28 February 2025
New guidance about Tiers of working have been issued by the Royal College of Emergency Medicine.
The review of Tiers has been considered as part of the ongoing discussions within the College relating to the position of PAs as part of the emergency medicine workforce and has been significantly debated and carefully considered. As part of this work the College also took the opportunity to bring the tiers up to date with developments around ACPs, new terminology around SAS doctors, and to introduce clearer guidance around supervision.
Our original position on the expansion of PAs within the workforce was published in June 2024 ( RCEM – Physician Associates | RCEM ) following a survey with members and it was unanimously agreed that RCEM does not support the expansion of the PA work force in EM, while acknowledging that some PAs are already working in the specialty.
The College has further debated the matter and in January 2025 agreed that any new PAs coming into the workforce should only work at the basic (Tier One) level which requires ‘direct supervision by a senior clinician’ and as a minimum ‘patients being admitted should be discussed with a more senior clinician and reviewed in person by a senior clinician if being discharged.”
The full details of our updated guidance on Tiers, which relates to levels of responsibility and supervision requirements, can be seen here and should be read in conjunction with the notes that accompany it.
RCEM’s position, recommendations and guidance should be considered best practice; however the College itself has no means of enforcing them and local staffing decisions remain with each individual Trust. RCEM recognises that many departments will have existing arrangements in place whereby individuals, or professional groups, are working within tiers in a way that is inconsistent with our guidance. We would recommend that such arrangements and the governance surrounding them are reviewed by the Clinical Lead for the service and our guidance is not intended to affect such arrangements retrospectively, and should not be used for this purpose.
