Dr Heidi Mounsey, Medicolegal Consultant at Medical Protection, answers some of the questions we have been receiving about supervising physician associates (PAs) and anaesthesia associates (AAs).
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Medical Protection has received a number of queries about supervision and the working arrangements of physician associates (PAs) and anaesthesia associates (AAs).
We know that this has been an area of concern for doctors and not just those who have contacted us proactively. We therefore thought that it would be helpful to summarise some of the key points in a brief article.
We are here to help
The first point we would like to emphasise is that if an issue arises in relation to the supervision of individuals working in a PA or AA role, you can as a Medical Protection member come to us to request support and assistance.
While this article provides an overview of the key considerations, we know some members will have specific concerns about your responsibilities in this area. We are very happy for you to contact us for tailored advice.
Delegation
GMC guidance sets out that when you delegate a task to a PA or AA, you should be confident that they have the necessary knowledge and skills to undertake the task, and that you have provided clear instructions about what is expected of them. You should encourage them to raise any questions or concerns they have about the task they are undertaking.
The GMC highlights that there is no one approach that would fit every circumstance, and supervision arrangements can range from “close personal supervision” to a “managed support system with clear escalation protocols”. The level of supervision should be tailored appropriately to the individual and subjected to regular review.
GMC guidance sets out that when delegating, such as requesting a PA to carry out a task or a review of a patient, you are accountable for the decision to delegate; the instructions you provide; the processes in place for ensuring patient safety; and the overall management of the patient if you are the clinician in charge.
You must be satisfied that the person you are delegating to is competent to carry out the task or will be adequately supervised. The GMC considers that delegation would usually be to colleague registered with a statutory regulatory body – e.g. another doctor registered with the GMC, or a nurse registered with the Nursing and Midwifery Council – but does note that if the individual is not registered with a statutory registered body, registered on a managed voluntary register may give some assurance of their competence. For PAs, until statutory regulation is in place, this would be the Physicians Associate Managed Voluntary Register.
When delegating, you should check that your colleague understands what they are being asked to take responsibility for, and that they have the opportunity to ask questions or raise any concerns they may have about undertaking the task. In addition, you should check they know when they should be seeking input from a more senior colleague, and that they are aware of any escalation protocols in place.
It may seem concerning to read about your responsibilities, particularly that you may remain accountable for the overall management of the patient, but you are not accountable for the actions (or omissions) of those to whom you have delegated, as long as you have delegated in line with the principles set out by the GMC.
Some members have asked us whether it is their responsibility to ensure PAs or AAs have the right skills for the post they are in. Employers of PAs or AAs should ensure that the individual they are recruiting has the appropriate skills and competence for the role they are recruited to within a team, and set out the responsibilities and expectations within that role. However, when you are delegating a task to a PA or AA, you should still ensure you are following the guidance outlined above. If you hold concerns that a PA or AA is not appropriately skilled or qualified for the tasks they are undertaking, we recommend that you raise this with your clinical lead/GP Partnership in the first instance.
Prescribing
When asked to prescribe on the recommendation of a PA, remember that you remain responsible for the prescription, and therefore you should be satisfied that the prescription is necessary and appropriate for the patient, and the medication is within your own competence to prescribe.
If you are uncertain whether the prescription is appropriate, you should take steps to assure yourself that the prescription is necessary and suitable for the patient – this may require you to examine or review the patient yourself.
You should be supported by your employer to carry out your supervisory role, including access to training where required. The scope and responsibilities of your role should be clearly defined, with time available to carry these out. If your individual responsibilities are unclear or you have any queries, we recommend you speak to your employer in the first instance.
RCGP Physician Associate Guidance for PAs in General Practice
The BMA, and more recently the RCGP, have published guidance on the PA role including their view on the scope of practice of a PA and supervision requirements. Some of our GP members have contacted us concerned about whether, if they chose not to follow these guidelines, they would be entitled to assistance and what the medicolegal implications might be.
Our advice is based upon GMC guidance on supervision and delegation. Caution is however advised when delegating and acting outside of the scope of practice of a PA as set out by the RCGP or BMA. Practices will need robust systems to ensure they are acting in a manner consistent with the GMC guidance on delegation and supervision of PAs. Practices would need to be able to demonstrate that roles are regularly reviewed by the partners to ensure that scope and levels of supervision are deemed to be appropriate.
Medical Protection members can seek assistance in the event of an adverse incident involving a PA they employ. While subject to the usual membership checks, MPS discretionary assistance can advise on matters where there has been an issue raised about the supervision and delegation of work to PAs, including those instances where this arose from acting outside RCGP/BMA guidance.
For GPs in England, claims indemnity for the NHS work of PAs is likely to fall to NHS Resolution under the Clinical Negligence Scheme for GPs (CNSGP) and in Wales to the NHS Wales Shared Services Partnership (SSP) Legal & Risk Services under the General Medical Practice Indemnity (GMPI) scheme. GP members in England or Wales may wish to seek clarification from NHS Resolution or NHS Wales SSP around indemnity arrangements for any GP supervising a PA or for the PA themselves in the event of a claim where this includes acting outside of the scope of practice set out in the RCGP/BMA guidance. NHS Resolution have published a FAQ on their website regarding the supervision of PAs which can be found at the following link: Clinical Negligence Scheme for General Practice (CNSGP) - NHS Resolution
Further information
As stated earlier, if you have any specific concerns about your responsibilities in this area, or if an issue arises in relation to the supervision of individuals working in a PA or AA role, we are very happy for you to contact us for further advice and support.