The ‘scope of practice’ debate: Who should decide what a physician associate can do?

As it stands, there is no statutory or centrally-backed guidance outlining how physician associates should work in general practice. Given the variety of potentially conflicting views, Eliza Parr explains the current advice and risks for supervising GPs

When physician associates (PAs) officially came under GMC regulation last month, the controversy surrounding their role and deployment showed no signs of stopping. But over recent months, a single issue – which on the surface may seem technical or even dull – has come to the fore. 

The ‘scope of practice’ for a PA (or lack thereof) has been central to disputes between medical organisations, even leading to High Court legal cases. Many doctor leaders argue that PAs cannot work safely in the NHS without a nationally-agreed and enforced scope defining what they can and cannot do. And so far, guidance published by royal colleges is simply advisory, and not centrally-backed. 

This lack of clarity around what PAs can (or should) do safely is not just an academic question for ivory tower officials. On the ground in general practice, it means GP partners may be left utterly confused about how to safely employ and supervise PAs. 

Between various pieces of guidance already published, and the vacuum left by the GMC’s refusal to set scope, where exactly do GPs and PAs stand?

What is a ‘scope of practice’?

The phrase – which means the range of activities a health professional is trained and safe to perform – has now become common parlance when it comes to PAs. But doctors, as fully qualified medical practitioners, are not subject to an equivalent scope. The GMC uses Good medical practice to regulate doctors, which, rather than dictating competencies for specific tasks or procedures, outlines the ‘standards of behaviour’ expected of them.

Since PAs came under GMC regulation in mid-December, they are now also subject to these same standards. But many want to see more specific guidance on what PAs should be allowed to do in clinical practice – for example what procedures they are safe to perform, and what kind of consultations they should undertake. In response, the GMC has argued that many other professional healthcare regulators do not define a post-qualification scope of practice.

Indeed, the Health and Care Professions Council (HCPC), which regulates roles such as paramedics and physiotherapists, takes this approach. It defines scope of practice as ‘the limit’ of a professional’s ‘knowledge, skills and experience’, but states that it does not itself define a registrant’s scope, saying it will develop over time.

Meanwhile, in dentistry, professionals are subject to a scope of practice by the General Dental Council which describes the areas in which they ‘have the knowledge, skill and experience to practise safely’. It sets out procedures and tasks different professionals can undertake if they are ‘trained, competent and indemnified’. 

Perhaps doctors, particularly those who supervise PAs, would want to see a similarly detailed document from the GMC.

What guidance is already out there for PAs working in general practice?

While PAs have worked in the NHS for over twenty years, their increasing numbers and NHS England’s plans for expansion started to raise concern among medical leaders throughout 2023. This also coincided with coverage of tragic deaths involving PAs including that of Emily Chesterton, as well as legislation for GMC regulation making its way through Parliament and finally passing just under a year ago.

As controversy surrounding the role reached a head, the BMA brought out its scope of practice for PAs and anaesthesia associates (AAs) in March 2024. The document was heralded by BMA leaders as ‘first of its kind’ guidance, intended to replace the previous ‘piecemeal’ approach whereby individual employers set their own guidelines for how PAs should be deployed. 

The headline advice for GP partners was that PAs should never see ‘undifferentiated’ patients in general practice, meaning GPs should triage all patients first and decide which ones a PA can see. 

Months later, after debates and votes at its council, the RCGP made its own bid to limit PA activity in GP surgeries. Similar to the BMA guidance, it set a very strict ceiling on their practice – which made sense after its leaders had recently voted to completely oppose the role of PAs in GP settings.

Should GP practices follow PA scopes of practice?

Many doctors welcomed the BMA’s scope for its clarity around specific PA tasks. But such guidance from a trade union can only ever be advisory, and GP practices are under no obligation to adopt it. 

In fact, the BMA’s advice to ban PAs seeing undifferentiated patients seemed to directly contradict NHS England mandates. The PCN contract, which dictates how Additional Roles Reimbursement Scheme (ARRS) staff must be used, says that where appropriate GP supervision is in place, PAs must ‘provide first point of contact care for patients with undifferentiated, undiagnosed problems’. 

Meanwhile, the RCGP has been clear that it cannot ‘enforce’ its scope on GP practices, but warned that it ‘may be taken into account’ by NHS Resolution or medical defence organisations in cases of alleged clinical negligence or professional mistakes. 

‘Ultimately, it is the decision of employers whether to follow this guidance, and the employer’s responsibility to ensure the appropriate treatment and handling of existing PA contracts,’ the RCGP told GPs. 

The GMC has also indicated that guidance from other bodies may be considered as part of fitness-to-practise proceedings. While the regulator will not itself set any scope, it will ‘have reference’ to documents produced by ‘royal colleges and other expert bodies’. 

GP partners are under no obligation to implement any of this published guidance for PAs currently working in their practice. But any hint that there could be medico-legal repercussions for not doing so will certainly give employers and supervisors pause for thought. 

Indeed, LMCs have been fielding queries from worried GPs on this issue. In November Humberside LMCs asked the BMA for legal advice on ‘where GP partners will stand if they continue to employ PAs working outside’ the current guidance from the union and the RCGP. Chief executive Dr Zoe Norris told Pulse there were concerns GPs who already employ PAs working beyond the scope may be pulled up by tribunals or adjudicators who say ‘you’ve chosen to ignore advice from your own union and royal college’.

Humberside LMCs said ‘informal feedback’ suggested that partners ‘would need to have clear reasons for not following’ current scopes. The BMA has since outlined its position to Pulse, emphasising that its guidance on PA scope, supervision and delegation aims to protect patients (see box).

Meanwhile, Medical Defence Union deputy head of advisory services Dr Catherine Willis told Pulse that it expects ’employers and PAs will work together to determine an appropriate scope of practice and safe level of supervision’, noting that it is not an MDO’s role to comment on how PAs are deployed.

On the flipside to medico-legal risk, there is another emerging legal quandary for GP practices surrounding scope. Those who do choose to follow BMA or RCGP guidance, may find themselves facing legal action from PA staff who claim they have been made redundant as a result. This action is being led by United Medical Associate Professionals (UMAPs), which became an official trade union for the PA profession before Christmas. They recently revealed plans to take forward 184 individual employment claims, all against GP practices who they say have implemented ‘discriminatory’ scope guidance produced by either the BMA or the RCGP. 

In a recent BMA bulletin, likely in response to these threats from UMAPs, the GP Committee emphasised that ‘it is for individual practices to decide’, but recognised that any ‘restructure’ could ‘result in a redundancy situation arising’. The union advised practices considering such redundancy to contact its employer advisory service.

Whether any of the cases led by UMAPs have a chance of success is uncertain. But defending an employment claim drains time and money, and the prospect of this may be deterrent enough for practices deciding whether to align their PA’s practice with current guidance. 

GP practices and PCNs employing those 2,000 PAs could therefore face legal issues on both sides – with potential consequences if they choose to implement the BMA/RCGP scope, and so too if they choose to ignore it. 

Will there be a nationally-agreed, mandatory scope of practice for PAs? 

When health secretary Wes Streeting launched the independent review of physician associates in November, the BMA said it must lead to a nationally-agreed scope of practice. Indeed, the review’s chair Professor Gillian Leng made clear that she will cover scope. 

Ahead of its publication, expected in the spring, the doctor’s union called for interim safety measures, arguing that ‘you do not fly a plane under safety review, you ground it’. Weeks later, a health minister confirmed in Parliament that the Government will not commit to any interim measures, highlighting that ‘NHS guidance remains in place’ in the meantime. 

But this guidance is scant. A document by NHS England published in March last year emphasised that all GP practices employing PAs must have a policy to restrict access to prescribing – an already well-known limit on their practice, since their prescribing is currently illegal. Beyond this, there is little on what tasks PAs can safely do and how they should be supervised. NHS England instead pointed to the Royal College of Physicians’ plans to generate additional guidance around scope, seemingly shrugging responsibility. 

Since then, central NHS bodies have recognised the lack of clear guidelines for both PAs and doctors. In October, NHS Employers acknowledged that there is currently ‘no single widely agreed’ scope of practice for PAs, despite several organisations declaring their own position. 

The Leng review may indeed remedy this. Given her promise to listen carefully to concerns, Professor Leng will surely be fielding a number of calls – perhaps from both sides of the debate – for a clear, national scope of practice. 

What has the GMC said about PA scopes?

Many doctors leaders believe this scope should come from the GMC, as the regulator of both PAs and AAs. While the GMC has so far been clear that it will not set a scope for PAs, it has dropped hints as to its views on the issue.

A coroner’s report in July, which concerned a death linked to actions by a PA, raised concerns about the lack of a ‘national framework’ for how the role should be trained, supervised and deemed competent. In response, the GMC said it had been ‘supporting the work’ of individual royal colleges, citing the RCGP’s scope. But it also encouraged those colleges, along with NHS employers, to ‘ensure that all guidance being produced is aligned and consistent’ so as not to ‘cause confusion’. (Some may argue that a solution to this potential confusion is perhaps for the GMC to produce its own ‘consistent’ scope.) 

And a GMC letter to the RCGP – sent in August but only published just before Christmas – revealed its views on the college’s own scope. The regulator worried that the ‘restrictive’ guidance ‘could have the effect of dissuading GP practices from employing PAs’. This sparked immediate criticism from the BMA, who accused the GMC of prioritising PA employability above patient safety. 

The GMC has shown no signs of producing a national scope of practice. But an ongoing legal case may end up forcing its hand. Last year, Anaesthetists United (AU) began legal proceedings against the regulator with aims to achieve ‘clear and enforceable guidance’ defining what PAs and AAs ‘can and cannot do’. The group – supported by the parents of Ms Chesterton – argues that the GMC has a statutory duty to set scope, and its refusal to do so is unlawful.

The case gathered publicity and substantial financial support last year, but this month it passed its first significant legal hurdle. A High Court judge granted the AU ‘permission’ to proceed to a judicial review, and also ‘expedited’ the claim since it ‘raises serious issues of importance’ to healthcare professionals and patients. This initial ruling by no means guarantees success at the full hearing – which is due to take place before the end of May – but it certainly indicates that the group of doctors have an arguable case. 

Between this legal case and the Leng review, spring 2025 will hopefully bring clearer directions from central bodies on how PAs should be deployed. For supervising GPs, and indeed the PAs themselves who face an uncertain future, this is sorely needed.