‘First of its kind’ guidance sees BMA set out PA ‘scope of practice’

Physician associates should never see ‘undifferentiated’ patients in a GP setting, the BMA has declared in new ‘first of its kind’ guidance.

Today, the union has published a national scope of practice laying out how physician associates (PAs) and anaesthesia associates (AA) should work safely in GP practices and secondary care. 

According to the BMA, the guidance is different from what it describes as the current ‘piecemeal or fragmented approach’ whereby individual organisations set their own guidelines for how PAs should be supervised.

In general practice, the guidance said a GP ‘should first triage’ all patients and ‘decide which ones a PA can see’, suggesting annual health checks as an appropriate contact. 

The union is also clear that PAs ‘must not make independent management decisions for patients’ and must be clear in all their communications that ‘they are not doctors’. 

This new scope of practice, which the BMA believes is the first time ‘such clear recommendations’ have been made nationally, was developed by drawing on doctors’ experiences. 

The union said that due to the expansion in the number of PAs over the last four years, the experience of doctors ‘has become more negative and patient safety concerns have dramatically increased’.

PAs have been around since 2003, however the role has expanded over recent years, and last year NHS England committed to increasing PA training places to over 1,500 by 2031, bringing the workforce to 10,000 by 2036.

As of June last year, there were 1,707 full-time equivalent PAs working in GP practices and PCNs. 

For those PAs, the BMA has emphasised the importance of supervision by a GP. 

The guidance said: ‘After appropriate triage, PAs may see selected patients, such as for annual health checks. 

‘If the patient requires any changes to management, the patient must be reviewed by a GP in person, unless this change is part of a pre-existing written management plan authorised by the patient’s GP. 

‘All changes to management suggested by a PA must be reviewed appropriately and approved by the patient’s GP in advance of changes being made.’

BMA council chair Professor Phil Banfield said the need for safe working guidance such as this is ‘paramount’ and that it has been ‘written by doctors, for doctors’ with a view to improving patient safety. 

‘With the Government’s clear intent to expand the numbers of MAPs in the medical workforce, but without the clarity on the scope of their skills and responsibilities, it is even more important that patients must know who is treating them and the skills and abilities that clinician has,’ he said. 

Professor Banfield also said the union knows that PAs and AAs are working in roles that ‘increasingly cross the line’ into situations which require the expertise of a doctor. 

The guidance will help the NHS to ‘effectively employ’ PAs to ‘assist medical teams’, which was their ‘original purpose’.

He added: ‘By setting out clear parameters for the distinction between doctors and MAPs, ensuring proper in-person supervision by qualified doctors, and ending the creeping substitution of PAs for doctors on rotas, this safe scope guide sets out a clear explanation of how medical associate professionals (MAPs) can be employed to maintain the provision of high-quality patient care in the NHS.’

The physician associate role has been the subject of much controversy over the last year, particularly following the death of Emily Chesterton, who was seen by a PA at her GP practice and who had not been aware that her appointments were not with a doctor.

Legislation bringing the PA role under GMC regulation has recently passed through Parliament, and will come into force at the end of this year, despite attempts to kill it. 

Both the Doctors’ Association UK (DAUK) and the BMA have raised serious concerns about the plans.

Last year, the doctors’ union called for an immediate pause on all recruitment of physician associates across general practice, and a survey found that almost 90% of doctors think PAs pose a patient safety risk. 

​And last week, the House of Lords heard that GPs and other doctors have reported 70 instances of avoidable patient harm and near misses ‘caused by PAs’.