What is a physician associate?
Physician associates (PAs) are healthcare professionals with a generalist medical education, who work alongside doctors, physicians, GPs and surgeons providing medical care as an integral part of the multidisciplinary team. PAs are dependent practitioners working with a dedicated medical supervisor but can work autonomously with appropriate support.
We are leading one of HEE's eight 'task and finish' groups looking at the potential growth of new roles in mental health settings. The group's role is to provide solutions to deliver the expansion of physician associates (PAs), and to build engagement, awareness and best practice. The PA task and finish group are made up of representatives from the College, HEE, medical directors from trusts employing PAs, PA course providers and physician associates. Frequently asked questions are set out below, and further information is available by emailing the workforce team.
The PA task and finish group have produced a toolkit for mental health trusts looking to employ physician associates.
The UK workforce includes around 450 graduate PAs and 1,200 students (2018). There are limited numbers of PAs currently working in mental health settings (approximately 20), though the numbers are slowly increasing and feedback from consultants supervising PAs is generally positive.
Physicians Associates have the knowledge base, skills and attitudes to deliver a holistic type of care and treatment under consultant supervision.
Their skills to support the physical health care of patients in mental health settings bring important benefits to mental health services and they have the potential to help consultants work to the top of their skill set, meaning that productivity is improved.
While trainee doctors rotate through different specialties, PAs offer continuity and stability both for patients and for the team in which they work. Physician associate support also provides cover so that trainee doctors can attend training or clinic. Over time physician associates will be able to help with induction, support and education of new junior staff and students.
In 2017 Health Education England (HEE) published their workforce plan, Stepping Forward to 2020/21 and envisaged a large growth in the PA workforce in mental health. An expansion programme is currently underway, and the College has called for approximately 10% of the new PA cohort to be working in mental health. The number of PAs in the overall health workforce is expected to rise from 450 currently to 3,000 in 2020.
Partly in response to Stepping Forward to 2020/21: Mental Health Workforce Plan for England (PDF), HEE commissioned several ‘task and finish’ groups in the summer of 2018 to look at the development and growth of new roles in mental health settings. The College chairs the task and finish group on physician associates.
Physician associates have been practicing in the UK since 2003, so are relatively new members on clinical teams. Physician associates' ability to practise medicine is enabled by collaboration and supportive working relationships with their clinical supervisors (consultants) and teams, meaning that there is always someone senior who can discuss cases, give advice, and attend to patients if necessary.
Physician associates can be found working in GP surgeries, A&E departments, inpatient medical and surgical wards and some mental health teams throughout the UK. The Faculty of Physician Associates has launched an Employer’s Guide to Physician Associates.
In emergency departments, just like in general practice, physician associates can see patients with undifferentiated diagnoses. They consult with patients in minors and majors as well as resuscitation and post resuscitation. They are also able to see medical, trauma, mental health, paediatric, obstetrics and gynaecology cases. Physician associates can take a history from patients, conduct the physical and mental state examination, request and interpret investigations, diagnose and manage patients.
They can make referrals both to in-house specialities as well as arrange for outpatient appointments or GP reviews. With appropriate senior medical support and input, PAs can discharge or admit patients and can arrange for intermediate care or community services. With experience and development physician associates can provide teaching support to train other physician associates and medical students as well as foundation year one and year two doctors.
Physician associates work within a defined scope of practice and limits of competence. They:
- take medical and psychiatric histories from patients
- carry out physical and mental state examinations
- see patients with undifferentiated diagnoses
- see patients with long-term chronic conditions
- formulate differential diagnoses and management plans
- perform diagnostic and therapeutic procedures
- develop and deliver appropriate treatment and management plans
- request and interpret diagnostic studies
- provide health promotion and disease prevention advice for patients
Currently, physician associates are not able to:
- request ionising radiation (e.g. chest x-ray or CT scan)
The current curriculum stipulates 90 hours in mental health.
PAs are working in several mental health trusts across the UK. The range of activities provided by these PAs includes:
- Full psychiatric (and risk) assessments
- Physical assessments and basic procedures
- Liaison with other services
- Carrying caseloads under supervision
- Preparing reports and discharge summaries
- Basic psychotherapeutic interventions
- Service Quality Improvement (QI) and audit activities
- Education of service users and other staff
- Assisting the managing consultant by, for example, writing letters, chasing referrals/treatments, and preparing hardcopy medical notes etc.
Apart from the activities listed above, the PA role could potentially include work with patients with neuro-developmental disorders and eating disorders, dual diagnosis services and medically unexplained symptoms clinics.
Physician associates are dependent practitioners working with a dedicated consultant supervisor but can work autonomously with appropriate support.
Supervision of a qualified physician associate is like that of a doctor in training or trust grade doctor in that the PA is responsible for their actions and decisions; however, the consultant is ultimately responsible for the patient.
The supervisor also has responsibility for ongoing development of the PA including review of workplace-based assessments, appraisal and development of a professional development plan (PDP).
Levels of supervision will vary somewhat from individual to individual and is dependent on several factors including, but not limited to, their past healthcare experience and years of experience as a physician associate. A new graduate will require much more intensive supervision compared to an experienced physician associate.
The Royal College of Physicians (RCP) established the Faculty of Physician Associates (FPA) in 2015 in conjunction with the UK Association of Physician Associates (UKAPA), Health Education England (HEE) and other medical royal colleges to strengthen and develop the close working relationship between doctors across the specialties and physician associates.
The aim of the Faculty is to support the professional development of physician associates, and thereby enhance patient safety, by providing access to the educational and professional development resources from the RCP, and our publications. the FPA is a national body, so standards apply across the UK.
The RCP also provides administration for the Faculty, which includes the running of the Physician Associate Managed Voluntary Register (PAMVR). We would strongly advise that employed PAs are required to be on the PAMVR; the Faculty, the RCP and others are seeking to achieve the statutory regulation of the PA profession.
As a relatively new role in the UK, physician associates are still seeking statutory regulation, therefore the title ‘physician associate’ is currently not a protected title. The Department of Health are considering regulation to provide a legally accountable framework to ensure patient safety, set standards for the profession, education, protection of the title, fitness to practice, and continuing fitness to practice. Whilst these are already in place for physician associates nationally and overseen by the FPA, they cannot be legally enforced without statutory regulation.
The fact that physician associates are not a regulated profession means that they cannot prescribe medication or order ionising radiation (i.e. order x-rays) and the title ‘physician associate’ is not protected.
At present there is a Physician Associate Managed Voluntary Register (PAMVR) housed at the FPA which keeps details of physician associates who meet all the required standards. The PAMVR does not currently have force of law, so is 'voluntary' as its name suggests. However, the Faculty of Physician Associates encourages all qualified physician associates to join the register, and all trusts and practices to ensure that the physician associates they employ are registered.
The Faculty of Physician Associates, Health Education England, Higher Education Institutes involved in training physician associates and the relevant medical royal colleges, including the Royal College of Psychiatrists, are seeking regulation of the profession and the establishment of a statutory register. Once this is in place, it is envisaged that those on the PAMVR will be transferred to the statutory register, the title physician associate will become protected and only those on the statutory register will legally be allowed to practice as a physician associate.
Physician associates are currently unable to prescribe medication in the UK.
Close work with supervising physicians and arrangements developed individually allow for flexible ways of working and continuation and expansion of quality patient care. For instance, many physician associates working in general practice may propose prescriptions (which is no different to non-prescribing nurses) and can quickly interrupt their supervising physician for a signature and then continue their work. If further advice on a case is required, the GP and physician associate take time out to discuss it and/or see the patient together to come to a decision on further treatment.
Prescribing rights for physician associates may change once statutory regulation is introduced. At that time, decisions will be made regarding physician associates prescriptive rights. As physician associates are not yet either licensed or regulated, this limitation also applies to requests for x-rays and other ionising radiation requests.
Yes, physician associates require professional indemnity coverage. The Medical Protection Society (MPS), Medical Defence Union (MDU) and Medical and Dental Defence Union of Scotland (MDDUS) all provide professional indemnity for qualified physician associates.
Within trusts, the practice of physician associates is covered by the Department of Health 2012 Clinical Negligence Scheme for Trusts (CNST). However, qualified physician associates are strongly encouraged to have their own personal professional negligence insurance from one of the medical defence organisations listed.
In primary care, it is imperative that physician associates have their own indemnity. The annual physician associate census shows that in most cases the cost of physician associate indemnity in primary care is covered by the employer and we recommend GP employers contact their own indemnity provider for guidance.
In certain areas of the UK, there are organisations which employ people to do technical tasks in the hospital such as phlebotomy, arterial blood gases, and administrative duties.
While they are also called 'physician associates' or ‘physician assistants’, they have not undertaken the training required for physician associates in the UK at one of the recognised universities (listed on our website), have not passed the UK PA National Certification Examination, and do not have the training of National Commission on Certification of Physician Assistants (NCCPA) certified American physician assistants. These are nationally set standards that enable the use of the title.
There is a clear distinction in the level of medical training, and for this reason, the Faculty of Physician Associates along with the universities involved in training PAs continue to work toward regulation of the profession to protect the title.
There is also a separate profession called physicians’ assistant (anaesthesia). This is a separate profession with a different set of competencies which enable them to work under the supervision of anaesthetists within the operating theatre environment.
Physician associates have a responsibility to keep up to date. Continuing medical education (CME) or continuing professional development (CPD) is key to a physician associate’s ongoing clinical practice, thus most physician associates are provided with some form of study leave. This is to be determined through discussions with the physician associate and their supervising physician as well as their employer.
All physician associates are currently required to fulfil CPD requirements to remain on the Physician Associate Managed Voluntary Register (PAMVR) which is to be audited by the FPA in conjunction with the Royal College of Physicians using the CPD diary.
The Faculty of Physician Associates requires documented evidence of members CPD as an essential component of the information needed to remain on the PAMVR. This evidence is required, under membership of the FPA, to be documented in the members' RCP CPD diary. All physician associates are currently required to complete 50 hours of CPD per year. Further information can be found in the CPD guidance for physician associates.
The recertification examination is designed to cover all core areas of practice that a physician associate is expected to maintain knowledge in, regardless of whether they are working in a specific specialty. Medicine is forever changing, and PAs have a responsibility to keep up to date. This ensures that physician associates are fit to practise and safe for patients.
To remain on the Physician Associate Managed Voluntary Register (PAMVR) physician associates must sit the recertification examination every six years. Physician associates have three attempts to sit and pass the recertification examination.
The first opportunity will be at the beginning of their fifth year of practice after qualifying as a physician associate and they must pass the examination before the end of their sixth year.
If any physician associate fails the recertification exam on three occasions or doesn’t pass the exam within the above timeframe, they will be removed from the PAMVR and their employer notified. They will then have to take the qualifying examination or follow the process that the statutory regulator stipulates to enter onto the PAMVR.