Physician associates: Direct instruction is a more appropriate term than supervision
BMJ 2025; 389 doi: https://doi.org/10.1136/bmj.r1096 (Published 29 May 2025) Cite this as: BMJ 2025;389:r1096
The rapid expansion of physician associates (PAs) and other medical associate professional roles has prompted renewed debate about what constitutes adequate supervision for NHS clinical staff. Guidance from NHS Employers and the General Medical Council (GMC) states that PAs must be supervised at all times.12 However, the definition of “appropriate supervision” remains broad and inconsistently applied, with ambiguity around terminology.
Recent guidance from the GMC draws a distinction between direct supervision by the named consultant supervisor of a PA and their day-to-day supervision, which in some clinical environments may be delegated to resident doctors.3
These resident doctors are expected to assess the capabilities of PAs, including situations where a PA may recommend medicines that require prescribing authority. In this situation the responsibility will fall on the resident doctor, rather than the named consultant, to ensure that the prescription is appropriate, necessary, and safe. In contrast with supervision models outside medicine where legal and professional responsibility lies with the employee, the NHS model places supervisors in a position of ultimate accountability for patient outcomes.4
Supervision is a cornerstone of professional development for doctors and patient safety in the NHS. For resident doctors, supervision by educational and clinical supervisors is well established, regulated, and designed to improve their competence and foster their transition towards independence.5 In contrast, PAs will always depend on doctors and won’t become autonomous. Therefore, the relationship between PAs and their clinical leads must be recognised for what it is: an ongoing process of direct instruction, not supervision.
Professional clarity
NHS England’s long term workforce plan proposed an increase in PA numbers to alleviate medical staffing pressures.6 But PAs are not doctors, and they don’t hold a licence to practise medicine. These fundamental distinctions have implications for the scope of practice and the supervision required to ensure patient safety.
PAs are a dependent role intended to work in support of doctors. “Direct supervision” describes the clinical situation in which a supervisor is present, available, and overseeing actions in real time. Recent guidance on scope of practice from the Royal College of Physicians and the Royal College of General Practitioners supports this view.78
This raises an important question about terminology and whether “supervision” is the correct term to describe the relationship between PAs and their clinical leads. In educational settings, “direct instruction” refers to a real time, guiding relationship in which the instructor bears full responsibility for the learner’s actions. This better reflects the relationship that must exist between a licensed medical practitioner and a PA in the current regulatory framework. The PA model is not one of supervised progression but of closely monitored support.
The use of the term “supervision” introduces ambiguity. It blurs the line between the structured, competence based progression of doctors and the static oversight required by PAs. For the sake of patient safety and professional clarity, it’s vital that we distinguish these models of oversight.
This distinction is not semantic: it is clinical, legal, and educational. It safeguards patients, supports clarity in team roles, and acknowledges the different pathways these roles follow. The NHS would benefit from adopting a transparent, graded model of direct instruction for all medical associate professionals, to ensure that expectations are standardised and that patient care is never compromised by vague or inconsistent definitions of supervision.
Footnotes
Competing interests: I was one of the group of fellows who called for the Royal College of Physicians’ extraordinary general meeting on PAs in March 2024.
Provenance: Not commissioned; not externally peer reviewed.