How PAs can be a successful part of an MDT

Pulse’s review into the role of the physician associate has highlighted issues around GP recruitment and clinical risk. Now, to provide the other side of the story, Stephen Nash, Chief Executive of UMAPs, gives his opinion on what are the positives of having PAs in a multi-disciplinary team. For the full investigation, see our dedicated home page

It has been glaringly obvious for some time that one narrative regarding physician associates (PAs), and medical associate professions (MAPs) has been allowed in the public space. Through organised campaigns, MAPs have retreated from social media under threats of doxxing, harassment and abuse from anonymous accounts and have been denied a voice. In 2023, UMAPs formed and has been a rallying point for friendly doctors and MAPs to safely discuss the role, and collaborate on making it safe for both employers and professionals. 

When Pulse asked whether we would like to write an article on the truth about MAPs to run alongside its PA investigation, we felt it was time to provide readers with a factual overview of the situation and the benefits of MAPs in general practice. 

PAs have been employed in the UK since 2003 with the formal recognition of the role’s professional body, the UK Association of PAs (UKAPA), in 2005. UKAPA produced standards for training, curriculum, national examination, and regulation. The PA Managed Voluntary Register (MVR) also formed pending regulation. UKAPA became the Faculty of PAs (FPA) within the Royal College of Physicians (RCP) in 2015. GMC regulatory process commenced in 2019, passing through Parliament and the House of Lords in January 2024. The title PA is also protected in law through the process of regulation.  

PA core training ensures that GP partners are being delivered high quality generalist medical professionals. To ensure that, with the growth of PA training, there continues to be strict quality assurance (as with all clinical trainees), in 2022 the PA Schools Council (PASC) published interim guidance. The GMC has already commenced a review of all higher education institutions training PAs.  

You may ask why it is important to give a brief history of PAs. It is because we are not ‘new’ – despite the disinformation campaign being deployed against us from once-advocates of the role. The health secretary in 2014 saw PAs as one of the professions best placed to help support the workforce. This was highlighted in 2016’s General Practice Forward View, and in HEE’s Evidence Brief – PAs. PAs have worked within multidisciplinary teams (MDTs) for 20 years to treat patients. 

Contrary to publicised information, there is a scope of practice: the Core Curriculum Framework (CCF) of which all PAs must prove knowledge through rigorous assessment before being able to work. This scope document is a clear framework for PAs working in whichever area of medicine they are employed. Naturally, the local ‘scope of practice’ differs by the need within the department. This is evident, and employers are directly responsible for ensuring the additional training of their employees is appropriate. It is also the responsibility of the employer to ensure that there is adequate provision of trainers and supervision of trainees no matter the role or requirement. 

PAs have always required a level of supervision by a consultant or GP. This has not changed since their introduction and is evidenced in all PA documentation. It is also very clear that for all trainees, the level of supervision is based on their competence and ability at each stage of their training, and supervision requirements are adapted accordingly.

This applies to all areas of practice including general practice. For multiple members of the MDT, the provision of appropriate supervision is an absolute requirement. In addition, continuing professional development is a professional expectation for members of the clinical and non-clinical teams as general practice and medicine changes and advances. 

The FPA produced a supervision document in 2019 to help guide employers – specifically supervising GPs – in expectations around supervision. More recently, an NHSE open letter gives further advice about appropriate employment and supervision of PAs. Similar documents are available for all members of the MDT through their professional bodies, many of whom require a level of supervision throughout their careers. Since 2019/2020, the PCN DES has outlined the role of the PAs in general practice and has continued to do so up to and including the PCN DES which now lists 18 other ARRS-funded members of the MDT. PAs, like many other members of the team, are also employed directly by practices. The professional requirements and clinical governance around appropriate support and supervision are the same irrespective of the route of employment. 

The landscape of general practice has changed significantly in response to patient needs and overall funding. Therefore, we see a variety of roles in general practice meeting the changing needs of patients in innovative and impactful ways. Impact studies have shown that the PA role offers a member of staff who has a breadth of generalist knowledge and, with appropriate support and supervision, is a flexible and permanent member of the MDT. Locally, there are many examples evidencing this and excellent workforce leadership; where ‘non-traditional’ roles are employed to meet the needs of their population and work together. The striking difference in these practices or PCNs is that there is a clear strategy to meet patient demand by utilising the skills of all their members of staff.  

We recently worked with an employer who had a fantastic training solution for their PAs. This is a common factor in thriving general practices utilising PAs in their workforce. In their first year the PAs, who are trained to recognise red flags and acutely unwell patients, work in a PCN-led urgent care facility. They work under their clinical supervisor, who has a specific timetable allowing them to see a reduced number of patients, but also be available to provide supervision and education to their PA team, while also having severe or complicated cases referred to them. The PAs coming into the PCN get exposure and insight into primary care that solidifies their training and provides them with a wealth of experience. 

In the second year, the PAs are distributed to practices to solidify their training in the management of chronic disease and primary care specialities. Practices can do this knowing they already have experience in managing the day-to-day presentations they’re likely to see. Their partners also know, from the time they’ve worked with the PCN urgent care facility, when it’s appropriate to get help and refer onwards. 

Helpfully, this type of model can be used as part of the preceptorship model for educating and deploying PAs by NHSE. This enables employers to benefit from NHSE grant money, while training their team of PAs and building their relationship of trust with colleagues. The benefit of this model is that GPs get a dedicated permanent member of the team who can: rapidly extend the availability of trained professionals to patients; gain trust in their colleagues’ abilities; and enhance the availability of clinicians who can help the wider MDT.  

The skillsets of PAs employed in the above examples can be extended from the core scope to meet the needs of the practice. PAs can either undergo additional training such as that through FSRH, or accredited minor surgery or dermatology/dermoscopy providers with appropriate in-house observed practice (as is required by the accrediting body.) Through experience, PAs can also build the ability to review and manage complexities of multiple presentations within their skill set through having worked alongside their supervisor. 

The supervisor relationship must allow for this growth and extension of skills so that the PA can reach their potential to the benefit of the MDT and patients. This relationship is not dissimilar to that required for other members of clinical staff within their first years of general practice, and when advancing their skills and offering additional services. The MDU and NHSE reference this development of appropriate supervision, and determination of this, for each PA, scope is determined by their skills and supervision at a local level; i.e. the responsibility of the employer.  

National provision of training, scope, code of conduct, mechanisms for fitness to practise, and revalidation has all been commenced by the FPA; with most aspects being held under the GMC as regulator from December 2024. PAs who are well supported by their employer and who meet their professional requirements, as set out within the PA code of conduct and MVR, are a versatile member of staff who work alongside GPs and consultants and act as a force multiplier to their doctor colleagues. However, we expect to see more obfuscation and disinformation as the doctor’s trade dispute conflates our role with the failures of its own stakeholders to protect our valued colleagues.

PA EL is part of the Caretaker Council – Primary Care Lead for UMAPs, and PA Stephen Nash is the Chief Executive of UMAPs

EDIT 18/06/24: UMAPs is a not-for-profit organisation limited by guarantee, and PA Nash volunteers there. There is no financial association between LocumPA and PA Nash and/or UMAPs – LocumPA recognises UMAPs as one of the organisations that supports the profession.