The RCGP has set out a clear scope for physician associates (PAs) which severely limits their current practice.
In new guidance published today, the college has stipulated that PAs must not see patients who have not been triaged by a GP; nor patients who present for a second time with an unresolved issue.
On clinical scope, the guidance suggests PA’s qualifications would be suitable for seeing the same seven minor illnesses captured by Pharmacy First, noting that this is a ‘good place to start’.
Across three new documents, the RCGP set out guidance on preceptorship and induction of PAs, supervision arrangements for GPs, and detailed descriptions of what a PA can and cannot do in clinical practice.
While the RCGP cannot ‘enforce’ this guidance – as this is the ‘decision’ of employing GPs – it ‘may be taken into account’ by NHS Resolution and medical defence organisations in clinical negligence cases, the college said.
On supervision, the guidance urged GPs to make time each day to ‘hot review’ all the cases a PA has seen that day.
‘The notes made at every PA/patient encounter must be signed off by the GP [clinical supervisor] at the end of the surgery day,’ it added.
This scope of practice, which RCGP council members voted on last month, was promised after a consultation found that over 80% of GPs believe PAs are having a negative impact on patient safety.
Despite a recent vote to completely oppose the role of PAs in GP practices, the college recognised that there are already around 2,000 existing PAs who require clear guidance.
It sets out a number of principles for how PAs should work in general practice, including:
- PAs must always undertake a Preceptorship Programme on entering general practice;
- PAs must always have a period of induction at the start of their employment with a GP practice, even if moving from one practice to another;
- PAs must always have a GP Clinical Supervisor (CS), who is responsible for determining the PA’s scope of practice at the start of their employment;
- A PA must not undertake activities outside the scope of practice described in this guidance, even if they have previously undertaken those activities in a non-PA role;
- PAs must not see patients who have not been triaged by a GP and only undertake work delegated to them by, and agreed with, their GP CS;
- The practice must have a protocol when booking appointments explaining to patients who they are going to see and giving them the option to discuss who they would like to see;
- PAs must introduce themselves fully to the patient, ensuring the patient understands who they are and that they are not a doctor;
- PAs must not be the sole healthcare practitioner on call, or the duty clinician, in the GP practice. They must not see ‘walk-ins’ that have not been triaged by a qualified GP;
- PAs must always document the care and advice they give, including any information shared, on behalf of the patient’s GP, with other members of the primary healthcare team and colleagues in other healthcare environments;
- In light of the arrangements for supervision, triage and scope of practice described in the RCGP’s guidance, we do not consider it currently viable for PAs to be employed in Out of Hours settings, or as locum PAs.
According to the RCGP, a PA can ‘take a history, complete a physical examination, and construct an appropriate diagnostic and management plan’ for patients.
However, the guidance added: ‘If a patient contacts the practice a second time with the same unresolved issue, they must be triaged to a GP.’
It set out detailed examples of patient presentations which are inappropriate for PAs, such as suspected mental illness, paediatric patients, or routine home and care home visits (see box).
On whether GP practices must follow this guidance, the RCGP said: ‘While it is not within the RCGP’s remit to enforce this guidance, it may be taken into account by NHS Resolution and the Medical Defence Organisations in a case of alleged negligence or clinical 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.’
In March this year, the BMA set out a similar scope of practice for PAs working in both primary and secondary care, which also stipulated that PAs must never see ‘undifferentiated’ patients in a GP setting.
The doctors’ union has also told GP supervisors that supervision of PAs must take place immediately after each patient and before they leave the surgery.
PAs will come under GMC regulation at the end of this year, however the regulator has been clear that it will set standards for PAs rather than a scope of practice for what they can and cannot do when working clinically.
The BMA has this morning announced financial support for a group of doctors who are legally challenging the GMC on this, arguing that ‘clear and enforceable guidance’ for PAs is needed.
In full: The RCGP’s scope of practice for PAs
| In scope | Can do with extra training | Out of scope |
|---|---|---|
| First contact presentations | ||
| First point of contact presentations of adults (>16) for suspected minor or common conditions (e.g. otitis media, UTI, sore throat etc ) with clear clinical pathways and escalation processes. The seven common minor illnesses used in the Pharmacy First programme in England are a good starting point. The list of minor conditions a PA can see must be agreed and documented, with clinical protocols for diagnosis and management. | PAs must not be triaged presentations for potentially serious conditions (e.g. abdominal pain, headache). | |
| Mental health | ||
| PAs must not be triaged patients with suspected mental illness. Subject to the boundaries of this guidance, PAs can see patients with a diagnosed mental health condition who are presenting about something else. If, during a consultation, the PA thinks the patient may have a new mental health problem, the case must be presented immediately to a GP CS for confirmation of diagnosis and management. | ||
| Paediatrics | ||
| PAs must not see any paediatric (<16 yrs) patients PAs must not do 6-8 week baby checks. | ||
| Obstetrics and gynaecology | ||
| PAs must not be triaged women who are pregnant, post-natal, and/or who have a suspected gynaecological problem. | ||
| Complexity/multi-morbidity | ||
| PAs must not be delegated the management of patients with complex multi-morbidities, complex or rare illnesses, or severe frailty. PAs must not be given urgent or routine home and care home visits to do. PAs must not initiate or complete end-of-life discussions with patients. PAs must not prepare end-of-life documents: DNACPR or RESPECT forms. | ||
| Sexual health | ||
| PAs can give advice on contraception and sexual health if trained and accredited to do so. | ||
| Patients with Learning Difficulties | ||
| PAs must not see patients with learning difficulties. | ||
| Travel health | ||
| PAs can give advice on travel vaccinations and general travel health if trained to do so. | ||
| Follow-ups and health checks | ||
| PAs may review and suggest changes to a patient’s pre-existing management plan. Any suggested changes to a patient’s management plan must be reviewed and approved by the patient’s GP. | PAs can support the management of a patient’s single, long-term condition by offering specialised clinics, according to practice protocols, NICE guidelines and algorithms, as used by the practice, and only if trained to do so. | |
| PAs can perform HRT reviews if trained to do so, and as long as the patient has not experienced side effects or new contraindications and there is a management plan in place. | ||
| PAs can undertake annual NHS health checks and provide lifestyle support, according to protocolised pathways. | PAs must not undertake annual NHS health checks for patients with learning difficulties, severe mental health issues or other complications. | |
| Clinical procedures and tests | ||
| PAs can undertake immunisations if trained to do so. | PAs must not administer steroid injections or any intra-articular injections | |
| PAs must not undertake minor surgery. PAs must not do IUS/ IUD/ Nexplanon insertions as they cannot prescribe and will not be able to manage a patient who collapses during the procedure. | ||
| PAs can do smear tests if trained to do so and with current registration on the relevant national sample taker register. | ||
| PAs must not request ionising radiation imaging or discuss imaging requests with radiologists. | ||
| PAs can do spirometry tests if trained to do so and interpret them with the agreement of their GP supervisor. | ||
| PAs can do point of care tests if trained to do so. | ||
| PAs can perform ECGs if trained to do so. | ||
| Interpreting tests | ||
| PAs can review test results as part of the NHS Health Check, discuss the results with patients and offer advice on ways to make lifestyle improvements where practice protocols exist. | PAs must not analyse and action diagnostic test results in areas not covered by the NHS health checks and where practice protocols do not exist. | |
| PAs in general practice must not interpret ECGs unless also checked by their GP supervisor. | ||
| Referrals | ||
| PAs can make referrals to community and social services in line with a discussion with the supervising GP and their agreement that the referral is needed. | ||
| PAs can administer secondary care referrals on behalf of a GP, but it must be clear to the referring speciality that the referral has been made by a PA on behalf of a GP, and under the supervision of that GP.PAs can give information to secondary care providers/clinicians on behalf of a GP and in line with the information provided by the GP. It must be clear to the referring speciality that the information is provided by the PA on behalf of a GP. | ||
| Where a GP in the practice has confirmed an adult safeguarding concern, the PA can administer the referral with the agreement of the GP CS, or GP with delegated responsibility for supervision, but it must be made clear to the service that the referral has been made by a PA on behalf of a GP, and the GP must supervise the process. | ||
| Prescribing | ||
| PAs cannot prescribe – either writing or signing prescriptions. While some PAs may have gained prescribing rights in a previous role, roles need to be clearly differentiated and PAs must not prescribe in their PA role. PAs must not cancel an existing prescription or undertake a medicines review without discussing with their GP supervisor. | ||
| Completion of forms/reports | ||
| PAs can undertake the following activities in line with practice protocols if indemnified to do so, and if their CS has ensured they have the competence to do so. All forms should be checked by the GP CS. The practice will need to check indemnity arrangements with their Medical Defence Organisation.-Completion of insurance reports, audits, returns to the PCN /Cluster / Trust / ICB / Health Board, benefit reports -Reviewing discharge summaries from OOH, if trained to do so thoroughly (which covers identifying actions and ensuring actions are completed). | PAs must not complete cremation forms (while these are still being used) PAs are not included in the appropriate legislation to sign ‘fit notes’ or declare someone fit to return to work, nor are they included in the legislation to declare that someone has a terminal illness for the purposes of claiming benefits.PAs must not complete Child Protection forms. | |
| Learning and teaching activities | ||
| PAs can be involved in and, with the agreement of the practice partners, lead on practice clinical audits, Learning Events, research and service development. | Experienced PAs can do some teaching of the student PA with the agreement of the GP CS. | PAs must not supervise, manage, or be responsible for de-briefing after a patient contact, members of the practice’s multidisciplinary team. |
| PAs can be involved in wider practice initiatives e.g. green, community engagement/ outreach. | PAs must not teach, supervise or undertake debriefs for GP Registrars / foundation doctors / medical students. |
In other words these are now unemployable and certainly not employable at the extortionate rate which they were previously paid
Why employ them in the first place. Anyone who has been in General practice for a short period of times know how risky it is trained doctors, forget untrained noctors! It may be easier to make them redundant as I don’t think any practice is now even going to consider hiring any more PAs?
A dead role just needing time to be fully buried.
some unethical partners would always find a way around until they get shafted by some complaint
Recent GMC case, GP got done for not re-examining the PA’s VE.
If these are their limitation what’s the point of employing them? End of PA role in primary care.
@Some Bloke, you recently wrote
“my PA is far better than any trainee or any newly qualified and most locums. Based on observation over past five years.”
Given your strong defence, will you still be using your PA (who is better than GPs according to you) or will they be of no use to you now and hence you’ll be making them redundant? I’m interested in what you decide…
Next in line ANPs please, as evidenced by ANP missing burst Appendix in Bridlington, all over news
Wandering how many commentators here hold RCGP registration? And are members of BMA?
And if not,- why not?
All very good, but the opportunity to extend this review to ANPs and Paramedics working in GP was missed. As a partner it feels like flying very close to the flame nowadays. What exactly is the point of allied health professionals if they need overseeing to the point of managing the patient yourself?
No answers to my question.
Shows how much confidence that our profession has in this guidance.
I will continue to employ my PA, if she was given an opportunity to sit RCGP exams, she would pass them much better than any trainee GP I ever had, so far at least.
Can pay for a degree, but can’t buy ability to think
Since when did anyone care what the RCGP thinks?
Another example of the profession being taken over by a vocal and militant minority