Delegation and accountability in the healthcare team

Healthcare is increasingly being delivered by multidisciplinary teams of doctors, nurses and other healthcare professionals. It's been reported that GP practices have recruited more than 31,000 front line staff other than GPs since 2019. This includes more than 1,500 physician associates as well as other roles like nurse associates, physiotherapists and dieticians.

In secondary care, anaesthetic associates and surgical care practitioners also form part of the healthcare team.

At the MDU, we often get asked about where the lines of accountability lie when working in teams.

For example, if a consultant offers advice to a junior colleague during a late night call, could they be held to account if the colleague omits important information that significantly alters the advice given? Or when a duty doctor in primary care allocates patients to a physician associate (PA) - are they responsible if the person makes a mistake?

We look at these and other common questions below.

What's the difference between delegation and referral?

The GMC has specific guidance on this topic, which summarises that "delegation involves asking a colleague to provide care or treatment on your behalf" and "when you delegate care you are still responsible for the overall management of the patient."

The guidance goes on to clarify that referral is "when you arrange for another practitioner to provide a service that falls outside your professional competence."

If the person I delegate to makes a mistake, do I bear responsibility?

'Good medical practice 2024', which takes effect in January 2024, makes it clear that when delegating (or referring) you must "promptly share all relevant information about patients (including any reasonable adjustments and communication support preferences) with others involved in their care, within and across teams, as required."

You also must be confident that the person you are delegating to has the requisite knowledge, training and skills to undertake the task you are delegating to them.

GMC guidance also adds, "You must give them clear instructions and encourage them to ask questions and seek support or supervision if they need it." (paragraph 66)

Advice for PAs, AAs and doctors who supervise them states: "Where you delegate care in line with the principles set out in our guidance, you are not accountable to the GMC for the actions (or omissions) of those to whom you delegate care. You will remain responsible for the overall management of the patient, decisions around transfer of care, and the processes in place to ensure patient safety."

Therefore, although AAs and PAs remain accountable for their actions, a doctor will retain responsibility for the overall management of the patient and the system of supervision.

What am I accountable for when working in multidisciplinary teams?

Every member of a multidisciplinary team is responsible for their actions and omissions. but effective teamworking requires some structure and leadership.

Providing clinical leadership is a key part of being a doctor, meaning doctors retain overall responsibility for patient care even when they delegate.

There is nothing new in this concept. 'Good medical practice' from 1998 makes it clear that when delegating, doctors "will still be responsible for the overall management of the patient." It goes on to differentiate this from referral, explaining that "Referral involves transferring some or all of the responsibility for the patient's care…"

This is in keeping with the spirit of the accountable clinician from the Academy of Medical Royal Colleges (AOMRC). When working in a multidisciplinary team, it's important for patients and other clinicians to be able to approach a senior clinician with overall responsibility for care to get support and ask questions. They will also play a key role in providing a response to any complaint or investigation if things do go wrong.

The AOMRC guidance is clear that while the responsible consultant/clinician might not be accountable for every aspect of patient care, they are the person who can ultimately be addressed about concerns relating to patient care.

While it relates to secondary care, the publication recognises that "the principles underpinning this guidance should apply as much in a community or primary care setting."

How can I ensure the person I delegate to has the right skills and competency to carry out the task?

You may not know the skillset and competence of every colleague in detail, especially in larger teams or teams that come together to provide out of hours cover. Therefore, it is important to have clear communication within the team and a framework for what is reasonable broadly for each role to undertake. When you become more familiar with your colleagues and their skills, you may consider that a broader range of tasks could safely be delegated.

It is also important to foster a culture where individuals speak up if they don't feel able to do what is asked of them because it is outside their knowledge and expertise.

GMC guidance on leadership has some useful guidance about working safely and effectively in teams. It recognises that while the formal leader of the team is accountable for their collective performance, it is the responsibility of the whole team to identify problems, solve them and take appropriate action.

The guidance (paragraph 17) states that as well as establishing clear scope for the roles and responsibilities of each team member, it should also be clear what the supervision arrangements are and the lines or accountability for the care provided to patients.

Establishing the lines of accountability at the outset of joining a team, or when a new member of staff or job role is introduced, can pre-empt problems further down the line.

What happens if I give incorrect advice about patient care to a colleague because I haven't been given the relevant information?

All regulated healthcare staff have a responsibility to share relevant information with colleagues to promote safe and effective patient care. A version of wording relating to this is found in the core guidance by regulators including the GMC, the Nursing and Midwifery council (NMC), the Health and Care Professions Council (HCPC), the Faculty of Physician Associates (FPA) and the General Pharmaceutical Council (GPC).

There is an expectation with most regulated health care professionals that they will share necessary information with colleagues to allow the provision of safe healthcare.

Doctors can use their knowledge and experience to ask further questions based upon the initial information shared to get a fuller picture. Consider how you will record your advice and the relevant facts it was based upon, or how you can ensure that what is recorded on your behalf accurately reflects the discussion.

Make sure there is a clear record of what was discussed especially when calls are not recorded. This will help to ensure the patient receives the correct care and can be used to justify your role in the event of an adverse outcome.

What does supervision of a PA or AA look like?

Department of Health guidance makes it clear that PAs and AAs can make decisions independently, although supervised by a doctor.

In England, this is reiterated in Health Education England guidance called: An assessment of the four medical associate professions (MAPs).

The document highlights that the supervision relationship will evolve with time and familiarity so that the level of supervision will lessen as both parties settle into the working relationship.

The Faculty of Physician Associates (FPA) Code of conduct has a helpful summary of how supervision works in practice:

"Individual PAs will still be accountable for their own practice, within the boundaries of supervision and defined scope of practice. Supervising clinicians must accept overall responsibility for any duties that are undertaken by a PA in training or a qualified PA. On this basis, doctors will determine the scope of duties and responsibilities of the PA on the basis of known competence, experience and expertise within the relevant area of practice." FAQs provide more detail.

How can I be confident a PA or AA is responsible for working within their scope of practice?

PAs and AAs are responsible for operating within their competence and agreed scope of practice.

The Association of Anaesthesia Associates suggest that its members 'mirror' the ethical guidance produced by the GMC for doctors pending statutory regulation.

The code of conduct for PAs directs them to recognise their limitations and ask for help when needed.

It also states that "PAs will be expected to work within the policies and guidelines of their employing organisation and will be accountable to that organisation if they practise outside those policies and guidelines."

The GMC has detailed guidance on what doctors are expected to do when delegating to PAs and AAs and what systems organisations should have in place. It explains that when delegating tasks doctors should be sure that:

• the person you are delegating to has the necessary knowledge, skills and training to take on the task
• you give clear instructions about what is expected, and encourage the asking of questions, or for help, when needed
• advocate for those you supervise
• support them to establish their role in the team by being clear with them and others about the skills and expertise they are contributing and how this interacts with the wider work of the team
• promote a culture of psychological safety and encourage effective communication between all members of the team
• make sure PAs and AAs are clear on how to escalate safety concerns.

Am I responsible for medication I am asked to prescribe by a PA or AA?

The FPA Code of conduct advises PAs at paragraph 17 that in providing clinical care they must, "suggest drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health and are satisfied that the drugs or treatment serve the patient's needs."

While this code of conduct places a responsibility on PAs, doctors are ultimately responsible for any prescription they sign. GMC guidance, Advice for PAs, AAs and doctors who supervise them, confirms that, "If you prescribe based on the recommendation of a PA or an AA, you'll be responsible for any prescription you sign. Be sure that the prescription is needed, appropriate for the patient and within the limits of your competence."

How can I satisfy myself that the prescription will serve patient need and is appropriate?

GMC guidance on prescribing advises you to have enough information about the patient to prescribe a treatment that meets their needs. In many cases, it will be relatively easy to establish this.

However, if there are any concerns, the prescriber will need to consider factors including the patient's wishes, any previous adverse reactions to medicines, current and recent use of other medicines, including non-prescription and herbal medicines, illegal drugs and medicines purchased elsewhere and other medical conditions.

How you clarify this information will depend on your familiarity with the PA or AA making the request, the drug being requested and the patient's needs. In some cases, a verbal summary from your colleague may be enough for you to establish this, while in others you may wish to check the medical records or make an assessment of the patient.

When will formal regulation for PAs and AAs be introduced?

Currently, PAs and AAs are not subject to statutory legislation. The government has announced plans for the roles to be regulated by the GMC. The legislation is expected to be introduced by the end of 2024 and the implementation of formal regulation will occur sometime later.

The fact that these roles are not regulated professions currently means they cannot prescribe medication or order ionising radiation (ie, order x-rays) and the job titles are not protected.

What is the impact of supervising PAs or AAs on indemnity?

In the majority of cases, PAs and AAs work in trust or state indemnified roles, meaning claims made against them or their employers would fall to a state or government indemnity scheme. We recognise that supervision and training of staff is important in healthcare. We do not charge a higher subscription to healthcare professionals for undertaking this supervisory role.

In summary

Concerns have been raised about how to integrate PAs and AAs safely and effectively into teams and about appropriate supervision of the roles and the medico-legal risks.

Royal College of General Practitioner's (RCGP) Fit for the Future plan cited that 57% of GPs said "their practice does not have access to the support and guidance to effectively integrate the new staff roles".

There is also acknowledgment from the RCGP that "Clearer guidance and support needs to be produced on effective supervision of physician associates". The college states that "The relationship is likely to be similar to supervision of other advanced clinical practitioners who are seeing face-to-face patients."

The RCGP suggests the development of an online toolkit to provide support to GPs. It could include guides to employing different practice team members and job descriptions explaining the capabilities and limitations of various roles.

The Royal College of Physicians also explains that PAs are accountable for the care they provide to patients but must be properly supervised. It states: "PAs can assess and agree on management plans with patients, but at all times it is clear they must be supervised by a specific consultant or GP." It explains that if the supervising consultant or GP is not available, they must agree with another doctor (ST3 or above) to provide supervision and advice.

The GMC, in a letter to NHS England, has also acknowledged the current discussion about the role of PAs and that there remain issues to be addressed including, "Directly tackling the perception that there is a plan for the health services to 'replace' doctors with PAs or AAs by convening and leading a system-wide discussion on an agreed vision for these roles. This should include how PAs and AAs fit into multi-disciplinary teams alongside other professions (especially doctors and advanced clinical practitioners), the frameworks needed for them to work safely, and a balanced position on PA and AA scope of practice."

The GMC has published further information on PAs and AAs, including their expected timeline to regulation and their views on the current debate about the roles of PAs and AAs in the health care team.

Many royal colleges have published extensive resources on the role and employment of associate practitioners (links below).

In the MDU's view, it is vitally important that the implementation of these roles is done properly across the healthcare system. There are practical issues and concerns that will need to be addressed by employers and NHS leaders, and it is essential that doctors are properly supported as part of this process.

We are also on hand to provide individual advice on a case-by-case basis to our members where a question or issue may arise in connection with a PA or AA colleague. Every case is different, and that is why we're available 24/7.

Resources

Faculty of Physician Associates - quality health care across the NHS (fparcp.co.uk)

Anaesthesia associates | The Royal College of Anaesthetists (rcoa.ac.uk)

Physician associates | Royal College of Psychiatrists (rcpsych.ac.uk)

Physician associates (rcgp.org.uk)

Physician associates | NHS Employers

Physician associate - Royal College of Surgeons (rcseng.ac.uk)

Surgical Care Practitioner programmes - Royal College of Surgeons (rcseng.ac.uk)

This page was correct at publication on 30/10/2023. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.