Supporting physician associates in clinical practice

MDDUS advisers have been responding to an increasing number of requests for advice from members about physician associates (PAs).

Common questions include:

• “Can our PA undertake house visits?”
• “Is it okay for me to sign a patient prescription prepared by a PA following their consultation with a patient?”

We are also receiving calls for advice from PAs themselves who are concerned about the expectations placed on them by colleagues, how their roles are evolving, and the ways in which they are supported and supervised.

And whilst these queries are mainly about PAs, the challenges apply in a range of ways for all members in medical and dental practice whose role interfaces with other professions.

What is a physician associate?

According to the Faculty of Physician Associates (FPA): “Physician associates are healthcare professionals with a generalist medical education, who work alongside doctors, physicians, GPs and surgeons providing medical care as an integral part of the multidisciplinary team.” The FPA oversees and administers the running of the Physician Associate Managed Voluntary Register (PAMVR).

PAs are not currently subject to statutory professional regulation, but this is set to change. Plans are underway to legislate for PAs (and anaesthesia associates) to be regulated by the General Medical Council. A consultation on draft legislation closed in May 2023 and it is expected that the formal legislative process will begin later in 2023, with GMC regulation commencing within 12 months of the legislation being passed.

Supervision essential

PAs are responsible for their own actions and decisions and have a professional obligation to ensure that they recognise and work within the limitations of their competence in any clinical duties that they undertake.

But the faculty is clear that PAs are “dependent practitioners” who work with “a dedicated supervisor”, who should be a fully qualified and experienced doctor. It states that they are able to work autonomously, but they must have “appropriate support".

Access to supervision and support can be difficult to manage in busy workplaces, however time must be built into systems to support this need. PAs must be able to seek advice from a supervising clinician or colleague, or request a patient is reviewed, when needed.

The GMC's ethical hub has more specific advice in Advice for PAs, AAs and doctors who supervise them.

Managing specific risks

PAs and house visits

When considering the above question about PAs carrying out house visits, the GMC advice document states: “When delegating tasks, you should be sure that the person you are delegating to has the necessary knowledge, skills and training to take on the task.”

The document also advises: “Working within your competence means understanding the boundaries of your ability, and knowing when to refer or escalate to a colleague.” Any PA asked to carry out a task or role they feel is beyond their competence has a professional obligation to raise their concern.

The supervising clinician should ensure the PA feels comfortable with any supervision arrangements and has appropriate support to carry out their clinical work safely within the context of a house visit.

As part of any new role, consideration should be given as to how the PA will escalate concerns or seek senior support if required. There should be an agreed process for timely access to a senior clinician and the PA should have the necessary competence and training in case an emergency situation arises in the community, where they will not have the on-site support of practice colleagues.

PAs and prescribing

In relation to the second query above, the guidance Good practice in prescribing and managing medicines and devices applies. In this, the GMC states that “you are responsible for the prescriptions that you sign” and that “you should only prescribe medicines if you have adequate knowledge of the patient’s health and you are satisfied that the medicines serve the patient’s needs".

Before signing off a PA’s prescription, you should take into consideration (amongst other things) “whether you have sufficient information to prescribe safely” including “access to the patient’s medical records”, “an adequate assessment of the patient’s needs” and that consent is obtained (paragraph 20).

The GMC guidance (paragraphs 76-78) specifically addresses circumstances in which a doctor is asked to prescribe at the recommendation of a colleague, stating: “you must be satisfied that the prescription is needed, appropriate for the patient and within the limits of your competence”.

It adds: “If you delegate the assessment of a patient’s suitability for a medicine, you must be satisfied that the person you delegate to has the qualifications, experience, knowledge and skills to make the assessment.”

Where specific advice is provided to the PA in relation to managing the patient or any follow up or safety netting, it is important to document this in the patient notes where possible.

• Recognise that every healthcare professional you interface with will have their own scope of practice and set of experience and competencies. These should determine what and how you delegate responsibilities and tasks. There is no ‘one size fits all’ model.
• Work with colleagues to understand an appropriate supervision model that fits their needs and supports patient safety.
• If you need more specific advice, do not hesitate to contact advice@mddus.com.

Liz Price is head of training at MDDUS