Estimated read time: 10 mins
The physician associate (PA) role was developed in the US in the 1960s. The UK introduced PAs in 2003 to help address staffing shortages and fill service gaps. They are permitted to register with the General Medical Council (GMC) in the UK as of this year but have a two-year period to apply for registration. The UK experience has been turbulent and has generated much debate in recent months.
The employment of PAs is a recent development in New Zealand and they are not yet regulated nor covered by the Accident Compensation Corporation (ACC). The Minister of Health recently announced that PAs will be regulated by the Medical Council of New Zealand1. The Honourable Simeon Brown states, “By regulating physician associates, they will be required to meet clear standards that are appropriate for the New Zealand health system, including training, supervision, and ongoing professional development.”
There are many questions about what is within their scope of practice, what training have they received and what is the responsibility (and therefore liability) of the supervising doctor.
According to the New Zealand Physician Associate Society (NZPAS) website, PAs work in collaboration and under the ‘license’ of their supervising doctor. NZPAS currently has 50 members.
To become a PA, you must hold a bachelor's degree in a health or biological sciences or allied health field. In the UK, the PA qualification is a two-year post graduate master’s degree. This equates to a total of one year of lectures and one year (1600 hours, 200 of which can be simulation) of clinical placement. For comparison, the nursing degree is three years of full-time study, including human sciences and clinical work. Medicine is six years study including roughly 4000 hours of clinical, then two years internship to obtain general registration then specialist qualifications and ongoing CPD requirements.
Once qualified, PAs have no further requirement for formal training or credentials and in New Zealand as a currently unregulated healthcare worker, they have no CPD requirements. It is likely that once they are regulated this will change.
According to the NZPAS website, once qualified the PA qualification allows the PAs to work in the following scope examples:
Obtaining medical histories
Ordering and interpreting tests
Diagnosing diseases
Managing acute and chronic conditions
Prescribing medications (please see below)
Referring to specialists
Performing minor operations
Managing inpatient care in hospitals
In New Zealand and the UK, PAs are not permitted to prescribe medication. However, their website states that prescribing medication and ordering tests requires extra steps:
Because PAs are currently an unregulated profession in New Zealand, many tasks like prescribing meds or ordering labs, require extra steps to obtain the supervising GP’s signature. This often slows the process of delivering effective healthcare outcomes for PAs. However, NZPAS is currently working toward regulating the PA profession in New Zealand. Visit our PA Regulation page to find out how you can help unlock the full potential of PAs for Aotearoa.
PAs have been in the UK for many years now, introduced to provide support to doctors. Following the unveiling of plans to substantially increase the number of PAs in the NHS however there was a significant backlash from certain parts of the medical community, particularly from doctors in training. There followed heated exchanges in social media which at times became toxic. The BMA are strongly opposed to the expansion of the PA role.
The results of a recent survey by the BMA2 showed that 87% of respondents felt that PAs and AAs (anaesthetic associates) always or sometimes presented a risk to the public. 55% of respondents said they faced a higher workload since PAs and AAs had been introduced. Only 9.9% felt that PAs and AAs improved patient care. 79.6% of respondents had concerns that PAs and AAs were undertaking work beyond their competence. 86% of respondents felt that patients were not aware of the difference between a PA and doctor. 80% felt that they would be more appropriately termed ‘assistants’ rather than ‘associates’. The BMA have recommended that there should be an immediate halt to the recruitment of PAs and AAs in the UK; titles should revert to Physician Assistant; scope of practice should be ‘limited to the original intention of supporting doctors with administration tasks and defined range of low-risk clinical tasks.’3
There have been a number of recent high-profile cases in the UK media about concerns raised regarding the safety of PAs in practice.4 In one case a woman died in 2022 after seeing a PA twice for the same issue. At the first visit she presented with calf pain and shortness of breath. She was diagnosed with calf strain and possible long covid. At the second appointment one week later, her leg was swollen and hot and she struggled to walk without shortness of breath. The PA did not examine the patient’s legs and diagnosed anxiety and long covid, prescribing propranolol for the anxiety. The patient took the propranolol and deteriorated at home later that day. An ambulance was called but she died of pulmonary embolus on the way to hospital. The patient was not aware that she had not seen a doctor.5
The UK health secretary has ordered a review of what PAs do in the NHS.6
As explained earlier, PAs are currently not regulated in New Zealand and do not have a defined scope of practice. They are currently not covered by ACC. The breadth of general practice is extensive, it requires a very broad knowledge base. As doctors we have had extensive undergraduate training, usually two years working as a house officer, completed post-graduate qualifications and become vocationally registered after many years of intensive training, passing rigorous examinations. As with all clinicians, each PA’s level of competence of will vary. When supervising a PA, it is important to understand their specific competencies.
The principles that underpin your responsibilities when supervising PAs are much the same as when supervising junior clinicians.
The Medical Council of New Zealand (MCNZ) has not yet provided any guidance on the supervision of PAs. However, in the UK, the General Medical Council (GMC) have issued sensible guidance on supervision of PAs. They advise that it is important you are “confident they have the necessary skills, knowledge and training to carry out the task; able to give clear instructions about what is expected; available to answer questions or provide help when needed; sure they are clear on how to escalate any concerns.”7
GMC guidance on delegation and referral8 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.
The Royal College of General Practitioners in the UK have set out the following guidance that may be helpful to refer to. :
The RCGP does not consider that remote supervision is appropriate for PAs.
It is important that:
The GP CS [clinical supervisor] or GP with delegated responsibility for supervision must be available to provide immediate support for PAs who are new to general practice, for at least the first 12 months in general practice.
All PAs must have regular supervision time, on a daily basis, to ‘hot review’ all the cases that have been seen that day. This time could also be used to review the progress of the PA and identify further training needs.
A weekly or fortnightly review meeting must take place between PA and GP CS to discuss areas that are working well, or those that need additional help or training to enable the PA to work to their full potential.
There must be regular in-house reviews, during protected time, to identify areas of interest, explore the development of longer-term goals and identify and use any skills not currently being employed.
The notes made at every PA/patient encounter must be signed off by the GP CS at the end of the surgery day.
Any clinical advice given by the GP CS or GP with delegated responsibility for supervision must be documented.
There should be regular communication between those who are responsible for supervising a PA, so all are aware of the PA’s progress and any challenges.
There must be a written protocol, that is discussed and understood in advance by the PA and GP CS, to facilitate safe prescribing for the patients seen by the PA. The PA will need access to an authorised prescriber to either sign off a prepared, or generate a proposed, prescription.
Introductory arrangements, as described in the ‘Preceptorship/ Induction’ guidance document must be followed, so that patients know who they are seeing and have consented to see that healthcare professional (Healthwatch, 2024).9
In New Zealand, the Code of Health and Disability Services Consumer’s Rights states,
Right 7 (8) Every consumer has the right to express a preference as to who will provide services and have that preference met where practicable.
To avoid the common misconception of patients, that a PA is a doctor, ensure that this is explained to them at the time of booking. The PA should introduce themselves appropriately, explaining their role.
The Medical Council of New Zealand (MCNZ) statement good prescribing practice10 includes:
Make the care of patients your first concern. You should only prescribe medicines or treatment when you have adequately assessed the patient’s condition, and/or have adequate knowledge of the patient’s condition and are therefore satisfied that the medicines or treatment are in the patient’s best interests.
Take an adequate history of the patient, including: family history of the disease or condition, any previous adverse reactions to medicines; previous and current medical conditions; and concurrent or recent use of medicines (including non-prescription, complementary and alternative medicines).
Consider whether a prescription is warranted, given the nature of the patient's complaint and presentation; and whether the complaint and presentation could be an adverse effect of a medicine.
Consider also whether non-treatment or a non-pharmacologic treatment could be as effective and safe.
Ensure that the patient (or other lawful authority) is fully informed and consents to the proposed treatment and that he or she receives appropriate information, in a way they can understand, about the options available; including an assessment of the expected risks, adverse effects, benefits, and costs of each option.
Satisfy yourself that the patient understands how to take or use any medicine prescribed and is able to take it or use it.
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 confirm 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.
The Health & Disability Commissioner states: “Doctors owe patients a duty of care in handling patient test results, including advising patients of, and following up on, abnormal results. The primary responsibility for following up on abnormal results rests with the doctor who ordered the tests.”11
PAs are not permitted to order investigations and any tests they feel are indicated will be in the supervisor’s name. The supervisor has primary responsibility for ensuring the test results are reviewed and acted on in a timely manner. This responsibility can be delegated to an appropriate person. Some GPs delegate this initial review of their inbox to a non-doctor with strict protocols to ensure that no significant results/letters are missed. This is no different when tests are ordered under your name by the PA. The supervisor is responsible to ensure that the protocol is appropriate and the delegated staff member suitably trained and competent for this role.
For practice owners, as the employer of the PA, you will, in certain circumstances, have vicarious liability for any errors arising from the PAs care. Good induction into NZ practice, and your clinic is essential. We suggest that you ensure you have comprehensive policies and procedures in place for both supervisors and the PA supervisee setting out expectations, what supervision entails, the limits of the PA’s role and lines of communication and accountability. Once in place it is essential that these policies and procedures are followed and preferably there are regular audits to ensure compliance.
If you are a supervisor, we are very happy to assist you in your role should you have any questions or concerns relating to the PA you are supervising.
For the practices who hold a Practice Package with Medical Protection you can come to us to request support and assistance if you have any concerns about a PA. If you would like further information about the additional cover that a Practice Package provides, please email NZPractice@medicalprotection.org
