PAs can see 'limited' undifferentiated patients under GP supervision, says draft guidance
Again for those that can't be bothered to access
Physician associates (PAs) working in GP practices can assess ‘limited groups of undifferentiated patients’ under heavy supervision from GPs, according to draft guidance produced by the Government.
Under the proposals, GPs would be expected to take the role of clinical supervisor, available for ‘prompt review of a patient on any given day’ and providing ‘day to day oversight and supervision’ of up to three PAs at a time.
GPs would be asked to spend 30 minutes per day after surgery reviewing all patients seen by each PA, according to the document seen by Pulse.
And practices employing PAs ‘must run an effective triage system’ that ensures PAs are only allocated patients ‘presenting with minor ailments’.
PAs ‘should not hold sole responsibility for making a final diagnosis’, the guidance stressed.
They can see patients ‘with known conditions’ or those requiring specific tests or interventions, ‘with approval of the named supervisor’.
However, they ‘may see or observe’ the assessment of other patients with new signs and symptoms ‘when directly accompanied’ by a GP throughout the appointment to support learning and provide effective follow-up, but should not see these patients alone.
The ‘clinical protocol’ was created following the Leng review, which last year recommended that PAs should not see undifferentiated patients ‘except within clearly defined national clinical protocols’.
The document was created by the review’s author Professor Gillian Leng, and has been shared by the Department of Health and Social Care with ‘stakeholder organisations’ as part of a consultation.
It describes the approach that has been taken to ‘build’ on the review recommendations and sets out guidance on ‘effective teamworking’, together with a national clinical protocol for the ‘consistent, safe and effective’ deployment of PAs across settings.
It said that PAs working in a primary care setting should assess only limited groups of undifferentiated patients because primary care does not represent an environment where ‘immediate in-person review can easily take place’.
It defines an undifferentiated patient as ‘a patient with new signs and symptoms who has not yet had an initial clinical assessment’.
The guidance also said that ‘in line with Jess‘s Rule’, if a patient re-presents to the service with the same ‘unexpectedly unresolved or worsening’ symptoms:
- On a second presentation the PA should discuss the patient with their supervisor either: i. before the patient leaves the surgery for in person consultations or ii. by the end of surgery for remote consultations, with consideration to arranging a face-to-face assessment by a GP.
- On the third presentation the patient should be given an appointment with a fully qualified GP.
To be effective as a triage system, all appointments booked with PAs must be either triaged directly by a GP ‘who has knowledge of the PA’s individual scope of practice’ or by a trained member of staff or an electronic system which has been approved for use by the practice.
In this case, there should be an initial review of the patient list assigned to the PA by the clinical supervisor available on the day, in advance of the patients being seen by the PA, the document said.
Supervisory roles
PAs must have a named supervisor responsible for ongoing oversight, training and development, who does not need to be physically present each day. In primary care, this must be a fully qualified GP; in other settings, a consultant.
They must also have a clinical supervisor available for prompt patient review and day-to-day supervision, who must be a fully qualified GP, consultant, or an ST4-level or equivalent resident, clinical fellow or specialty doctor.
Source: A clinical protocol for physician assistants, their supervisors, team members and employers: Teamworking and undifferentiated patients
The document said: ‘The clinical supervisor should review and approve the list of undifferentiated patients with minor ailments assigned to the PA, ensuring the allocation matches the PA’s capability and experience.
‘The restrictions on assessing undifferentiated patients [in primary care] relate to the relative lack of immediate supervisory support in primary care, the lower level of training received by a PA compared to a GP, and the risks to patient safety of a misdiagnosis.’
It pointed out that when the clinical supervisor is ‘confident’ in the PA’s ability, they should still discuss all patients with the PA ‘at the end of each morning and afternoon surgery’.
During the PA’s first year in primary care, the supervisor should spend ‘a minimum of 30 minutes after each surgery’ to discuss with the PA all the patients they have seen, and a minimum of 15 minutes after the PA’s first year.
In addition, the supervisor should allow additional time during the day to discuss any patients which present in the PA’s practice and may require immediate consideration or review, as well as manage any prescribing requests which cannot wait until the scheduled slot after the surgery.
Published in July 2025, Professor Leng’s review also recommended that PAs should be renamed as ‘assistants’, and that they should have at least two years’ training in secondary care before being allowed to practise in primary care.
While the review made the recommendation on undifferentiated patients, it did not set a broader ‘scope of practice’ for PAs or anaesthesia associates (AAs) to work within.
The RCGP and BMA both published guidance on PAs in 2024 severely limiting their scopes of practice, and both organisations have called on the Government to introduce a nationally agreed scope of practice.
In 2023, Pulse reported on a GP practice which stopped employing PAs after a coroner found that ‘poor quality care’ had contributed to the death of 30-year-old Emily Chesterton. The coroner concluded that Ms Chesterton ‘should have been immediately referred to a hospital emergency unit’ and that ‘if she had been, the likelihood is that she would have been treated for pulmonary embolism and would have survived’.
Physician associates trade union United Medical Associate Professionals (UMAPs) was granted permission to challenge the legality of some aspects of the review and its implementation by the Government, though not on the specific recommendation about undifferentiated patients.
A Department of Health and Social Care spokesperson told Pulse the finalised protocol would be a ‘nationally consistent framework’ but would not create ‘statutory requirements’ or ‘directly enforceable legal duties’
They said: ‘The protocol is intended to provide a nationally consistent framework for the safe deployment of physician assistants, particularly in relation to seeing undifferentiated patients.
‘Once finalised, it will be published alongside implementation guidance and used by employers, supervisors and clinical teams to inform local governance arrangements, supervision models, workforce planning and clinical pathways.
‘The protocol will be advisory guidance rather than legislation and will not create new statutory requirements or directly enforceable legal duties. However, organisations and professionals would be expected to have regard to it alongside professional standards, clinical guidance, local governance arrangements and the needs of individual patients.’
So if I employ a PA, I get the pleasure of paying to train them and I have to find an additional 30mins after their surgery to debrief them?? 😄
Whose still employing new PAs under this guidance??