Pharmacy First 'good starting point' for PA scope of practice, says RCGP

Pharmacy First 'good Starting Point' For PA Scope Of Practice, Says RCGP

The clinical pathways delivered under Pharmacy First are a 'good starting point' to define the scope of practice for Physician Associates (PAs), the Royal College of GPs (RCGP) has said.

Pharmacists must undertake additional training to deliver minor ailments consultations under Pharmacy First.

But the RCGP suggested that 'first point of contact presentations' of over 16s with suspected minor or common conditions, 'with clear clinical pathways and escalation processes' would be within the scope of practice for PAs without any extra training.

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It suggested this could include conditions such as otitis media, urinary tract infections (UTIs) and sore throats.

This comes as part of three new documents issued by the RCGP which set out guidance on preceptorship and induction of PAs, supervision arrangements, and detailed descriptions of what a PA can and cannot do in clinical practice.

On clinical scope, the RCGP said: 'The seven common minor illnesses used in the Pharmacy First programme in England are a good starting point.

'The list of minor conditions a PA can see must be agreed and documented, with clinical protocols for diagnosis and management.'

The RCGP stressed that PAs 'must not see patients who have not been triaged by a GP' and must only undertake work 'delegated to them by, and agreed with, their GP CS [clinical supervisor]'.

And it said the triage process must 'incorporate patient preferences about the healthcare professional they see'.

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The RCGP also advised practices that they should only employ PAs that appear on the Physician Associate Managed Voluntary Register - meaning that they have successfully completed the two-year postgraduate programme and passed the PA national exam, or, once the profession is regulated by the general medical council (GMC), physicians who appear on the GMC’s Register of PAs.

The Royal College of Physicians' Faculty of Physician Associates notes that 'PAs are dependent practitioners working with a dedicated medical supervisor'.

And the RCGP has called for a national preceptorship programme to fund the supervision and ongoing education of PAs in GP practices in England.

The RCGP also suggested that other clinicians working in general practices might be involved in supervising some teaching sessions with the PA preceptee, although the GP clinical supervisor and GP educational supervisor would be 'ultimately responsible for these teaching sessions'.

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While the RCGP said it was not within its remit to 'enforce this guidance', it noted that it 'may be taken into account by NHS Resolution and the Medical Defence Organisations in a case of alleged negligence or clinical or professional mistakes'.

‘Ultimately, it is the decision of employers whether to follow this guidance, and the employer’s responsibility to ensure the appropriate treatment and handling of existing PA contracts,’ it added.

What does PA training involve?

To be accepted onto a postgraduate PA training course, most applicants will need a bioscience-related undergraduate degree.

The two-year postgraduate training course then ‘involves many aspects of an undergraduate or postgraduate medical degree’ and focuses mainly on general practice and general adult medicine in hospitals, according to the NHS careers website. Following this, trainees must pass the PA national examination, which allows them entry onto the Faculty of Physician Associates (FPA) voluntary managed register.

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According to the Royal College of Physicians' Faculty of Physician Associates, at the point of qualification PAs are expected, among other core competencies, to be able to:

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  • Perform a physical examination tailored to the needs of the patient and the demands of the clinical situation, including, as appropriate, neurological examination, musculoskeletal examination, blood pressure (BP) measurement and control, male and female uro-genital examination, breast examination, ophthalmic examination, oropharyngeal examination cardiovascular examination, respiratory examination, abdominal examination and dermatological examination
  • Perform a comprehensive mental state examination, tailored to the needs of the patient and the demands of the clinical situation, including as appropriate, assessment of appearance and behaviour, levels of consciousness, posture and motor behaviour, thoughts and perceptions, affect, speech and language, orientation, memory and higher cognitive function
  • Interpret the findings from the consultation (history, physical examination and mental state examination) in order to determine the need for further investigation and, with the patient/carer, the appropriate direction of patient management
  • Understand the indication for initial and follow-up investigations
  • Select, interpret and act upon appropriate investigations
  • Determine the relevance of screening tests for a given condition
  • Formulate a differential diagnosis based on objective and subjective data
  • Make use of clinical judgement to select the most likely diagnosis in relation to all information obtained
  • Recognise when information/data is incomplete and work safely within these limitations
  • Recognise key diagnostic errors and the issues relating to diagnosis in the face of incomplete data
  • Recognise when a clinical situation is beyond their competence and seek appropriate support
  • Working under medical delegation clauses, determine and propose appropriate therapeutic interventions from the full range of available prescription medications used in the clinical setting
  • Write accurate and legible prescriptions in out-patient, in-patient and primary care setting for review and signature by a supervising clinician
  • On commencing intravenous infusion, write accurate and legible prescriptions for appropriate fluid regimes for review and signature by a supervising clinician
  • Use the British National Formulary (BNF) and local formularies appropriately and be familiar with the yellow card system for reporting side effects/drug interactions
  • Recognise their responsibility for facilitating patient concordance for the drug regime being proposed by them and prescribed by their supervising clinician.

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