Catherine Reilly examines the feedback of medical bodies during the review of the physician assistant role
The Medical Council says it may need to develop guidance for doctors on working with physician assistants (PAs). However, the “parameters” of the role in Ireland must first be established.
Last month, the HSE published the Independent Review of the role of Physician Assistant in the Irish Public Health System. The review was led by former CEO of the RCPI and the Medical Council, Mr Leo Kearns.
The Medical Council provided “verbal” feedback during the review. “The Council recognised that the role may contribute positively if clarity on scope and governance is strong, but noted that ambiguity around professional identity and supervision arrangements can undermine both public trust and interprofessional cohesion,” according to the review.
“The Council also emphasised the need for all registered medical practitioners to be cognisant of the guidance regarding consent and patient safety as provided in the Guide to Professional Conduct and Ethics.”
Recommendations
The review emphasised the importance of developing a “robust governance framework” for PAs. A PA must work under the direction of the consultant/doctor responsible for the patient’s care and have a designated consultant supervisor. Hospitals must ensure that relevant policies and governance structures are in place and maintain evidence of compliance. The role’s implementation must be monitored at national level. The issue of PA regulation was outside the scope of the review.
The review recommended the establishment of a core and extended scope of practice for PAs. Direct patient interactions from the core scope of practice may include taking routine histories, conducting a basic physical exam, and recording an ECG, for example. All newly appointed PAs must undertake a period of clinical induction to support them and provide assurance as to competence in relevant activities from the core scope of practice.
The extended scope of practice may include, for example, support for chronic illness clinics in line with clinic-specific guidelines; and patient follow-up within local protocols. Measures must be in place locally to verify competence. Procedural activities may include phlebotomy, urinary catheterisation, cannulation, injection (subcutaneous and intramuscular), suturing, and non-surgical wound care. Evidence of competence in these clinical procedures must include successful completion of recognised third-party training courses and qualifications, in addition to subsequent practice and assessment under direct supervision.
Should an institution wish to include a further activity in a PA’s scope of practice (beyond those listed) it must make an application at national level. “It is also appropriate to recognise that additions may be made to the core and extended scope of practice in the future and the recommended governance framework accommodates this growth.”
The review recommended an “exclusions list” of activities that must not be delegated to PAs due to legal restrictions, required medical expertise, or patient safety considerations. Examples included prescribing medications, ordering ionising radiation, diagnosis, and obtaining informed consent for procedures outside the PA’s scope of practice. Initial deployment should be primarily within the medical and surgical functions of acute hospitals, where the role has “demonstrated value and governance structures can be consistently applied”.
“Although the number of PAs employed in publicly funded services is small (38 across the system), feedback from clinical teams where the role is already in place is positive,” according to the review.
PAs were “consistently described” as providing valuable continuity, coordination, and organisational support within consultant-led teams, particularly in environments characterised by high NCHD rotation, fragmented pathways, and operational complexity. “Their permanent presence contributes to safer care through consistent documentation, reliable follow-up processes, and support for multidisciplinary communication, while freeing NCHDs to focus on training and clinical decision-making.”
However, the role had evolved without a “clear, nationally agreed definition of its purpose, scope of practice, or governance framework”. This had resulted in “considerable variability” across sites, uncertainty for clinicians and PAs, and avoidable risk. “In the absence of such clarity, the future development or expansion of the PA role cannot be safely supported.”
Training bodies
The RCPI, the College of Anaesthesiologists of Ireland (CAI), and the Irish College of General Practitioners (ICGP), provided submissions to the review.
Across these submissions, there was a “consistent view regarding pre-requisite conditions” for any consideration of PA deployment – ie, a clearly defined scope of practice, robust governance and supervision arrangements, and transparent patient communication.
The ICGP highlighted issues of concern within general practice. This included management of undifferentiated presentations, the need for standards-driven induction and supervision, and patient safety concerns and public misunderstanding noted in the UK experience. It emphasised that any PA activity in general practice must be tightly supervised by a GP within a transparent framework.
The CAI did not support introducing anaesthesia associates in Ireland. It cited incompatibility with a consultant-delivered model of anaesthesia, unresolved regulatory and indemnity questions, potential diversion of training capacity, and heightened patient safety risks in time-critical, high-acuity environments. It recommended prioritising increased consultant and trainee capacity and pointed to emerging nursing-led anaesthesia programmes as a more coherent pathway within existing regulated frameworks.
According to the review, the RCPI questioned whether the purported benefits of the role are unique to PAs. It said continuity, flexibility and service gains may be better achieved by investing in current roles and governance structures. It emphasised public confidence, regulatory robustness, and the opportunity costs of establishing a novel profession.
Unions
Trade unions participating in the consultation included the IHCA, IMO, Irish Nurses and Midwives Organisation (INMO), Siptu, Fórsa, Connect Trade Union, Unite, and the Psychiatric Nurses Association.
There was consistent agreement on the need for a clearly defined scope of practice, together with a transparent supervision and line management structure that avoided ambiguity in accountability and ensured that delegation mechanisms did not increase risk for clinicians or patients.
Industrial relations concerns were highlighted, especially by the INMO, which stressed the risks inherent in regulated professionals delegating to an unregulated profession, particularly if supervision structures are unclear or if responsibilities drift beyond the PA’s defined scope. They emphasised that workforce shortages should not be addressed by substituting established regulated roles with an unregulated grade.
IHCA representatives acknowledged that consultants working with PAs are generally positive about their contribution, particularly regarding continuity of care and coordination. However, they and others were “explicit” that uncontrolled movement of PAs between specialties or clinical settings would carry risks and that strict adherence to a defined scope of practice would be required to maintain patient safety.
Upon the review’s publication, the IMO welcomed its “clear distinction” between a doctor and PA and its recommendation to refer to the grade as ‘physician assistant’ rather than ‘physician associate’.
However, the Organisation said that no clear regulatory obligations had been outlined and it was “unclear” how consultants would be able to supervise, train, and monitor PAs given their “existing onerous workload”.
ISPA
The Irish Society of Physician Associates (ISPA) said it welcomed many of the review’s recommendations. However, the ISPA was seeking an opportunity to discuss “some aspects of those recommendations and clarification on the lifting of the [HSE] employment embargo”.
Ms Helen Farrell, ISPA President, told the Medical Independent (MI): “The case studies included in the review itself demonstrate that physician associates are already functioning as integral members of multidisciplinary teams across a range of specialties. In practice, PAs contribute far beyond administrative support, including patient assessment, clinical decision-making (under supervision), continuity of care, service development, procedural skills, and coordination within teams. Consultants and MDT colleagues working directly with PAs consistently express support for further development and expansion of the role in line with service needs.”
Ms Farrell said that the ongoing HSE recruitment pause had “created considerable uncertainty and has negatively affected morale and mental wellbeing across the profession”, particularly among newly qualified PAs.
A HSE spokesperson told MI it will work with clinical leaders, professional bodies, and stakeholders to implement the review recommendations.
The HSE is working with the Department of Health to develop the “appropriate mechanism” to facilitate the recruitment of PAs into services, with a grade code that determines the terms and conditions “appropriate to the job specification and the scope of practice outlined in the report”.
All HSE recruitment must be within its allocated headcount and funding envelope, they added.
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