Summary

Medical associate professions (MAPs) include physician associates (PAs), anaesthesia associates (AAs) and surgical care practitioners (SCPs). MAPs are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor (a General Medical Council registered consultant or general practitioner). They provide care to patients in GP practices, hospitals and in the community.

The NHS in England is committed to supporting MAPs to work effectively and safely as part of the multi-disciplinary team and to supporting doctors in their supervision responsibilities.

This document is a summary of existing guidance on the deployment of MAPs to support organisations employing MAPs in NHS settings. It brings together information previously shared that describes the common expectations of how organisations providing NHS care should deploy MAPs, specifically the:

• actions needed to ensure clarity of competencies and responsibilities
• safeguards in place to ensure patient safety
• support and development that MAPs should have

The General Medical Council (GMC) is currently consulting on the rules, standards and guidance that will implement the legislation introducing the regulation of physician associates and anaesthesia associates. We welcome this as a significant step towards bringing both roles into statutory regulation to further embed them into the NHS workforce, and as an opportunity to further strengthen support, development and accountability. Surgical care practitioners are not within scope of the consultation as they are already regulated under their original profession, and are registered non-medical healthcare professionals who have extended the scope of their practice by completing an accredited training programme.

Context

Throughout its history, the NHS has continuously changed to improve patient safety and experience. As healthcare has evolved, reflecting the changes in medicine and science, roles have changed, scopes of practice evolved, new specialisms have been set up and new professional roles created.

There is consensus that greater skill mix within healthcare teams is a positive development in modern clinical practice and an important component in the NHS’ mission to provide safe, accessible, and high-quality care for patients.

Although first introduced to the NHS in England in 2004, MAPs are comparably new roles in the NHS that are part of that multidisciplinary approach to healthcare. The role of PAs is not unique to the NHS – a variety of health systems around the world use roles similar to PAs and, as of 2022, at least sixteen countries including the Netherlands, Canada, Australia and New Zealand have in different ways began an expansion of a role like that of a PA that functions under the supervision of a doctor.

Similar professions exist in nursing and dentistry working to a nurse or dentist as part of multidisciplinary teams.

The National Institute for Health and Care Research has also published research in 2019 which found PAs positively contribute to the medical and surgical team, patient experience and flow, and help support the clinical teams’ workload.

The NHS has been clear that PAs are not doctors, and cannot and must not replace doctors. PAs are not a substitute for doctors; they are trained to work with doctors and other health professionals as supplementary members of a multidisciplinary team.

PAs must always work within their competencies ; and must be supervised appropriately. Employers must ensure that the overall responsibility for supervision of PAs is by a named senior doctor. Patients must always receive clear and accurate information about who is treating them and making decisions about their care.

PAs support doctors and perform tasks which help doctors do their job. The same is true for AAs and SCPs – these roles are not a replacement for anaesthetists, or surgeons, but rather they support doctors in their role.

MAPs are an important part of how the NHS will deliver healthcare in the future. Under the NHS Long Term Workforce Plan, we aim to have trained 10,000 physician associates and 2,000 anaesthesia associates by 2036/37. However, as we have said, we will set our recruitment trajectory based on how confident we are that the local education capacity and faculty is in place to train all professionals to the highest standards.

This will be on top of the NHS’ massive expansion in the number of doctors that we are training to join the future NHS workforce. The NHS currently employs around 134,000 hospital doctors and in primary care there are around 36,000 GPs. Under the NHS Long Term Workforce Plan, we will double the number of medical school places to 15,000 by 2031/32 and increase GP specialty training places by 50% to 6,000 over the same period, building on a 25% increase in medical training places already delivered since 2018, with a commensurate increase in specialty training places that meets the demands of the NHS in the future.

The future of the NHS is a larger medical workforce, supported by and working with multidisciplinary teams to deliver high quality care for patients.

As we grow the NHS workforce, and expand the different roles within it, it is right that we continually update the standards we work to so the NHS better supports our staff and does everything we can to improve patient safety and quality.

Role description of MAPs

The three roles we commonly refer to as MAPs and covered by this guidance are:

Physician associates (PAs): PAs are generalist healthcare professionals who work alongside doctors and provide medical care as part of the multidisciplinary team. PAs are trained at University, in some cases alongside medical students but this does not mean they are at medical school training to be a qualified doctor. PAs can work, but always under the supervision and ultimately direction of a named senior doctor. PAs work in hospitals and general practice, supporting doctors. A PA will deliver aspects of patient care including some defined tasks and procedures. For example these tasks can include medical histories, examinations and managing and diagnosing illnesses under the overall supervision of a named senior doctor. PAs currently work in over 40 specialties across GP practices, hospitals and community care, with roles determined by local need and decisions. The largest proportion of PAs work with doctors and other colleagues is in primary care, followed by emergency and acute medicine. Other specialties include geriatrics, stroke, community, dermatology, and ENT.

With careful workforce and service planning based on local needs, PAs can support the delivery of effective and efficient medical services across the wider health system. PAs complete a two year post graduate diploma or an MSc. The Faculty of Physician Associates requires all PA students who have completed a PA programme to take the Physician Associate National Examination (PANE). The PANE is developed and delivered by the Assessment Unit on behalf of the Royal College of Physicians (RCP). The PANE is open to any candidate who has completed the requirements of the Competence and Curriculum Framework for the Physician Assistant within a UK university postgraduate programme in Physician Associate Studies (either as a postgraduate diploma or a master’s course) and had completion signed off by their relevant university exam board. First introduced in 2004, there are currently 3,500 PAs in the NHS.

Anaesthesia associates (AAs): AAs are highly trained, skilled practitioners who work as part of the team under the direction and supervision of a consultant anaesthetist.  AAs work in hospitals as part of the anaesthesia team, performing pre- and post-operative assessment and intervention and providing anaesthesia during surgery. AAs complete a post graduate diploma of two years minimum duration, with previous clinical or degree level experience. First introduced in 2004, there are currently approximately 150 AAs in the NHS.

Surgical care practitioners (SCPs): SCPs are registered, non-medical healthcare professionals (for example regulated nurses or other regulated operating department practitioner) who undertake post-registration clinical practice before undergoing further structured training. SCPs work under the direction and supervision of a surgeon. First introduced in 1993, there are approximately 600 SCPs in the NHS. 

Common expectations on the deployment of MAPs

Employers should ensure the following expectations are adhered to in the deployment of MAPs in settings providing NHS care.

Clarity of competencies and responsibilities

1. MAPs should have the capabilities as described in the Core capabilities framework for medical associate professions. The Framework describes the core skills, knowledge and behaviours and specifies that which is common between different MAP roles and settings to enable greater consistency in developing and evaluating the core skills and knowledge of individual MAPs. The framework sets out clear expectations for each of the MAPs roles on the requirements for effective and safe practice.

Physician associates should note the existing Code of Conduct from The Faculty of Physician Associates.

2. MAPs have the right, and duty, to work within the qualified competence and scope of clinical practice that is agreed with their supervising senior doctor, and to accept delegated tasks or responsibilities that fall within these capabilities.

3. MAPs work must be directed and overseen by a supervising senior doctor who has delegated responsibility to the MAP in line with the standards and guidance in Good Medical Practice, Leadership and management for all doctors, and Delegation and referral.

In primary care this must be a GMC-registered general practitioner (GP) and in secondary care a GMC-registered consultant. As previously communicated, work undertaken by PAs must be supervised and debriefed with their supervising GP. We ask that practices review their processes to ensure that they have appropriate supervision, supporting governance and systems in place. Underpinning this is the supervising GP’s confidence of the PA’s competence, based on the knowledge and skills gained through their training and development. NHS England supports GP practices to provide a structured preceptorship for physician associates in their first primary care role.

4. All MAPs must have defined roles and clear job descriptions. In particular, when deciding if a PA role is required in a medical setting, management should have regard to the High Level Principles Concerning Physician Associates released by the Academy of Medical Royal Colleges and if a PA role is deemed appropriate, they should then follow the NHS England guidance on Ensuring safe and effective integration of physician associates into departmental multidisciplinary teams through good practice. Organisations should also note Faculty of Physician Associates guidance on ensuring safe and effective integration of physician associates into the clinical workforce.

In addition, in general practice, employers should follow NHS England guidance on ensuring safe and effective integration of physician associates into general practice teams through good practice.

5. Professions regulated by the GMC, which will include PAs and AAs from December 2024, must meet Good Medical Practice 2024 standards and any other regulatory requirements as described by the GMC.

6. For surgical care practitioners, the Royal College of Surgeons of England and the Royal College of Surgeons of Edinburgh published The Curriculum Framework for the Surgical Care Practitioner in 2022 which set out the expected technical skills and knowledge for a SCP and is taught at two universities.

7. NHS England strongly recommends that employers only consider recruiting MAPs who are on the relevant Voluntary Register: the AA Managed Voluntary Register (MVR)  held with the Royal College of Anaesthetists (RCoA), the PA Managed Voluntary Register, held by the Faculty of Physician Associates hosted by the Royal College of Physicians or the SCP Managed Voluntary Register, held jointly by the Royal College of Surgeons of England and the Royal College of Surgeons of Edinburgh. These registers enable supervisors and employers to check whether an individual is appropriately qualified and working safely to the standard expected in the UK.

Safety, accountability and transparency

8. All doctors supervising the work and training of MAPs must have the appropriate capacity and capability for the role and the organisation’s medical leadership should assure themselves of this.

9. Doctors and other healthcare professionals have a duty to delegate tasks or responsibilities appropriately, following regulatory guidance i.e. GMC, NMC, supported by an understanding of the roles and skill mix in their team

10. PAs are not substitutes for doctors of any grade or experience; rather, they are specifically trained to work collaboratively with doctors and others as supplementary members of a multidisciplinary team alongside nursing and other ARRS colleagues. As previously communicated, PAs should not be used as replacements for doctors on a rota. Understanding the challenges faced by trusts in accurately reflecting multidisciplinary staffing within rota software constraints, we encourage you to:

• Assess the current capabilities of the rota software used to represent staffing within each department.

• Ensure each department has undertaken a department-specific assessment to establish safe minimum staffing levels, considering skillsets and scopes of practice, supported by a service evaluation of patient group needs.

• Ensure that the full name and job title of each healthcare professional, including physician associates, are prominently visible on any rota system.

• As part of the induction process, educate all staff members on how the rota is informed, operated and displayed to promote understanding and transparency.

11. It is important that all staff are able and supported to introduce themselves and their role clearly, to ensure that patients understand who is caring for them. The Faculty of Physician Associates has produced guidance to support staff which is available on their website.

12. All patients should be supported to understand the role of each healthcare professional they are seeing and are not led to believe that the professional they are seeing has competencies beyond their scope of practice or skills set.

13. All clinical and administrative/clerical staff (for example, receptionists) must be educated on the PA role and make it clear to patients that they are seeing a PA. As part of good governance processes, all staff should be aware of how to triage patients so that they are seen appropriately by a clinician working within their level of competence.

14. MAPs must have access to areas of the electronic patient care record that fall within their responsibilities, training, or competencies. PAs are not allowed to prescribe or order ionising radiation. Therefore, in the context of electronic patient care records, every practice should have a comprehensive policy outlining access and restriction requirements for each professional group. This policy should cover aspects such as appropriate access to prescribing, results, referrals, and patient clinical notes, and provide assurance that clinicians are not able to undertake activities falling outside of their role’s scope of practice (for example, in primary care by providing a smart card loaded with TPP or EMIS system role profiles for PAs that does not permit access to prescribing activities).

15. New qualifications and capabilities must be explicitly recorded to ensure patients and team members have clarity about what new skills MAPs can deliver beyond those they originally qualified with.

16. As with all healthcare staff, NHS organisations or those providing NHS care must have procedures in place for staff and patients to report any individual working outside of their scope of practice, competency, or working in a way that causes alarm or concern. Leadership should ensure these processes are well communicated and assure themselves that staff and patients feel comfortable to report concerns. If concerns around working are reported, leadership has the responsibility to investigate and act appropriately.

Support and development of the MAP workforce

17. Doctors supervising MAPs and the medical leadership of the organisation must ensure that MAPs are treated with respect and dignity at work, as with all other healthcare staff.

18. There must be appropriate employer policies, systems, and permissions to ensure MAPs are supported, supervised and integrated into teams. MAPs should have access to debriefing with their supervising doctor.

19. As with all healthcare professionals, MAPs should have appropriate access to high quality relevant training and development opportunities over the course of their careers in line with national standards and regulations.

Next steps

We are aware that there is considerable discussion about these roles and we continue to work with partners, including MAPs and doctors, to agree how we deliver the NHS Long Term Workforce Plan and address the concerns raised around how Medical Associates can deliver their role safely and effectively.

NHS England recognises that there is more to do to develop the role of MAPs and ensure these committed professionals are properly supported and working to a respected scope of practice.

The GMC is currently consulting on the regulation of PAs and AAs and although we await the outcome of the GMC’s consultation, NHS England will review this guidance in light of the GMC’s consultation.

We will also work with partners, like the GMC, royal colleges, faculties, doctors, trade unions, and MAP groups to explore the development of national standards for MAPs by specialty, preceptorship support and frameworks, capability and career development frameworks, and appraisal and supervision guidance. 

We will ensure any future guidance is in keeping with any regulatory decisions and we will provide further details shortly.

Contact

If you have any questions or would value a conversation about any issues related to MAPs, please email us at england.maps@nhs.net

Publication reference: PRN01388