GPs should assess patients before they see physician associates, doctors suggest

New guidelines on the physician associate role have been published by the Royal College of General Practitioners.

The RCGP’s Professor Kamila Hawthorne said ‘there are just too many PAs that we feel are not being supervised’ (Handout/PA) (Royal College of General Practitioners)

Leading doctors have warned that physician associates should not see patients who have not been assessed by a GP first.

In new guidance, the Royal College of General Practitioners (RCGP) also says physician associates (PAs) should explain they are not doctors when introducing themselves to patients and wear clear name badges.

The recommendations follow a vote by the college’s governing council to oppose the PA role in general practice, citing patient safety grounds.

PAs are graduates – usually with a health or life sciences degree – who have undertaken two years of postgraduate training.

Their role is to “support doctors in the diagnosis and management of patients” and they can be deployed across GP surgeries and hospitals.

However, they have come under scrutiny in recent years following the death of Emily Chesterton, who suffered a pulmonary embolism in 2022 at the age of 30. She was misdiagnosed by a PA on two occasions.

According to the RCGP, there are about 2,000 PAs employed in general practice, and its new guidance is intended as a “practical resource” for GPs and practices that employ PAs.

The document includes a scope of practice, which, among other things, suggests PAs should not see a patient who has not been triaged by a GP first and should only undertake work delegated to them by their GP supervisor.

PAs should always document the care and advice they give to patients, including information shared on behalf of the GP, with notes made at every PA appointment signed off by a GP at the end of a surgery day, according to the guidelines.

Staff must wear “clearly visible name badges”, and PAs must ensure patients understand their role and the fact they are not a doctor upon introduction.

The guidance also states practices should have a list of multidisciplinary team members on their website, with a description of each of their roles and a protocol when booking appointments to explain to patients who they will see, with an option for them to discuss who they would like to see.

I think there just hasn't been proper guidance put out there

Prof Kamila Hawthorne

In June, a survey of RCGP members found 81% thought that negative effects on patient safety were one of the challenges of using PAs in general practice.

Speaking exclusively to the PA news agency on why some PAs may not be being supervised properly, RCGP chair Professor Kamila Hawthorne said: “I think there just hasn’t been proper guidance put out there.

“It has not been obvious to anybody who should be putting that guidance out.

“I think we’ve all assumed it should be NHS England that does it, just because NHS England is the organisation that has developed them and promoted them and is talking about career progression in physician associate careers.

“So, you know, they should have really been thinking about, well, what happens postgraduate when they’ve qualified? Medics do an awful lot of postgraduate training, but there’s just nothing set up for PAs.”

The RCGP recommends that all PAs wishing to work in general practice undergo a one-year programme to transition them into the workplace, also known as a preceptorship.

In terms of supervision, the college suggests PAs always work under the supervision of a named doctor, who will oversee their work in practices.

This responsibility may be delegated to another named clinician on occasion, although the RCGP stresses that “it must always be clear to all concerned who the GP with delegated responsibility is”.

All named supervisors must have training in education and supervision prior to taking on the role, according to the guidelines, with training covering the PA role as well as their knowledge and skills.

There should also be a supervisor to oversee the educational and professional development of PAs during the preceptorship period.

Asked if, with the right guidance, PAs could be beneficial to lighten GPs’ workload, Prof Hawthorne told PA: “Well, that was our original position. At the moment, our council doesn’t feel that’s the case.

“Who knows whether, as time goes by, we’ll change it back again. But for the time being, I think it’s better to stick with the reality of where we are now.

“There are just too many PAs that we feel are not being supervised and are seeing undifferentiated cases of people who may have nothing much wrong with them, but who may have something significantly wrong with them, and the PA is not experienced enough and is not trained, really, to be able to identify who’s got something seriously wrong and who hasn’t.”

It comes as the doctors’ union, the British Medical Association (BMA), said it was financially supporting a legal challenge by Anaesthetists United calling for more clarity about the use of medical associates.

The legal challenge has been supported by the parents of Ms Chesterton.

An NHS spokesperson said: “The NHS has always been clear about the role medical associates play in supporting clinical teams to provide high-quality care for patients – they are not replacements for doctors, but support teams with specific tasks they are trained to do, under supervision.

“We know that the confidence of the public and the medical community is absolutely essential as we develop an NHS workforce that is fit for the future, which is why the NHS has issued updated guidance on the appropriate deployment of these roles, and we will continue to work together with government and medical and patient groups to provide clarity on these roles for patients and the public, ahead of the GMC regulation coming into effect at the end of the year.”