New GMC guidance for doctors supervising physician associates

GP leaders have said that new guidance published by the GMC for doctors supervising physician associates (PAs) fails to account for the ‘very specific risk environment’ in general practice.

The guidance, published last week, brings together ‘key principles’ from the standards document Good Medical Practice and other ‘relevant guidance’ into a single resource, the GMC said.

The advice, developed ‘with input from doctors who supervise PAs’, provides information on working with PAs – around supervision, delegation and accountability – as well as sets out employers’ responsibilities.

While the GMC has said it will not set out a scope for PAs, the document said duties performed by PAs may include:

• taking medical histories from patients
• performing physical examinations
• diagnosing illnesses
• seeing patients with long-term chronic conditions
• performing diagnostic and therapeutic procedures
• analysing test results
• developing management plans
• providing health promotion and disease prevention advice for patients.

It further explained that PAs should work under the overall supervision of a ‘named senior doctor’, as agreed with the employer – usually a GP, consultant or autonomously practising SAS doctor.

Named supervisors should be supported by their practice/ employer and speak with them to establish the scope of their role, the time they have to carry out the supervisory responsibilities, and discuss any extra training needs.

Meanwhile, practices employing PAs should make sure their clinical governance arrangements take account of the fact that they are ‘trained and registered on the basis that they will always work under supervision.’ Then GMC also recommends that organisations identify a senior individual (equivalent to being at board level, for example) to be responsible for PAs.

And the GMC warns that the GP practice ‘directing and controlling a regulated activity’ is responsible for compliance with regulation and legislation, as set out by the CQC. As such, ‘this means that even if a practice is not responsible for someone’s direct employment, it may be responsible for making sure it has oversight of that person’s support, supervision, guidance, advice and information’.

The guidance also seeks to address the issue of accountability for the actions of PAs, stating that doctors are accountable for their own ‘actions, steps, and decisions’ and for the overall management of a patient, where they are the responsible consultant/clinician.

However, ‘PAs and AAs are accountable for the actions, steps and decisions they take to prioritise patient safety’; and that they ‘are under professional obligations to recognise and work within the limits of their competence and to seek help if they are not confident they have the knowledge, skills, or training to carry out a task safely’, even where they had agreed to carry out the task independently.

The guidance goes on to make recommendations for doctors seeking to establish what level of care a PA is capable of providing to patients (see box).

Last year, the RCGP set out a scope for PAs that severely limited their practice, stipulating 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.

Referring to this and other guidance documents, the new GMC guidance said: ‘Some royal colleges and PA and AA professional bodies have published interim guidance on post-qualification scope of practice. Though there is no set consensus, you may find them helpful as a starting point. The Leng Review is also likely to make recommendations in this area later in 2025.’

The independent Leng review into physician associates ordered by the Government is due to report in June. Led by Professor Gillian Leng, the review’s main task is to determine if PAs and AAs ‘are safe and effective as members of a multidisciplinary team, across all tasks, roles and settings’.

Commenting on the new GMC guidance, RCGP told our sister title Pulse it was ‘disappointed’ that it does not account ‘for the very specific risk environment in general practice’. It also said that some of the duties of a PA listed in the guidance had been objected to by the college.

RCGP chair Professor Kamila Hawthorne said: ‘It is the college’s position, following consultation with members and discussion amongst our governing council, that physician associates do not have a role in a general practice setting.

‘However, acknowledging that there are around 2,000 PAs already working in general practice, we have produced guidance for practices on induction, supervision and scope of practice for practices that do employ PAs. 

‘It is also our position that whilst regulation of PAs is vital, the GMC is not the most appropriate regulator. However, as their regulation of PAs has already begun, we have always said we would work with them in order for regulation to be as safe and appropriate as possible.

‘While we are pleased that the GMC has referenced our supervision guidance in their own resource, we are disappointed that it doesn’t account for the very specific risk environment in general practice – and the college’s objections to some of the duties listed – which we raised with them during the development of this resource.’

Professor Azeem Majeed, a GP and head of primary care and public health at Imperial College London, said the ‘complex’ issue of PA scope is not addressed clearly in the new guidance.

He said: ‘The guidance acknowledges that PAs are accountable for their own actions, while doctors remain responsible for the overall management of a patient when they are the responsible clinician.

‘However, in practice, this division of responsibility is not always straightforward. A key issue will be how the “scope of practice” for PAs and AAs is defined and implemented.

‘If the scope of practice is broad and these professionals work largely independently, then supervising doctors will face greater medicolegal risks.

‘This tension is at the heart of the ongoing debate about the role of PAs and AAs in the NHS. To truly contribute to care pathways and alleviate workforce pressures, PAs and AAs need to function autonomously.

‘But that autonomy must be balanced with clear lines of accountability and appropriate regulatory safeguards to protect both patients and professionals. Without this clarity, both doctors and employers will be placed in difficult positions.’

Doctors Association UK GP spokesperson Dr Steve Taylor agreed that the guidance ‘fails to address’ important issues in the supervision of PAs.

He said: ‘In many cases the supervisor will not have sufficient knowledge of the PA’s training, knowledge, or capabilities.

‘Because the supervisor retains responsibility and accountability for patient care, the supervisor will need to be confident that the patient is being treated appropriately, safely and has been thoroughly accessed.

‘Supervision is not straightforward and currently there are no training requirements for supervisors. This means patients primarily, PAs and doctors are being placed in positions that are not ideal at best and unsafe at worst.’

A GMC spokesperson said its new resource doesn’t ‘set any new standards, but reflects our existing guidance and provides good practice advice and support for doctors with supervision duties to apply our professional standards in practice.’