The Role of Physician Associates within General Practice

Avon LMC has previously published guidance on the role of Physician Associates within general practice in the newsletters dated 12 June 2024 and 16 Oct 2024. In view of the Leng Review (16 July 2025) we are now updating this guidance.  

We acknowledge the uncertainty that PAs are currently facing following the publication of this review, and we recognise the emotional toll this may be having on individuals. NHS England has made wellbeing resources available for all NHS staff, including a 24/7 text support scheme.

As a Local Medical Committee, we do not have the authority to make decisions on behalf of practices regarding the employment or utilisation of PAs. However, we are able to share guidance from various professional bodies to help practices make informed decisions.

Leng Review

The Leng Review is an independent review commissioned by the Department of Health and Social Care to evaluate the safety and efficacy of Physician Associates and Anaesthesia Associates.

Following an evidence review and public consultation, the review makes the following recommendations:

• Change the job title from Physician Associate to Physician Assistant
• Enable ongoing training, credentialing, and structured career development
• Restrict the management of undifferentiated symptoms to clearly defined national protocols
  • e.g. minor ailments in adult patients as outlined by the RCGP
• Require newly qualified PAs to spend their first two years in secondary care
• Assign a named GP supervisor with overall responsibility
• Clearly identify the role through name badges and patient-facing materials
• Establish a professional standards faculty

NHS England Guidance

NHS England has responded to the Leng review and advises the following immediate changes:

• Change the job title to Physician Assistant
• PAs should not undertake triage duties in General Practice
• PAs should not see undifferentiated patients
• Employers should review PA roles and job description

The PCN DES Contract Specification updated on 31/07/25, after the Leng review was published, remains unchanged with regards to ‘key responsibilities’ for PAs. This is likely due to the judicial review in progress, instigated by UMAP (United Medical Associate Professionals).

The ‘key responsibilities’ for PAs in the updated PCN Network DES are as follows:

“where their named GP supervisor is satisfied that adequate supervision, supporting governance and systems are in place, provide first point of contact care for patients presenting with undifferentiated, undiagnosed problems…”

UMAP statement following Leng Review

UMAP (United Medical Associate Professionals) has shared a statement following the Leng Review and the recent NHSE response. It has advised that, before implementing changes to PA roles, employers should seek legal advice regarding the interpretation and legality of NHS England’s recent guidance, in order to ensure compliance with employment law.

They are also seeking a judicial review against NHS England and the government following the recommendations being made within the Leng review.

RCGP Guidance

Following membership consultation in May 2024, the college updated its guidance on PAs in October 2024 to include information on induction and preceptorship, supervision, and scope of practice.

The supervision and scope of practice recommended for embedded PAs within general practice is as follows:

• All patient presentations should be triaged by a GP
• Repeat presentations of same condition must be directed to a GP
• Debriefing for every patient encounter (can be at end of session) with named GP Clinical Supervisor (who is not remote)
• 2-weekly review meetings with GP Clinical Supervisor
• Scope restrictions (which broadly mirror BMA guidance on GP scope):

WITHIN PA SCOPE OF PRACTICE	OUTSIDE PA SCOPE OF PRACTICE
Minor illness over 16 years with clear clinical pathways and escalation process Pharmacy First conditions are a good start	Anything potentially serious eg: abdominal pain, headache
NHS Health Checks	Mental Health
With extra training: – Sexual Health/Smears (no LARC) – Travel advice/imms – Single LTC management – HRT reviews – ECG/Spirometry	– Frailty – Comorbidity – Home visits/care homes – End of Life Care/ACP – LD
	Under 16
	Obstetrics and Gynaecology
	Minor surgery/joint injections/LARC

GMC Guidance

As of December 2024, the GMC  began regulating Physician Associates and Anaesthesia Associates, alongside doctors. This transitional process will be fully implemented by December 2026.

The GMC has updated its guidance on the Supervision of Physician Associates. Key points are:

• PAs must work under supervision, with supervision levels tailored to experience
• Delegation and escalation processes must be clearly defined
• Prescribing responsibility remains with the prescriber.
• Doctors are not accountable for PA actions if delegation aligns with GMC standards

In an update published on 05/06/24, the GMC states that doctors are not accountable for the decisions and actions of PAs, provided they have delegated responsibility to them in line with the standards and guidance in Good medical practice, Leadership and management for all doctors, and Delegation and referral.

The GMC has also addressed concerns raised by a 2017 Medical Practitioners Tribunal ruling, clarifying that issues related to PA supervision were not the sole basis for action taken.

The scope of practice of a PA is not addressed but the GMC has produced a document describing the capabilities and outcomes newly qualified PAs must meet to be registered by the GMC.

CQC Guidance

GP mythbuster 82: Physician Associates in General Practice was updated in December 2024.

• PAs must always work under the supervision of a senior GP
• Supervisors must be readily accessible and capable of providing real-time support
• PAs must be on the GMC register, which includes successful completion of the Physician Associate Registration Assessment. (RCP-led)

The scope of practice is not addressed.

BMA Guidance

The BMA has produced guidance on the Safe scope of practice for PAs which states:

• PAs should only support doctors and not see undifferentiated patients
• When seeing patients already triaged by a GP, PAs must not make independent clinical decisions
• This scope of practice is reflected in both BMA and RCGP guidance

Since the publication of the Leng review, they produced further guidance on the utilisation of PAs.

Clinical Negligence Scheme for General Practice (CNSGP)

Since April 2019, NHS GP practices operating within England have benefited from a state indemnity scheme called CNSGP. In their FAQ section, they confirm that both PAs and their supervisors are indemnified for clinical negligence liabilities arising from any incidents.

Avon LMC wrote to CNSGP who confirmed (on 05/08/25) that as long as care provided by PAs is part of the practice’s contractual obligations, any resulting negligence claims are likely to be covered—even if the scope differs from the recommendations made by the RCGP or the Leng Review. Their full response is as follows:

We can confirm that PAs working for general practice who are carrying out activities connected to delivering NHS primary medical services on behalf of the provider under a primary care contract in England (GMS, PMS and APMS arrangements) will be indemnified under the Clinical Negligence Scheme for General Practice (CNSGP) for clinical negligence liabilities arising from incidents that occurred on or after 1 April 2019. 

 This indemnity extends to activities carried out by PAs which are connected to the delivery of other NHS services provided by general practice and known as ‘Ancillary Health Services’ where these services fall within the relevant definition in regulation 2 of the CNSGP Regulations.

 GP partners/GP principals and other clinical staff responsible for the supervision of PAs within general practice can also be reassured that they will be indemnified as above, 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.  Please see the full FAQ on our website here – Clinical Negligence Scheme for General Practice (CNSGP) – NHS Resolution Indemnity under CNSGP is not conditional upon having followed RCGP guidance or implemented changes as per the Leng review as to scope of practice.  The question of scope of practice for Physician Associates is not a relevant consideration for NHS Resolution in determining eligibility for indemnity under the CNSGP. 

 A PA who has seen a patient of any age or complexity of presenting complaint, both before and after the publication of the RCGP guidance in question and the Leng review, would benefit from indemnity via CNSGP provided that they were carrying out activities connected to delivering NHS primary medical services under a primary care contract in England (i.e. GMS, PMS and APMS arrangements). 

 Whilst the question of scope of practice is not a relevant consideration for NHS Resolution in determining eligibility for indemnity under the CNSGP, it may be a relevant factor as part of any subsequent liability investigations into a claim more generally if the practice has a system of working which engages Physician Associates in a way which is contrary to RCGP guidance or and The Leng Review.

 It is entirely outside of our remit to provide any advice to Physician Associates or GP surgeries as to how to configure their services, deploy their staff, or say what is or is not appropriate clinical practice in primary care. Any concerns you may have about the medico legal issues arising from the RCGP’s guidance on scope of duty would be better addressed by your Medical Defence Organisation (MDO), trade union or other such body who will be able to provide you with appropriate advice.

What this means is that any clinical negligence claims against a PA (or their supervision) will be covered by CNSGP, but they do not cover claims arising from other liabilities, such as GMC hearings or criminal investigations. This would need to be discussed with a practice’s individual MDO provider. (MDU, MPS or MDDUS)

Medical Defence Union (MDU)

The MDU has written guidance (dated June 2024) on how to integrate PAs safely and effectively into teams and manage medico-legal risks. This reiterates GMC guidance stating that you must be confident that the person you are delegating to has the requisite knowledge, training and skills. If appropriate delegation has occurred, then PAs remain accountable for their actions.

Avon LMC Safeguards for embedded Physician Associates in General Practice

In summary, Avon LMC recommends the following safeguards for practices/PCNs employing established PAs:

• Discuss any job title changes with the employee and review employment contracts
  • see ACAS guidance.
• Ensure participation in the Physician Associate Registration Assessment.
• Review roles and job description  in line with RCGP scope of practice.
• Develop protocols for appropriate triage of patients directed to PAs
• PAs must not conduct clinical triage unless performing care navigation
  • refer to BMA guidance on care navigation vs clinical triage
• Debrief all patient consultations at the end of each session with a named supervisor
• Allocate sufficient time for daily supervision by a qualified GP (not GP Registrar or ACP)
• Appoint a trained GP Educational/Clinical Supervisor responsible for training and performance
• Schedule monthly tutorials (as a minimum) with a GP supervisor to review cases
• All medication entries in EMIS should be made and issued by the supervising GP following case discussion
• Comply with IR(ME)R regulations with only registered healthcare professionals being permitted to request ionising radiation examinations
• Seek additional professional advice as needed:
  • Indemnity provider for non-clinical claims (Avon LMC awaiting response)
  • Corporate liability insurance
  • HR and legal advice. . Guidance from Kraft HR Consulting can be found here.