Making changes to the PA role after the Leng review – HR tips

HR expert Liz Willett warns practices of some of the risk practices face implementing changes to the PA role and advises on key steps to take

The Leng review, published in mid-July, made several key recommendations for the role of physician associate within general practice.  These are summarised as:

1. A change to the name to physician assistant and a change to the uniform and visual identification so they are clearly differentiated from doctors.
2. Newly qualified physician assistants to spend two years working in secondary care before they take on a role in primary care.
3. A new job description set out for PAs’s first role in primary care.
4. PAs to be supervised by a senior doctor with clear parameters for all PAs.
5. PAs to have the opportunity for career development and become a ‘senior physician assistant’
6. Royal colleges to review the curriculum and training provided to PAs.
7. Limits to patients being seen – PAs should not see undifferentiated patients except within clearly defined national clinical protocols. 

Since the recommendations were accepted in full by the Government, NHS England has now written two separate letters to practices and PAs, setting out guidance.  

The letter instructs practices to reassure PAs that their jobs are safe and they will be supported in the changes that the Leng review proposes – and asks them to circulate the letter to PAs affected.  The letter also informs practices and PAs that with immediate effect:

• The PA job title will change to physician assistant
• PA employees with less than two years’ service will be moved immediately onto a new proposed job description (as set out in the Leng review)
• More experienced PAs should have their roles reviewed by their named supervisor to confirm they have the appropriate skills and training, and to modify the roles if necessary.
• All PAs will immediately cease triage activity and seeing undifferentiated patients.
• All new PAs entering primary care should have completed a minimum of two years’ employment in secondary care first.

Our HR concerns regarding the position set out in the letters are as follows:

1. Changing the job title from physician associate to physician assistant may result in a perceived and real loss of status, which if undertaken without proper consultation, could result in grievances and ultimately, claims of constructive unfair dismissal.
2. Changing job descriptions and duties requires consultation with the affected individuals.  If undertaken without proper consultation, claims of constructive unfair dismissal may result ahead of time-consuming grievances.
3. The supervision model for PAs is not well defined but GPs are expected to implement it with immediate effect. However,  expecting busy GPs to immediately understand and support a new framework for working with PAs, with no training and support is poor change management and puts unreasonable pressure on the profession.
4. The new job description for new physician assistants does not appear to have been put through job evaluation as a revised template.  There may be pay and grading issues that have not been identified yet and will certainly result in the need for consultation.
5. The letters from NHS England  appear to take no account of the local workforce plans for the deployment of ARRS funding and the PCNs’ autonomy to make decisions in this respect.
6. Practices and PCNs are at risk because their insurance will be at risk. If they don’t follow NHS England advice, their insurance is unlikely to cover them. So consultation must happen quickly and perhaps interim measures agreed pending a more detailed review. 

Based on these concerns, our advice is set out below.

Before you take any action, stop and think

Don’t send out the letters to PAs without thinking it through. Check your insurance coverage and take HR advice and engage in consultation with PAs (more on that below).

Take a compassionate approach

There is no doubt that the controversy over PA roles has caused a lot of uncertainty and in some cases disputes and rancour on a local level, which has had an impact on those people who have chosen to dedicate their time and effort into gaining the physician associate qualification.  Please remember that the people who undertake these roles are deserving of respect, kindness and compassion.

Also consider what support may be offered to the affected individuals as the response to the review is developed.  This may involve referral to wellbeing support and access to peer and supervision support within practice/PCN.  Support offered via NHS England is signposted in their letter and here.  

Take a structured HR approach to implementing change

There is obviously a significant role that the newly defined physician assistant can play as part of a multi-disciplinary team.  It is worth while taking the time to consider how these roles can effectively be deployed in a way that makes a difference to patient outcomes and practice workflow.  This may involve a change in the current model of deployment.  As the role develops in terms of experience and further qualification, it may also be utilised in new ways in future.

However, whenever there is a change to the deployment of human resources, a process must be followed.  This is underpinned by a business plan, which should be well thought out and be clear on the key business objectives to be achieved and the proposals being considered.

Your business plan may include the following:

• Evaluation of the status quo
• Identification of the drivers for change
• Identification of the success criteria
• Presentation of proposals for achieving the change
• Costings and evaluation of the different proposals for consideration
• Consideration of how the changes will be implemented
• Seeking approval from the necessary stakeholders
• Identification of who will lead the change and what support and access to resources they will receive
• An equality impact assessment.

If your current PA model includes them seeing undifferentiated patients and being involved in triage, the drivers for change will be urgent, particularly as clinical liability insurance may well be affected.

There may be interim changes that you can quickly agree in order to give you time to think about alternative models of deployment that will best support patient demand and workflow management.

Consultation is required when making these changes. It’s recommended you seek HR advice for this.

Unless you are working with a large cohort of PAs, the consultation process can be individual and relatively short.  It should still be meaningful and individuals will have the right to be accompanied by trade union representatives or work colleagues in any meetings where changes to their roles are discussed.  They should have written confirmation of what is being consulted on and the timescales for change.  If changes are imposed, they should have the right to appeal these changes.

Don’t forget consultation with the supervising GPs. You will need to ensure that your supervising GPs are consulted with as well.  They should be clear on the level of supervision required of them and how to demonstrate and record this, identify any additional training and time they might need to do so and ensure that they feel supported on their role as supervisors of PAs.  The BMA will have their own views on this too.

Monitor for updates and clarification. Ensure that you are clear on:

• Insurance implications
• Supervision models
• Job evaluation impacts
• Funding and support for qualifications

There are some recommendations from the Leng review that practices can put in place immediately without the need for consultation. These are:

• Engaging wellbeing support for all affected employees.
• Ensuring new physician assistants being hired can demonstrate having two years post qualification experience in secondary care.
• New PA hires in primary care are recruited to the new job description as set out in the Leng review.
• Sourcing training and support for supervisors

Liz Willett Chartered MCIPD is Managing Director at Kraft HR Ltd, which works closely with practices, federations and PCNs in the Midlands and further afield