New guidance on use of physician associates

A leading medical royal college says physician associates (PAs) should only be supervised by senior doctors, and not doctors in training, in guidance issued to members.

The Royal College of Physicians’ (RCP) announcement follows an acrimonious debate in the medical profession over the use of PAs, who are intended to assist doctors and can perform some health examinations.

There have been claims that the scope of the role is not clear, that patients are not always aware of the status of PAs, and that their differentiation with doctors is becoming blurred.

An independent review of the role, announced by Health Secretary Wes Streeting, will report in the spring.

PAs and AAs (anaesthesia associates) are seen as a crucial component of staffing in the health service, according to the current NHS workforce plan for England.

PAs can work in GP surgeries and hospitals. They are not authorised to prescribe medication, but they can order certain scans, take medical histories and conduct physical examinations.

Anaesthesia associates (AAs) support surgery teams and are a much smaller cohort.

Both PAs and AAs have to complete a two-year master’s degree. Typically they will have undertaken a previous bioscience-related degree, but that is not a prerequisite.

Numbers have been gradually increasing, but a recent plan called for a rapid expansion in the number of PAs and AAs – from just over 3,000 to 12,000 by 2036.

The Royal College of Physicians, which has members across the UK, says the interim guidance announced on Tuesday should take effect at once – ahead of the health secretary’s official review.

It states that a supervising clinician should be “immediately available in the same clinical environment to provide advice to the PA and, if required, an immediate in-person review of a patient”.

This goes further than more general guidelines from NHS England, which require PAs only to be directed and overseen by a senior doctor.

The Royal College guidance is advisory, and designed to give members clarity over what is appropriate for their role and what employers can reasonably ask them.

Some resident doctors (formerly known as junior doctors) have complained that they are expected to monitor the work of PAs, and that these clinicians have taken on tasks traditionally done by doctors.

Dr Ben Chadwick, chair of the group writing the guidance, said he hoped the new interim guidance “offers clarity in how PAs can best be supervised and supported”.

The document covers hospital doctors who are members of the RCP – but not those who work in radiology, emergency medicine, general practice and other specialist areas with their own Royal Colleges.

The guidance also sets out current policy which states:

• PAs must support – not replace – doctors, and have a clearly defined role in the multidisciplinary team.
• PAs must never function as senior decision-makers, nor should they decide whether a patient is admitted or discharged from hospital.
• Resident doctors (junior doctors) are not, and must not be expected or asked to be, responsible for the clinical supervision of PAs. PAs should only be supervised by consultants, specialist or associate specialist doctors.
• PAs cannot prescribe medications regardless of any prior healthcare background while working as a PA.
• PAs must clearly explain their role to patients, their families and carers, as well as colleagues and supervisors.

In November, the Health and Social Care Secretary Wes Streeting announced an independent review to report in the spring of 2025.

He said at the time that many PAs “are providing great care and freeing up doctors to do the things only doctors can do”.

But he said there were “legitimate concerns over transparency for patients, scope of practice, and the substituting of doctors”.

Streeting said he hoped the review would “take the heat out of the issue”.