Employing a Qualified PA

Both primary and secondary care face increasing workforce pressures and physician associates might be part of a wider solution to help. It is imperative that employers consider whether it is PAs who have the right skills to perform the roles that are needed and that they will be a cultural fit for the organisation.
Useful tips for this:
• Perform a skills gap analysis and compare this to a number of health professional roles
• Do not replace one health professional with another. If a doctor is needed for the role then a doctor is what should be sought
• Consider the reason for employment of PAs; this might include continuity in high volume areas where junior medical staff work across varying shift patterns
• In secondary care, PAs can allow doctors to see more patients. In primary care, PAs have their own appointment list but there must always be a GP on hand in the practice for supervision
• The business case for PAs will be informed by the drivers to employment. This may include time release for doctors by adding an additional team member, better GMC feedback as ability to attend training increases, reduced clinic waits (RRT), better patient feedback in areas where complaints are high.

This will help to shape your own views on how PAs can work within an organisation and what they can offer clinical teams.  It will also allow those with concerns or misperceptions to have these addressed before PAs are introduced into the team.  The FPARCP and KSSPAS can help to signpost employers to others who have successfully introduced PAs locally.

Physician Associates need variation in their day to day work.  Like any health professional they have a responsibility to undertake the necessary administrative elements of their work but they need the opportunity to practice all of the skills attained during training including patient history taking, clinical examination and formulating differential diagnoses and management plans.  Varied job plans are likely to ensure that PAs remain in one organisation for a period of time as well as having time for personal development, audit and quality or service improvement activities.  Job plans should allow for regular contact with the named supervising physician and also ensure the PA has access to senior clinicians for advice, support and to take on tasks that currently restrictions prevent for PAs (such as ordering ionising radiation and prescribing).  Sample job plans are available from the FPARCP.

Consider the working hours of the PA in relation to where you see the role working best and based on your rationale for employing them.  In secondary care budgets will have to allow for an uplift if PAs are working outside of normal working hours as is the case for all Agenda for Change clinical staff.   The pay scale in used in Primary care is usually locally negotiated and will not be subject to the restrictions of Agenda for Change.

Often the first step to recruitment is in taking Physician Associate students as evidence suggests that PAs have previously worked close to where they have trained.  It also allows the PA students to become the ambassadors for the role by promoting the role within the organisation.  Many of the University programmes training PAs run recruitment days allowing potential employers to pitch employment opportunities to the students.

Physician Associates are usually advertised at Agenda for Change band 7 although some Internship years for those who are newly qualified may be advertised at band 6.

Internship years are popular with newly qualified Physician Associates as they can offer variety of experience to help shape the career direction of undecided PAs.  It does mean, however that the recruitment process is continual and arrangements with local universities training PAs may be one way of providing continued resource of graduating PAs.  Other employers may seek to employ PAs who will stay for a longer period of time, who will ultimately gain organisation knowledge which can generate significant work and team efficiencies.

Only consider employing PAs who have completed a recognised UK or US training course and have passed the UK national examination that allows them to practice in the UK.  Ensure that applicants are listed as current members of the Managed Voluntary Register held at the FPARCP (PA-MVR).

Job adverts are usually posted on NHS jobs and the FPARCP website. www.jobs.nhs.uk

If your organisation is based in Kent, Surrey or Sussex and you are considering employing a PA, please contact the KSS School of PAs for further help and advice: kss.schoolofpas@nhs.net.  Please also advise us of all PA appointments so we are able to keep a record of where PAs are working within the region.

In Secondary Care, PAs are employed on NHS Agenda for Change contracts. These are either Band 6 or Band 7 roles. Band 6 contracts usually apply when a structured internship year is offered.

In primary care the salary for a PA can be negotiated dependent on experience. Job descriptions should describe the work environment as well as provide an indicative job plan. It should also highlight supervisory arrangements and job plans should allow opportunity for regular contact with the supervising doctor.

PAs are employed by the GP practice or trust where they work and their salary is paid by their employer.

The title ‘Physician Associate’ is not protected therefore employers should be diligent in their recruitment process. It is imperative that job descriptions state applicants must hold a PG Diploma/MSc in Physician Associates Studies from a recognised US or UK programme and that they have passed the UK Physician Associate National Exam. We also recommend that you only employ PAs who have full FPARCP membership and are therefore listed on the PA-MVR. US trained Physician Associates should have and maintain their National Commissions on Certification of Physician Associates (NCCPA) accreditation to work in the UK and should also be listed on the PA-MVR.

Employers of newly qualified PAs or PAs moving to a new specialty may wish to offer a one year ‘internship’ so that the PA is able to consolidate their core knowledge and skills and demonstrate their competence in practice. During this period the PA should be supervised more closely, have experiential learning in the clinical area in which they are working, and should maintain a portfolio of cases and case discussions with clinicians which may also be reviewed with their clinical supervisor. The FPARCP website has additional information about internship.

PAs work to a code of conduct which is available on the FPARCP website.

Fitness to practice issues must be reported to the PA-MVR to ensure that no PA remains on the register without demonstrating fitness to practice.

One of the main benefits of employing physician associates is the value realised over time as the PA becomes imbedded into the team.  The organisational and logistical knowledge they acquire can help drive efficient working.  PAs become skilled in the clinical area in which they work and so employers need to ensure retention in the longer term.  Varied job plans are one means but the ability to promote personal and professional development is important.  PAs must maintain a Continued Professional Development diary held at the Faculty of Physician Associates at the RCP and as part of this must attain 50 hours of CPD activities per year.  Employers might consider ways in which to support PAs in achieving this either in time release, financial support to attend CPD accredited courses and educational opportunities including post graduate academic qualifications.  The 2017 Census suggests that 35% of respondents received on average 5 days of paid study leave per year (and a median of £500 in financial support).

Employers should consider how a PA has access to development in the workplace.  Opportunities for internal development in areas such as research, audit, leadership and management are some examples and allowing time for such activities in job plans is recommended.  Employers may also wish to allow time release for PAs wanting to support the national development of the profession by working with FPA committees, specialty societies/colleges or Higher Educational Institutions as educators of future PAs.

Employers should provide regular appraisal (at a minimum of annually) that reviews progress made against a personal development plan as well as performance within the role.  Appraisal documentation is available from the FPARCP which can be used in combination with organisational appraisal documentation.

All PAs require an annual appraisal with their clinical supervisor. Over the course of any given year, a PA is likely to have worked with different team members so gaining feedback from colleagues is vital prior to the appraisal. Many primary and secondary care organisations also have their own appraisal documentation or achievement review systems with additional documentation. This may involve review by the line manager rather than clinical supervisor. The FPARCP website has forms that can be used to collect patient and colleague feedback, evidence case-based discussions and to confirm direct observation of procedures:

http://www.fparcp.co.uk/your-career/cpd

Recommendations for reviews, appraisals and the number of workplace based assessments are set out below. The frequency of review meetings may depend on individual PAs and whether areas have been identified for additional support.

On appointment each PA should be given a named clinical supervisor. This will be a Consultant or General Practitioner who will work with the PA. The clinical supervisor and PA should organise a start of employment meeting as part of the induction period. Graduates or those coming into primary or secondary care from another healthcare setting should focus on identifying their learning needs and how these can be addressed in the first year and beyond. Regular review meetings are recommended for those in new healthcare settings or those in their first year after qualification.

Some employers may wish to offer newly qualified PAs a one year ‘internship’ to allow the them to consolidate core knowledge and skills and demonstrate competence in practice. During this period the PA should be supervised more closely, undergo experiential learning in the clinical area in which they are working, and maintain a portfolio of cases and case discussions with clinicians which may also be reviewed with the clinical supervisor.

Each Trust should develop its own framework of standards for the PAs it employs.  This should cover employment considerations, supervision arrangements, appraisal processes and professional development. Suggested content for a governance policy includes the following:

Pre-employment checks

The PA’s qualifications and registration on the PA-Managed Voluntary Register (PA-MVR) should be checked.

The Faculty of Physician Associates (FPA) recommends that employers only employ PAs who have graduated from a recognised UK or US training programme.  The FPA will accredit UK training programmes in due course.

The governance policy should specify that PAs have a contractual obligation to be registered on the MVR held at the RCP in London and that registration status will be checked at appointment and annually thereafter.  All essential job specifications and adverts should also state this. Employers should also stipulate the outcome of failure to comply with this obligation.

Indemnity arrangements

It is up to employers to determine whether PAs require professional indemnity coverage and this should be mentioned in the governance policy.  For NHS Trusts, indemnity is not required but it is advisable to provide the PA with access to ‘non-claims’ benefits such as assistance with disciplinary proceedings, advice on ethical or professional issues and access to support at coroners’ inquests.

In most primary care organisations, PAs must have personal indemnity cover which may be funded by the employing practice.

Job plans

Specific job plans are not required in a governance policy but it is useful to include any recommended sessions that PAs should undertake. This helps to guide departments when formulating or changing job plans.  For example, each PA might be expected to have a session in front door medicine seeing new patients, or to take part in audit or quality improvement projects. If PAs are required to take part in out of hours activities, this information should be included as well as the associated supervision arrangements.

Salary

Secondary care salaries are in line with Agenda for Change standards and the matching process for Agenda for Change demonstrates that at qualification, Physician Associates are Band 7.

In primary care, PA salaries vary and are set by individual practices.

First year of employment

This includes preceptorship arrangements and probationary periods. This section should cover arrangements for probationary periods, supervision and reviews for newly qualified PAs or those transferring from other clinical environments. The FPA website gives some recommendations on the frequency and type of review.

Core skills that PAs can carry out in a Trust

This section should provide a list of duties, core skills and procedural competencies to ensure that all staff understand PAs’ core practical skills as well as restrictions to practice.

Controls & restrictions

This section will apply to controls regarding consent, ordering investigations, referrals, prescribing, transcribing medications, discharge medication and letters, certificate of death, end of life care and DNAR.

Given the current restrictions on practice (prescribing and ordering x-rays) the policy should refer to how PAs work in practice, for example in completing discharge paperwork. Supervision arrangements should also be considered, as well as who is responsible for reviewing when the PA’s named supervisor is not present.

Extended skills, competency levels, supervision and excluded skills

Extended skills beyond those that PAs have acquired during training should be listed, as well as how those skills are acquired, recorded and competency assessed.  Consider the type of competency assessment required and review the framework for PAs taking on new skills. This will help to ensure only competent individuals are teaching PAs new practical skills and that they have adequate supervision, assessment and ongoing review. Consider how the restrictions on practice affect the procedure, ie prescription and administration of local anaesthesia. List any excluded practical skills.

Supervision arrangements for PAs

Policies should be clear on the supervision arrangements for PAs. As PAs work under the GMC clause of delegation, supervisors may delegate clinical duties to PAs when they are not present. This may, however, leave the PA unsupported. For example, if a patient requires medication or ionising radiation, this may be delayed if a PA is working alone. On a day to day basis it might be better for a PA to be paired with a fully registered doctor and not a foundation year 1 doctor, for example.

This section should also include a brief summary of responsibilities to support and review PA practice. This would be similar to the arrangement between an educational supervisor and a doctor in training. Line management could be from a senior PA.

Organisational structure chart and processes relating to governance of PAs

Clearly set out reporting lines in terms of clinical supervision, line management and any internal arrangements to monitor PA practice and whose responsibility it is to lead this.

Support available for PAs approaching the re-certification exam

This section might list sanctioned leave or financial support to aid the PA in re-certification. It should also clarify the outcome, should a PA fail to achieve re-certification (for example termination of employment).

How the Trust will help PAs ‘stay generalist’

This section may outline opportunities to attend internal teaching relevant to the core curriculum framework and time to maintain acute admissions experience. This is particularly important for PAs working in sub-specialist areas who may struggle to maintain generic competencies of knowledge.

CPD requirements and study budget/leave arrangements

This section of the policy should stipulate requirements and any employer support available such as the provision of study budget and study leave. Guidance on CPD requirements is available on the FPA website.

Description of teaching programme available

Many larger employers provide a PA teaching programme which ideally should be mapped against the Core Curriculum Framework and matrix of conditions.

Review/appraisal processes

This will vary from employer to employer but should utilise tools similar to those used by doctors in training.  A variety of work based assessment tools are available on the FPA website along with guidance on the frequency of reviews and a suggested number of assessments.

Fitness-to-practice processes

This section should detail how the employer will deal with fitness to practice concerns regarding PAs, who is responsible for informing the FPA and, where necessary, who will remove the PA from the register.

Arrangements for PA students on placement

This section should detail general supervision arrangements for PA students hosted by the employer.

Despite the rapid expansion of physician associate programmes across the UK, many health professionals have yet to meet or work with PAs in their working lives.  It is imperative therefore to make sure that current workforces have an understanding of the role and the rationale for employing PAs.  This can be done in several ways such as leaflets, weekly messages and email updates. TV screens in clinical areas are also useful at increasing awareness both for staff and for patients.  In secondary care, departmental meetings, grand rounds and educational sessions are useful times to speak to doctors in training.  Involvement of other health professional groups such as nurses, physiotherapists and occupational therapists, to provide the wider MDT with an understanding of the role of a PA, is vital.

Role awareness is essential to acceptance of PAs into the clinical team so that all are aware of the competencies and limitation of PA practice.  In areas with frequent staff rotation, inclusion of PAs in induction of new staff is a useful means to achieve this and must be continued at each point new staff are introduced.

Role awareness among doctors in training is particularly important as PAs will be working in many situations directly alongside trainees.  The FPARCP are working with the training colleges as part of a wider communication strategy to publicise and define the role of a PA in working with trainees.  In the workplace it is essential to do the same in order that trainees understand the role of the PA, why they were employed, scope of practice and what is expected of trainees working with them.

Similarly it is important that associated practitioner roles such as Advanced Clinical Practitioners, Nurse Practitioners, Pharmacists, etc. have an understanding of the role to promote cohesive working and the strengths of a diverse workforce.

Leaflets are available from the FPARCP about the PA role to help with this.

Employing organisations need to promote the work of PAs to their patients.  This often begins when a PA is employed as PAs are the greatest ambassadors for their profession.  Provision of lanyards, clear identification badges or labelled/coloured scrubs (dependent on the area the PA is working) that state ‘Physician Associate’ can help with this.  Organisations may want to design their own branded leaflets explaining the role.  Involvement of patient representative groups is recommended to ensure clear language is used.  Short videos/stills with subtitles on screens in patient areas is also a useful way for patients to become familiar with PAs working in clinical environments.