for you to apply safe parameters of working in your workplace. You can report it using the BMA’s MAPs reporting portal, raise the issue with the Local Negotiating Committee, or contact a BMA adviser. You should also use local processes to raise any patient safety concerns via the Datix system or equivalent. This also applies if your employer is asking you to act outside these recommendations.


Recommendations for doctors who are not supervising MAPs

1.  If you are working with MAPs in your department or primary care setting, you should treat them civilly and with respect as with all staff you work with. Everyone across the health system is working under pressure and is trying their best to help patients. Doctors are role models for professionalism.

2.  You should know who a MAP’s named supervisor is and how to contact them at all times.

3.  You should familiarise yourself with the BMA’s Safe Scope Practice for MAPs Recommendations.

4.  If you are asked to supervise a MAP, and are not in a position to do so, please refer them to the BMA’s Safe Scope of Practice for MAPs Recommendations. The BMA will support you if you assert, politely, that you are not able to provide supervision for MAPs within your own competencies and/or capacity and redirect them to their named supervisor.

5.  If a MAP raises a patient concern to you and you are not the named supervisor:

  • If there are immediate safety concerns about a patient, this should prompt a doctor’s swift assessment and management.
  • If there are no immediate patient safety concerns, then the MAP should be redirected to their named 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 Datixes. This may include MAPs working in an unsafe way beyond their competence, being placed on a doctors’ rota, or substituting doctors in any way, including providing supervision of doctors.

8.  You should raise serious safety concerns formally in writing with the Trust/Board if you are put in the position of working with a MAP being used inappropriately on a rota, for example, covering doctor on-call shifts, and this cannot be remedied by speaking to relevant people to have them taken off that shift. This would be in line with GMP 75, 2 b. It may be that you would feel more comfortable to raise this as a group (e.g., with co-signatories) and to cc in a local BMA rep/IRO.

9.  If you raise any concerns that are not addressed, you should formally write to the  Trust/Board in secondary care outlining the basis of your concerns and identifying the supervisor who should be responsible for the patient care and outcomes of the MAP’s work. You may wish to also advise your medical defence union if you have had to assume responsibility for MAPs during on-calls due to failure of the employer to ensure that there is appropriate supervision by the named supervisor. Please also raise this with the BMA via the MAPs reporting portal.

10.  In primary care, you should escalate concerns to the practice partners, senior partner or practice manager in the first instance and escalate this to the health board, Trust, or ICB in line with local governance pathways, with which you should familiarise yourself. Please also raise these concerns with the BMA via the MAPs reporting portal.

11.  If you are concerned about loss of training opportunities for doctors/medical students in your workplace, please continue to raise this 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.

12.  You can also involve the LNC or local BMA team in any implementation difficulties.

*The Safe Scope of Practice for MAPs Recommendations are aimed at NHS Employers and Trusts and should not be treated as employment advice to members on their current interactions with MAPs. In respect of the Safe Scope of Practice for MAPs Recommendations and this document, reference should be made to individual employment contracts, work schedules,etc. before taking any action that may be in breach of contract and/or GMC guidance. Nothing in this document is intended to displace the requirements of GMC GMP. The BMA will keep this document and the Safe Scope of Practice for MAPs Recommendations under review and may update them from time to time.