Physician Associates in general practice: Scope of practice

This guidance is for GP practices that employ Physician Associates (PAs). Its purpose is to describe the scope of practice for all PAs working in UK general practice and should be read in conjunction with the College’s policy position on PAs, as well as related RCGP guidance (on Supervision and Induction & Preceptorship).

Physician associates (PAs) are dependent healthcare professionals who, in general practice, work as part of the multidisciplinary team with supervision from a named GP Clinical Supervisor (GP CS). 

This scope of practice guidance is couched in deliberately narrow terms for the following reasons:

• Patient safety is paramount. Patient presentations are often complex, undifferentiated and multiple in general practice. Levels of risk and uncertainty in diagnosis and management can be high and there are fewer opportunities than in secondary care settings to seek contemporaneous guidance from senior colleagues. 
• The research and evidence base for the effectiveness and safety of the PA in the UK general practice environment is, currently, limited.
• The RCGP has sought and heard the views and experiences of its membership which urged significant caution in the way in which PAs are deployed in general practice.

This document will be reviewed in 12 months and the RCGP commits to monitoring the situation and reviewing the document as the evidence in this area develops. 

While it is not within the RCGP’s remit to enforce this guidance, it may be taken into account by NHS Resolution and the Medical Defence Organisations in a case of alleged negligence or clinical or professional mistakes. Ultimately, it is the decision of employers whether to follow this guidance, and the employer’s responsibility to ensure the appropriate treatment and handling of existing PA contracts.

1. PAs must work within their scope of practice, which must not extend beyond the scope of practice in this guidance. They must also work within the scope of practice of their GP CS. 
2. PAs must always undertake a Preceptorship Programme on entering general practice, the completion of which is a prerequisite to practise within the scope of practice in this guidance (see Induction & Preceptorship guidance). Preceptorships are currently available in England.  The RCGP would like to see Preceptorships available and funded across the UK where PAs are working in general practice.
3. PAs must always have a period of induction at the start of their employment with a GP practice, even if moving from one practice to another (see Induction & Preceptorship guidance).
4. During their preceptorship, PAs must be trained specifically within a general practice context, to recognise when patient presentations are outside their scope of practice and must be brought to the attention of their GP supervisor. 
5. PAs must always have a GP CS. The GP CS is responsible for determining the PA’s scope of practice at the start of their employment, in consultation with the PA’s Educational Supervisor (GP ES) (if during the preceptorship period), and with reference to known and developing capabilities. Both the GP CS and GP ES need to be familiar with the PA’s training in Physician Associate Studies. (See Induction & Preceptorship and Supervision guidance).
6. A PA must not undertake activities outside the scope of practice described in this guidance, even if they have previously undertaken those activities in a non-PA role.
7. PAs must not see patients who have not been triaged by a GP and only undertake work delegated to them by, and agreed with, their GP CS. This work must be in line with the agreed scope of role for that PA in the practice. Practices must have clear protocols in relation to the triage process. The protocols must incorporate the patient preferences about the healthcare professional they see (see below).
8. Practice websites must contain a list of the members of the multi-disciplinary team working at the practice, and a description of what each of these members do.  The practice must have a protocol when booking appointments explaining to patients who they are going to see and giving them the option to discuss who they would like to see (Healthwatch, 2024).ⁱ
9. All members of staff must wear clearly visible name badges with their role below their name, and if working from a clinical room, their name and role should be on the door. PAs must introduce themselves fully to the patient, ensuring the patient understands who they are and that they are not a doctor (FPA, 2023).ⁱⁱ
10. PAs must not be the sole healthcare practitioner on call, or the duty clinician, in the GP practice. They must not see ‘walk-ins’ that have not been triaged by a qualified GP.
11. PAs must always use the GP practice clinical guidelines and protocols.
12. PAs must always document the care and advice they give, including any information shared, on behalf of the patient’s GP, with other members of the primary healthcare team and colleagues in other healthcare environments. The notes made at every PA/patient encounter must include any advice given by the GP CS and must be signed off by the GP CS at the end of the surgery day. (see the RCGP Supervision Guidance document).
13. PAs must promote evidence-based practice and would be expected to take part in GP practice learning events and activities such as clinical audits. 
14. PAs must have a formal annual appraisal, in which their professional development needs are discussed and documented.
15. In light of the arrangements for supervision, triage and scope of practice described in the RCGP’s guidance, we do not consider it currently viable for PAs to be employed in Out of Hours settings, or as locum PAs.
16. The induction, supervision and ongoing training of PAs should be available to CQC inspections to ensure patient safety is being observed.

First point of contact/undifferentiated patients/clinical triage

PAs must not see patients who have not been triaged by a GP and only undertake work delegated to them by, and agreed with, their GP CS. This work must be in line with the agreed scope of role for that PA in the practice. Practices must have clear protocols in relation to the triage process, which incorporate patient preferences about the healthcare professional they see.

The PA can take a history, complete a physical examination, and construct an appropriate diagnostic and management plan, which is shared with the supervisor either contemporaneously if additional advice or confirmation is needed, or at the end of the session (a hot review) for a more experienced PA once the GP CS has determined that the PA is safe to do this. 

If a patient triaged to a PA presents with a new issue during the consultation the PA may be able to make a provisional diagnosis, depending on their scope of practice, but must then present that case to the GP CS (or GP with delegated responsibility for supervision). 

If a patient contacts the practice a second time with the same unresolved issue, they must be triaged to a GP.

PAs must not be given responsibility for clinical triage or undertake clinical triage.

PA scope references

• ⁱHealthwatch (2024) Am I seeing a physician associate or a doctor? [Accessed 27 August 2024]
• ⁱⁱFaculty of Physician Associates (2023) FPA Titles and Introduction Guidance. [Accessed 28 August 2024]