The DHSC (Department of Health and Social Care) in England describes a PA (physician associate) as "a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision."
PAs currently work and train, largely in hospitals, across England and Scotland. However, in the 2016 GPFV (GP Forward View), the then Secretary of State for Health and Social Care, Jeremy Hunt, mandated that there should be 1,000 PAs working in primary care in England by 2020/21.
More recently, the DHSC announced the introduction of statutory regulation for PAs, the lack of which has been a concern for our members over the last few years.
The view from the BMA general practitioners committee:
"Physician associates can perform a valuable role as part of the extended primary care team. There is scope for them to take some pressure off GPs by performing some defined clinical tasks. They are not, however, a substitute for a doctor who undergoes years of medical training that enables them to provide complex, highly skilled care to their patients. GPs play a particularly important role in diagnosing serous conditions, a task that that can only be done with an appropriate level of medical expertise and experience."
Considerations when employing physician associates
As a result of these commitments, we have compiled a list of considerations when employing a PA below (taken from the Faculty of Physician Associates' employers guide to PAs) for practices who are thinking of employing a physician associate.
- Job plan and scope of practice
- Regulation and indemnity
- FPA code of conduct
- Preceptorship programme
Job plan/scope of practice
Prior to deciding whether to employ a PA It is important that practices ensure that the role and remit of a PA are what is needed by the practice team/network. This is to ensure practices do not employ a PA where an alternative healthcare professional would be better suited (for example, an advanced nurse practitioner, GP, practice nurse or other healthcare professional).
It is strongly recommended that GP practices only consider recruiting physician associates who are registered on the PAMVR (Physician Associate Managed Voluntary Register).
Job descriptions advertising for the role of a PA must state that it is essential for applicants to hold a PG diploma or MSc in Physician Associate Studies from a recognised UK or US programme and that they have passed the UK physician associate national exam.
It is advised to write a clear job plan so that everyone understands (both the PA and the supervisor) what is expected of them. The job plan should include: hours of work, opportunities for development and required duties. In primary care it is useful to have one dedicated GP supervisor.
Regulation and indemnity
In October 2018, Secretary of State for Health and Social Care, Matt Hancock, announced the introduction of statutory regulation for physician associates. However, with the legislative process still to be navigated and a regulator yet to be chosen, we are still some way from this becoming a reality. This means that PAs are currently not permitted to prescribe and it is important that practices take this into account when considering employing a PA.
Practices also need to be aware that physician associates require professional indemnity coverage in order to practice in the UK. Currently, the Medical Protection Society (MPS), Medical Defence Union (MDU) and Medical and Dental Defence Union of Scotland (MDDUS) will provide professional indemnity for physician associates working in general practice.
In primary care it is useful to have one dedicated GP supervisor for a physician associate. Supervision of a qualified physician associate is comparable to a doctor in training, in that the physician associate is responsible for their actions and decisions. However, it is the GP who is ultimately responsible for the patient. This means that there must also always be a GP supervisor available who can discuss cases, give advice, and attend to patients if necessary. Before employing a PA, practices must give serious consideration as to whether they have sufficient capacity to provide the necessary level of supervision.
The FPA (Faculty of Physician Associates) recommends that practices who are thinking of employing a newly qualified physician associate might wish to consider offering a one year 'internship'. This is so that the PA can consolidate their core knowledge and skills and demonstrate their competence in practice. During this period, PAs should:
- Be supervised closely
- Have experiential learning in the clinical area in which they are working
- Maintain a portfolio of cases and case discussions with clinicians which may also be reviewed with their clinical supervisor (usually a GP).
As a clinical supervisor there is also a responsibility for the ongoing development of the PA including appraisal and development of a professional development plan (PDP).
FPA code of conduct
Practices should familiarise themselves with the FPA code of conduct which outlines what is expected from a qualified PA working in a clinical setting.
To enable PAs to transition into employment within primary care effectively, HEE have developed a preceptorship scheme. This scheme gives the practice a £5,000 allowance to support the supervision and educational needs for newly qualified physician associates working in primary care in England.
For further information including the application process for the preceptorship programme please get in touch with your HEE area lead.
Addressing members' concerns
Due to an initial lack of central coordination or a formal national programme for the implementation of PAs into the NHS, there has been considerable local variation in their scope of practice, how they are trained and how they are supervised.
Consequently, a considerable, and understandable degree of anxiety has been generated as to what PAs mean for the future of the role of doctors, and also about the way their introduction is already impacting on the day to day working life of medical trainees and doctors in the NHS.
Since HEE (Health Education England) has taken on lead responsibility for preparing the workforce for the implementation of PAs on an NHS-wide scale, however, efforts have been made to secure:
- formal regulation
- a defined scope of practice, including clinical supervision arrangements between doctors and PAs
- a formal, structured career pathway – the BMA is represented on the national HEE-led Medical Associate Professions Career Framework and Quality Working Group, looking specifically at preparing the primary care workforce for the introduction of PAs
Case studies from practices working with PAs
Share your experience of working with a PA
If you would like to share your experience of working with or employing a PA in general practice, please fill out this case study template and send it to [email protected].
Audley Health Centre - experience of employing a PA
We were keen to explore employing a PA as we had experience of PA students in the practice from Wolverhampton University and recognised that they could bring an element of diversity as well as supporting the clinical team.
We were fortunate that our GP federation were supportive of the PA model and ran an internship. This meant that they handled all the recruitment and pre-occupational checks and paperwork. The practice has found having a PA to be a very positive experience. It has enabled us to fully utilise care navigation by having different personnel to direct patients to. A lot of routine conditions can be directed to the PA, which means the GPs can deal with the more complex and multi-morbidity patients.
Our PA has now fully integrated in to the practice. A thorough induction and introduction to the team as well as clear guidelines is essential. Receptionists need to fully understand who and what can be booked in to see the PA in order to respond to patient’s questions or needs appropriately.
Our nursing staff also fully understand the role of the PA and can therefore effectively triage patients. Since employing a PA, we can now see a reduction in GP appointments and workload. Patient access is also much improved and this fits with the Five Year Forward View principle of ‘making time in general practice’.
Plans for workforce expansion
We will be considering workforce expansion soon as one partner will retire in four years’ time and another two will either retire or reduce their sessions within the next couple of years.
Newly trained doctors are opting to either locum, become a GP with a specialist interest or even emigrate. We need to consider engaging or employing a range of different allied healthcare professionals that can support practice and patient needs whilst ensuring sustainability, security and safety to deliver primary care services.
Sheffield Teaching Hospitals NHSFT collaborative out of hours GP service - experience of working with PAs
I found the PAs, who were both from the USA, to be very skilled. They did need some cultural guidance regarding UK patients, but their skills improved quickly as they efficiently consulted more and more patients.
There were some drawbacks, however. They needed to debrief every patient with a GP, particularly to get a prescription, often meaning we would have to review the patient ourselves before issuing a prescription. This would take up GP time. It wasn’t a major issue, as our practice is a large organisation with many GPs working in a more flexible way. This could, however, cause disruption to a smaller practice by taking up significant amounts of GP time in supporting them.
The PAs integrated into the team well as it was already a multidisciplinary service. It did not affect appointment waiting times in any way, but it did increase the workload of the GPs.
Plans for workforce expansion
At present, there are no further plans for workforce expansion and the PAs are no longer working at the Sheffield GP collaborative. There has been a recent increase in community matrons doing home visits, but this is the only major change and no further changes are planned.
A GMS super partnership based in Sandwell and West Birmingham CCG - working with PAs
PAs are an excellent resource, they are keen and enthusiastic to be involved in general practice, and we couldn’t manage without them, we also take on PA students at the practice.
I would recommend employing a PA, but the only problem is the limitation on them and the fact they are not eligible to be prescribers, which limits what they can do, despite the fact many are very experienced indeed. The PAs have helped us maintain our service, as it has been very difficult to recruit GPs, without PAs we would be at breaking point.
Plans for workforce expansion
We will continue to maintain our numbers. I think we employ more PAs than any other practice in the UK and we are now looking to see what other roles they can be used in, for example, in chronic clinics as there are shortages of experienced nurses too. Ideally, we need the DoHSC to allow PAs to become prescribers.
Case study from NHS England on a PA working in general practice