Physician associates (PAs) working in GP practices are still covered against clinical negligence liabilities even if their activities differ from recommendations made by the Leng review and the RCGP, NHS Resolution has said.
It clarified that indemnity under the Clinical Negligence Scheme for General Practice (CNSGP) ‘is not conditional upon having followed RCGP guidance or implemented changes as per the Leng review’.
Their guidance to LMCs also added that GPs and other clinical staff responsible for the supervision of PAs within general practice can be reassured that they will be indemnified under the scheme, in respect of incidents ‘involving PAs which result in a clinical negligence claim that is brought against the partners/principals or practice’.
The Leng review, which was published in July and whose recommendations were accepted in full by the Government, found that PAs should be renamed ‘assistants’, should not see undifferentiated patients outside of clearly determined protocols, and that they should have at least two years’ training in secondary care before being allowed to practise in primary care.
Following the review, although GP practices were asked by NHS England to take ‘immediate actions’ to implement the changes, last month an NHS England FAQs document appeared to water down these actions, saying that any changes are contingent on ‘local change management policies’, employment law and discussions with trade unions.
NHS Resolution, which runs CNSGP, the state indemnity scheme for general practice in England covering clinical negligence liabilities in relation to incidents that occurred on or after 1 April 2019, said that the question of scope of practice for PAs is ‘not a relevant consideration for NHS Resolution’ in determining eligibility for indemnity under the scheme.
It said: ‘NHS Resolution can confirm that PAs working for general practice who are carrying out activities connected to delivering NHS primary medical services on behalf of the provider under a primary care contract in England, namely one which falls within Part 4 of the NHS Act 2006 (GMS, PMS and APMS arrangements), will be indemnified under the Clinical Negligence Scheme for General Practice (CNSGP) for clinical negligence liabilities arising from incidents that occurred on or after 1 April 2019.
‘This is because CNSGP provides indemnity cover for all GPs and staff working under an NHS GP contract in England in respect of liabilities in clinical negligence.
‘This indemnity extends to activities carried out by PAs which are connected to the delivery of other NHS services provided by general practice and known as “Ancillary Health Services” where these services fall within the relevant definition in regulation 2 of the CNSGP Regulations.’
The Leng review did not set out a scope of practice for PAs but outlined a proposed job description for newly-qualified PAs working in primary and secondary care, which were based on their core training and informed by initial scopes of practice produced across the royal colleges, including the RCGP.
The job description for PAs in general practice severely limits their practice, by suggesting they should ‘play a central role in all aspects of preventative care, including undertaking NHS health checks and provide lifestyle support, and support the administration of basic therapeutic procedure’.
The PA scope of practice produced by the RCGP in October last year 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’.
The RCGP and DHSC have been approached for comment.
Meanwhile, a legal case against the GMC over its refusal to set an official scope of practice for physician associates (PAs) has been dismissed on all grounds.
The judicial review was brought by Anaesthetists United (AU), along with the parents of Emily Chesterton, a 30-year-old woman who died after seeing a PA in general practice who she believed was a GP.
Proceedings were also supported by the BMA, while the Doctors’ Association UK donated £30,000 to the group’s fundraising campaign.
It was aiming to achieve ‘clear and enforceable guidance’ setting out what PAs and anaesthesia associates (AAs) ‘can and cannot do’, and argued that the GMC has a statutory duty to set those standards.
But last week Mrs Justice Lambert dismissed the judicial review on all grounds, and said that she is ‘satisfied’ that the GMC’s exercise of its role as regulator of associates ‘was coherent and rational’.
The main grounds of the case were that the GMC ‘failed to produce standards’ that would:
- set ‘adequate limits’ on the tasks PAs may undertake post qualification by the introduction of a scope of practice
- ensure that informed patient consent is obtained for treatment by requiring associates to state unequivocally that they are not medically qualified
- ensure that PAs are safely supervised by doctors, including when delegating appropriate clinical tasks
- and that this failure by the GMC ‘was irrational’.
The judgement found ‘no failure’ by the GMC to take into account ‘material evidence or mandatory relevant consideration’ and ‘no logical error or critical gap’ in the GMC’s reasoning.
However, the judge said that there exists ‘a genuine debate’ about whether the imposition of national limits on the practice of associates is ‘overall in the interests of patient safety’.
But she added: ‘It is not for me to enter the debate and resolve it one way or the other. That is not this court’s role: my only role is to determine whether the defendant’s decision not to impose a ceiling on practice is irrational.’
A spokesperson for the GMC said: ‘Our thoughts remain with the Chesterton family. Today, our regulation of associates—supported by a robust system of registration —ensures they are safer and better equipped to carry out their duties and can be held to account if they pose a risk to patients or public confidence.
‘We welcome the decision of the High Court to dismiss the claims on all grounds and we are pleased the Court found our approach when considering how we would regulate associates, and our decision not to impose limits on their practice, was “coherent and rational”.’
The BMA’s chair of council Dr Tom Dolphin said that the outcome was ‘disappointing’, but added that it is ‘important to make clear’ that the court ‘has not vindicated’ the GMC’s refusal to set a scope or adopt scopes set by others.
‘It is important to make clear that the court has not vindicated the GMC’s refusal to set a scope or adopt scopes set by others. Instead, it has simply stated the GMC’s decision not to do so was not unlawful.’
A version of this article was first published by our sister title Pulse.
