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’.

Dr Eggitt adds: ‘We say “undifferentiated”, but to a certain extent they are slightly differentiated, because they’ve been reviewed by care navigators, the new word for what would have otherwise been receptionists. So the receptionist has decided that this patient is suitable to be seen by a physician associate.’

But this triage model is based on Dr Eggitt’s confidence in his current PA – ‘if a new PA came in next week, I wouldn’t expect them to work in the same way’.

In Hull, physician associates at the Haxby Group surgeries see ‘acute illness’ as their ‘main body of work’, according to GP partner and director of workforce Dr Kevin Anderson. ‘The GP would always have looked at the case and thought that’s appropriate for a PA to see, so they’re never undifferentiated’.

Another GP partner in the North West says his PA tends to see ‘all the very simple stuff, like coughs and colds’. The partner adds: ‘If you’re unsure what the diagnosis is, from the initial triage, then you wouldn’t assign it to the PA.’

But some practices have decided against employing PAs because of fears around clinical risks. Nottingham GP partner Dr Irfan Malik says seeing undiagnosed patients, who may present with subtle symptoms, is what makes general practice a ‘very risky’ area. ‘Even with years and decades of training, in general practice it’s still very difficult to diagnose some conditions, especially rare conditions, or for example, meningitis in a child. Illnesses can present very early on, and even in experienced hands general practice is difficult and risky. But when you’ve got a PA, maybe they don’t understand the full risks that they’re being put into.’

Another GP in London, who preferred to remain anonymous, points out that other health professionals who may have far more experience would not see undifferentiated presentations.

‘With my pharmacist, who is very highly qualified and experienced, she will not see a patient until the patient’s had a medical assessment and a diagnosis on a treatment plan. She will never see a patient to make a diagnosis. She’s an expert in my opinion, but she absolutely refuses because she knows all the risks.’

Impact on patients

While doctors across all specialties have expressed serious concerns about the safety of PAs, there is little empirical evidence to show the real clinical impact. Since the profession is not yet regulated, there is no data on the number of fitness-to-practise investigations. And under the Freedom of Information Act, NHS Resolution was not able to share data on the number of claims made involving physician associates in general practice.

In primary care, complaints are often dealt with at practice level, and may not be recorded routinely by commissioners. So evidence of clinical negligence or risk may be limited to anecdote. In March, the House of Lords heard survey data from DAUK which suggested that doctors across acute trusts and GP practices have reported 70 instances of avoidable patient harm and near misses caused by PAs. This included fatalities, missed diagnoses, sepsis, and heart attacks.

While these reported incidents represent the sharp end of risk surrounding PAs, there are perhaps more subtle impacts of their rapid expansion. When practising a more ‘defensive’ style of medicine, physician associates may err on the side of caution and recommend more treatment than necessary, or inappropriate tests. One GP partner in the North West says there are concerns about PAs practising defensively and ‘what might happen to antibiotic stewardship’.

‘I think defensive medicine is an issue, and perhaps people need to look at their antibiotic prescribing, for instance – certainly, that’s something we’ve seen anecdotally, when we’ve been supervising other PAs […] Prescriptions still have to get signed off by the GP, but if PAs are recommending it more often than not, rather than standing their ground, it’s still going to put pressure on the GP to issue.’

And beyond clinical risk, there’s the issue of trust between patients and GP practices. The BMA and vocal critics have frequently raised the issue of PAs misrepresenting themselves as doctors – and, to be fair, GP practices themselves being ambiguous about it. The FPA has addressed this concern, putting out guidance in October which emphasised the importance of PAs introducing themselves clearly to patients, avoiding any titles which could be confused with a doctor.

But for those outside the healthcare bubble, how understandable is the term ‘physician associate’?

Healthwatch England is looking into the issue on a national level, and collected evidence to submit to the GMC’s recent consultation on PA regulation. Locally, Healthwatch Haringey has been actively raising questions about the role of PAs ever since the death of Ms Chesterton, whose practice was in this area of London. At a patient participation group (PPG) meeting in February, the Healthwatch team said they believe there is a ‘knowledge gap’ as ‘most of the public do not know what PAs are and how they differ from doctors’. The organisation would like to see ‘reviews in place’ for these professionals once the GMC regulation begins. Attendees at the meeting also said the national Healthwatch team is seeking information about whether receptionists at triage explicitly tell patients they will see a PA.

Despite concerns from both patients and doctors, the Government does not look set to halt the expansion of this role anytime soon. And whether doctors like it or not, GMC regulation of PAs in the coming months is all but certain.

But to expand the role safely – while ensuring buy-in from the medical profession – GPs sorely need more concrete guidance on what PAs can and cannot do, and how they should be supervised. Individual PAs are not inherently dangerous, and spotlighting those few high-profile mistakes risks ignoring the fact that doctors too make errors. However, it should be possible for the Government to address valid concerns from doctors while condemning any personal attacks on PAs.

In fact, the Government has previously warned about potential safety issues. When assessing the safety of associate roles in 2017, Health Education England concluded that patients are at ‘high risk’ of harm from PAs. The report highlighted that they are ‘often alone with vulnerable patients’ while making ‘autonomous diagnostic and treatment decisions’. This is what cemented the Government’s decision to regulate the profession. But it’s taken seven years to finalise those plans, and during that time PAs have been working in general practice and hospitals unregulated, while growing in number.

One GP partner in the North West says the various, and sometimes conflicting, guidance on PAs has ‘muddied the waters’. More clarity, it seems, is key to giving GPs confidence when employing and supervising the role. But where that clarity will come from – NHS England, the GMC, the BMA, or the RCGP – remains to be seen.

Coming up in the series

We have published our feature on how physician associates have affected GP recruitment, in part contributing to fewer salaried and locum work.

Tomorrow, Tuesday 11 June, we will be looking into the effective of PAs – do they save money, are they reducing GP workload, and what is their impact on GP training?

On Wednesday 12 June, we will have a data analysis, looking at the characteristics of practices and PCNs that are more likely to recruit PAs – in terms of practice funding, deprivation levels, geography.

Over the next week, we will also be featuring first person pieces from PA representatives plus a Pulse editorial. Make sure you check our dedicated homepage throughout.

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