The battle over the proper delineation of the role of Physician Associates (PAs) in particular has been taken in to the once prestigious Royal College of Physicians (RCP), which in recent years has strongly embraced the idea of PAs.

Unlike the Royal College of Anaesthetists, which last October convened an extraordinary general meeting at which over 90% voted to pause the rollout of Anaesthesia Associates, the RCP leadership has been most reluctant to open up any discussion of the way in which PAs have been used.

A damning new open letter signed by 29 leading Fellows of the RCP, including eleven professors sets out a long list of errors and omissions  by senior officers and the chief executive of the RCP that should be investigated “with a particular focus on governance and probity.”

In 2015 the RCP established the Faculty of Physician Associates, which oversees PA training and examinations. But so far the leadership has not responded to requests that it declares the RCP’s significant financial interests in the development of the PA role, which may go further than the membership fees from 3,000 PAs (which would rise as the planned future PA workforce grows to 10,000 by 2037.)

With concern rising and polling by the BMA suggesting almost nine in 10 doctors believe that the way physician associates are used currently in the NHS puts patients at risk, the RCP was eventually persuaded to call only the third Emergency General Meeting in its 515 year history.

Leading off the discussion, the RCP leadership had the nerve to present slides giving a completely misleading picture of the results of a survey of members’ views. The EGM presentation argued that 66% of doctors who currently work with PAs were ‘neutral or positive’ about PAs.

However when the raw data was eventually published it revealed that just 30% had responded positively, while 42% were negative and 27% had been neutral.

The subsequent scandal has been reported as far away as the Australian journal Medical Republic, with the RCP’s clumsy attempt to “spin its way out of trouble” with phony figures compared with “the Royal Family’s approach to Kate Middleton’s absence.”

There have been calls for mass resignations of those responsible for the RCP’s handling of the issue, with the college’s deputy registrar having already announced she would be stepping down after three years in the role.

RCP president Dr Sarah Clarke has issued a bizarre statement to members, which appears to be claiming innocence and searching for a scapegoat to blame for the skewed statistics:

“I apologise unreservedly for any confusion. We are working to understand why this happened so that I can ensure that we improve our processes.”

There has also been anger at the failure of the Royal College of General Practitioners to draw sufficient red lines delineating GPs from PAs. This has led to a decision by its UK council to add two more specific points to the five fairly general points previously adopted, insisting:

  • Training, induction, and supervision of PAs in general practice must be properly designed and resourced
  • At a time of significant GP workforce challenges, funding allocation, resources, and learning opportunities in general practice must be prioritised for the training and retention of GPs

Moreover the General Medical Council, which has now been given the role of regulating PAs, following new regulations pushed through Parliament with backing from Labour and Tories, is also under fire for its complicity in seeking to ‘dumb down’ the training of doctors and thus blurring the lines between medical doctors and other staff.

The GMC’s Medical Director and Director of Education and Standards Professor Colin Melville has recently written a blog suggesting ways of reducing the level of training for doctors, arguing:

“we must re-examine what doctors need to know and what skills they require given the changing patient and healthcare system landscape. […]  With up-to-date information at our fingertips via trusted sources on our smartphones we don’t need the huge repository in our heads from textbooks and lectures. Content in the curriculum can be streamlined.”

Prof Melville aroused more suspicion by continuing: “there are steps we can take here and now, such as reducing the burden of assessment in royal college exams and in workplace-based assessment.”

His suggestions implicitly echo controversial suggestions last year by NHS England chair Richard Meddings that doctors’ training should be cut from seven years to five, with an ominous reference to the (controversial) role of PAs in the USA. He said:

“What we’ve never done is look at whether we need seven years to train a doctor. France does it in five years and if you go to America you are likely to be seen by a physician associate much of the time.”

The BMA has expressed concern that the GMC, far from genuinely regulating PAs as provided for in the recent legislation, will simply register PAs and shuffle the complex problem of regulation off to Royal Colleges and employers:

“We are very concerned by the fact that the GMC has no plans to set safe parameters on PA and AA scope of practice after regulation, and they have instead proposed that employers and the Royal Colleges should be setting these boundaries.”

With no other clear leadership properly defending the boundaries of the medical profession, the BMA earlier this month adopted its own ‘Scope of Practice’ document, setting out the range of tasks and services that Medical Associate Professionals (MAPs), including physician associates (PAs) and anaesthesia associates (AAs)  can legitimately be asked to cover.

Among the key proposals,:

MAPs should not be seeing ‘undifferentiated’ patients. This means that all patients should be seen by a doctor first who then decides that it is appropriate for a PA/AA/SCP to do some limited and protocolised care.

“In a hospital setting, this means that [MAPs] should not work in an ED setting unless a supervisor reviews each patient in person

“In a GP setting, a GP should first triage all the patients and decide which ones a PA can see for some protocolised reviews in stable patients

“In general [MAPs] should be assisting the medical team by helping with tasks like taking bloods and ECGs, helping to prepare discharge notes, helping with ward round documentation, and organizing appointments. This is consistent with their level of formal qualifications.

“To overview their work, they need close, in person, supervision by a consultant or GP who consents in writing to supervise them.”


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