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Physician Associates in general practice: Supervision

Publication date: 09 October 2024

Introduction

This guidance is for GP practices that employ Physician Associates (PAs). It describes arrangements for the supervision of PAs in general practice and should be read in conjunction with the College’s policy position on PAs, as well as  related RCGP guidance (on Induction & Preceptorship and Scope of Practice).  

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Supervision guidance for Physician Associates in general practice

The guidance acknowledges that patient presentations are often complex in general practice. Levels of risk and uncertainty in diagnosis and management are high and there are fewer opportunities than in secondary care settings to seek contemporaneous guidance from colleagues. Newly qualified PAs have only had two years’ clinical training, and therefore need rigorous supervision and a carefully prescribed and agreed scope of practice (see Scope of Practice guidance). Patient safety is paramount, and this guidance is written with that in mind.

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). In addition to the GP CS, the PA will have an Educational Supervisor (GP ES) who oversees their educational and professional development during the preceptorship period.  The GP ES may, in some cases, be the same person as the GP CS. This guidance provides further information about these roles. 

The significant responsibility and skills required for supervision must be recognised and resourced, and GPs need to be able to choose whether they are willing to undertake supervision of PAs. There must be protected time in GP CS, GP ES and PA job plans for supervision. If the time and resources to supervise a PA are not available, then PAs should not be employed in the practice. GPs who become CS or ES GPs, will need training in supervision and the knowledge and understanding of the training of PAs in the UK.

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.

Governance considerations relating to the employment and supervision of PAs

GMC guidance Effective clinical governance to support revalidation (General Medical Council, 2024a)i says ‘…organisations that employ anaesthesia associates (AAs) and PAs should make sure their governance arrangements take account of the fact that these professionals are trained and registered on the basis that they will always work under supervision. We recommend that organisations identify an individual at Board level who is responsible for AAs and PAs, and that local processes are established governing how these professionals are deployed and supervised. The aim of such processes should be to ensure high quality, safe care, and to support effective multidisciplinary working.'

In Good Medical Practice, the GMC highlight that doctors must be confident that any person they delegate to have the necessary knowledge, skills and training to carry out the task they are delegating (General Medical Council, 2024b, para.66).ii

The GMC’s advice for doctors who supervise PAs and AAs (General Medical Council, 2024c) states: ‘Where you delegate care in line with the principles set out in our guidance, you are not accountable to the GMC for the actions (or omissions) of those to whom you delegate care. You will remain responsible for: the overall management of the patient, decisions around transfer of care, and the processes in place to ensure patient safety.  If you prescribe based on the recommendation of a PA or an AA, you’ll be responsible for any prescription you sign. Be sure that the prescription is needed, appropriate for the patient and within the limits of your competence.iii

NHS Resolution provides guidance on indemnity for PAs in England and the responsibilities of supervising GPs and practices (NHS Resolution, 2024).iv Its Clinical Negligence Scheme for general practice (CNSGP) provides indemnity cover for all GPs and staff working under an NHS GP contract in England.  GP partners/GP principals and other clinical staff responsible for the supervision of PAs within general practice are indemnified in respect of incidents involving PAs which result in a clinical negligence claim that is brought against the partners/principals or practice, or where their role in the incident involving the actions of a PA and resulting in a claim was limited to supervision of the PA.  The scheme does not provide indemnity cover for non-clinical matters, advice or professional (regulatory) matters. NHS Resolution recommends indemnity cover be obtained from an MDO or other indemnity provider for those matters outside the scope of CNSGP.

The GP Clinical Supervisor 

In general practice PAs must always work under the supervision of a named GP known as the Clinical Supervisor (GP CS).  

The GP CS is responsible for overseeing the work of the PA in the GP practice and is the clinician to whom the PA will come for advice and to debrief cases on a regular basis. The GP CS must be available for advice and to review patients themselves if clinically indicated to ensure patient safety.  The GP CS retains overall clinical responsibility for the patients the PA sees, irrespective of whether the PA seeks advice from the GP CS.

The GP CS may, from time to time, delegate responsibility for supervision to another qualified GP in the practice who has agreed to undertake the supervision. It must always be clear to all concerned who the GP with delegated responsibility is.

The GP CS and those with delegated responsibility for supervision, must be on the GMC GP register and the NHS Performers List.  It may be appropriate for salaried and retainer GPs to undertake the supervision of PAs, either as the GP CS or those with delegated responsibility for supervision.  However, it is not appropriate for locum GPs to supervise PAs because of the need to understand the PA’s skills and competencies before delegating tasks to them, and the varied location of their work.  Trainee GPs must not undertake supervision of PAs under any circumstances. 

The GP Educational Supervisor

There will also be a named GP (the GP ES) who oversees the PA’s educational and professional development, in consultation with the GP CS, during the preceptorship period.   They will be responsible for ensuring that there is an induction and appraisal, and that further education and training is arranged to fill any knowledge and skills gaps. The GP ES must be on the GMC GP Register and NHS Performers List too.

The roles of GP CS and GP ES may sometimes be undertaken by the same person, especially in small practices. However, in England the ES role could be taken by a GP outside the practice within the PCN, giving external reliability to the educational supervision.

The GP ES may work in the same practice as the GP CS or in a different practice. They are likely to be part of the same Primary Care Network, if working in England.

Supervisor training

The GP CS, GP ES and any GP with delegated responsibility for supervision must have completed training in education and supervision prior to taking on the supervision of a PA. This training should also cover the role of the PA and include information on the knowledge and skills the PA should have acquired by the end of their training in Physician Associate Studies. UK Departments of Health are expected to be able to advise on and/or offer suitable courses. 

Supervisory arrangements

The induction and (where applicable) the preceptorship process should be in place at the beginning of a PA’s employment in general practice (see Induction & Preceptorship guidance).   

We would expect a PA to be supervised by the GP CS or GP with delegated responsibility for supervision in the same clinical environment, so they are available for contemporaneous support, including in person review.

The level of supervision, albeit within the same clinical environment, can vary depending on the clinical experience of the PA, by agreement with that PA and their CS. This will be decided by the GP CS, taking into account the PA’s competencies and the formal process of appraisal and any agreed changes to the scope of practice and job plan. 

The RCGP does not consider that remote supervision is appropriate for PAs.

It is important that:

  • The GP CS or GP with delegated responsibility for supervision must be available to provide immediate support for PAs who are new to general practice, for at least the first 12 months in general practice.
  • All PAs must have regular supervision time, on a daily basis, to ‘hot review’ all the cases that have been seen that day. This time could also be used to review the progress of the PA and identify further training needs.
  • A weekly or fortnightly review meeting must take place between PA and GP CS to discuss areas that are working well, or those that need additional help or training to enable the PA to work to their full potential.
  • There must be regular in-house reviews, during protected time, to identify areas of interest, explore the development of longer-term goals and identify and use any skills not currently being employed. 
  • The notes made at every PA/patient encounter must be signed off by the GP CS at the end of the surgery day.
  • Any clinical advice given by the GP CS or GP with delegated responsibility for supervision must be documented.
  • There should be regular communication between those who are responsible for supervising a PA, so all are aware of the PA’s progress and any challenges.
  • There must be a written protocol, that is discussed and understood in advance by the PA and GP CS, to facilitate safe prescribing for the patients seen by the PA. The PA will need access to an authorised prescriber to either sign off a prepared, or generate a proposed, prescription.
  • Introductory arrangements, as described in the ‘Preceptorship/ Induction’ guidance document must be followed, so that patients know who they are seeing and have consented to see that healthcare professional (Healthwatch, 2024).v
  • PAs must not be moved routinely between significantly different environments on an ad hoc basis as their training is not designed to support this and it undermines supervision. 
  • There needs to be consideration of a GP CS’s job plan to ensure they have capacity to supervise safely.

Appraisal

Annual appraisal for PAs must be mandatory and part of the contract between the employer and the PA. In the short term, we expect appraisals to be conducted by the GP ES during the preceptorship period and the GP CS thereafter.  However, arrangements for PA appraisal under GMC regulation are yet to be clarified.  The FPA’s appraisal document, which forms part of the FPA personal and professional development toolkit, is currently used.

PA supervision references

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