Clinical associates and physician assistants: raising risks or opportunities for improved health care?

Clinical associates and analogous non‑physician clinicians are no longer a stop‑gap; they are a strategic answer to persistent workforce gaps and maldistribution that compromise access and equity. The term clinical associate (ClinA) primarily describes a mid-level healthcare worker in the South African public service context, introduced in the mid 2000’s to bridge the gap between nurses and doctors in rural areas. Nowadays they have roles in private health care, employed either by private hospitals of individual specialists to perform tasks such as admitting and following up on patients, obtaining consent and assisting in theatre, thereby freeing up specialists to see more patients and perform more procedures. They have been regulated by the Health Professions Council of South Africa (HPCSA) since 2016. In the United Kingdom they are called physician associates (PA’s). The GMC commenced regulating PA’s in December 2024, and by December 2026 all PA’s have to be registered to be able to practice.

There are no regulated ClinA’s or PA’s in Australia, the role is not recognized by the Australian Health Practioners Regulatory Agency, primarily because of opposition by the Australian Medical Association citing concerns about patient safety and the potential for a new profession which is not regulated. Instead, an alternative workforce model has been created, including nurse practitioners who are registered nurses with advanced training, able to prescribe medicine and manage patients independently, allied health professionals such as paramedics and a heavy reliance on international medical graduates.

To qualify, a ClinA must complete a three-year Bachelor of Clinical Medical Practice undergraduate degree whereas PA’s typically complete a 2-year postgraduate Diploma/MSc after a bioscience/health-related bachelor’s degree; the programmes must be aligned to the national PA curriculum and they must pass the national PA examination. 

Evidence from South Africa’s cadre shows significant contributions to rural service delivery and cost‑effective care when deployed with clear scopes and supervision [1,2]. These successes primarily follow the 2016 addition to the The Health Profession Act of a regulation defining the Scope of Practice of Clinical Associates. Some of their permissions include obtaining a history, performing a clinical examination, ordering or preforming diagnostic and therapeutic procedures for common and important conditions in South Africa, ordering and interpreting the investigations such as an HIV test, chest x-ray, ECG’s, urine tests, stool tests, throat swabs, collecting sputum samples and hematological and biochemical blood tests. They may perform a list of procedures in children and adults. PA’s are distinct from the South African ClinA’s. The GMC doesn’t define a single, fixed scope of practice, the supervising doctor is responsible for delegating and supervising the tasks. A PA’s scope of practice is defined by working under supervision, as a member of a medical team according to a locally agreed “ceiling” of practice. They cannot be used to replace or fill rota gaps for fully trained doctors.

Internationally, systematic reviews of physician/physician associates in hospitals report comparable quality and patient flow benefits in defined roles, supporting team‑based models rather than one‑to‑one substitution [3]. Beyond medicine, the task‑shifting literature in surgery and anaesthesia demonstrates that, with appropriate training, oversight and case selection, outcomes can be safe while expanding coverage, though heterogeneity and reporting bias warrant humility [4,5]. 

Medicolegal risk for clinical associates (including physician/associate clinicians) centres on scope clarity, supervision and diagnostic decision‑making. Examples of cases managed by MPS include an orthopaedic case where a patient underwent a knee arthroscopy. Post operation the patient developed septic arthritis, requiring an ICU stay. An expert was consulted and was critical of the post-operative care and delay in diagnosis of sepsis where all the follow-up appointments were undertaken by a ClinA employed by the member, rather than the member themselves. where all the follow-up appointments were undertaken by a ClinA employed by the member, rather than the member themselves. In an ENT case, a patient suffering with chronic sinusitis underwent sinus surgery, all of the pre-operative consent and post-operative care were completed by a ClinA employee. Complications with the surgery emerged. The expert consulted in this case was also critical in relation to the quality of the consent and post-operative care. In both of these examples the patients were not warned that a ClinA would undertake all their post-op care (with no/minimal specialist involvement), that they did not involve the specialists early enough, and they should not have been undertaking the consent process. The process of consent is clearly defined in the HPCSA’s Booklet 4, where ideally the practitioner providing the treatment should obtain a patient’s informed consent. However, they do state that the process may be delegated when that person has sufficient knowledge of the treatment and risks, but ultimately the treating clinician remains responsible for ensuring the patient has been given sufficient time and information to provide informed consent.

US malpractice data show substantially lower malpractice‑payment report rates for physician assistants than physicians (1.4–2.4 vs 11.2–19.0 per 1000 annually), but a higher proportion of diagnosis‑related allegations among PAs (≈53% vs 32%), highlighting supervision at points of diagnostic uncertainty [5]. Evidence on task‑shifting safety remains heterogeneous, underscoring the need for explicit protocols, training and governance of delegated acts [1]. In South Africa, where clinical associates must work under medical supervision, reviews have identified scope‑of‑practice ambiguities and inadequate supervision as persistent risks [6]. 

For medical specialists, the choice is whether to shape this evolution or be shaped by it. Specialists should lead governance of roles, define escalation thresholds, and co‑design training pathways, while insisting on transparent outcome monitoring and scope regulation. Where these conditions are met and upheld clinical associates extend specialist reach, reduce delays, and free specialists for complex diagnostics, procedures and system leadership [1–5]. The global experience provides the argument for deliberate integration—complement, don’t replace—and regular rigorous evaluation anchored in patient outcomes [1,4,5,7]. 

References 

1. Ngcobo S, Bust L, Couper I, Chu K. The role of clinical associates in South Africa as a health workforce: A scoping review. Afr J Prim Health Care Fam Med. 2024;16(1):a4421. doi:10.4102/phcfm.v16i1.4421. 

2. Tshabalala Z, Smalley S, Louw M, Capati J, Cooke R. Clinical associates in South Africa: optimising their contribution to the health system. South African Health Review. 2019:183–192. Health Systems Trust. 

3. Halter M, Wheeler C, Pelone F, et al. Contribution of physician assistants/associates to secondary care: a systematic review. BMJ Open. 2018;8:e019573. doi:10.1136/bmjopen-2017-019573. 

4. Marks IH, Thomas H, Bakhet M, Fitzgerald E. Global surgical and anaesthetic task shifting: a systematic literature review and survey. Lancet. 2015;386(Special Issue):S15–S16. 

5. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J, et al. Assessing the impact of anaesthetic and surgical task‑shifting globally: a systematic literature review. Health Policy Plan. 2023;38(8):960–976. doi:10.1093/heapol/czad059. 

6. Brock DM, Nicholson JG, Hooker RS. Physician Assistant and Nurse Practitioner Malpractice Trends. Med Care Res Rev. 2017;74(5):613–624. doi:10.1177/1077558716659022. 

7. Mullan F, Frehywot S. Non‑physician clinicians in 47 sub‑Saharan African countries. Lancet. 2007;370(9605):2158–2163.