The pace and intensity of the row over the role and regulation of Physicians Associates (PAs) and Anaesthesia Associates (AAs) have both rapidly increased in this pre-election period, forcing a major climbdown and apology in Bradford, a Royal College President to stand down, another Royal College to change course, and two separate legal challenges to the failures of the General Medical Council (GMC).

Bradford District and Craven Health and Care Partnership Board (@BDCFT), a sub-committee of West Yorkshire Integrated Care Board (ICB), describes itself as “the key-decision making body for health and care in our area.”  But it triggered a furious social media reaction across the country when it launched an advertising campaign for an ‘It’s a GP Practice Thing’ campaign promoting the role of PAs, depicting a smiling young woman with the words “The Physician will see you now”.

A genuine mistake?

Other posters in the series claimed that PAs were “specialists” in heart disease and cancer, while (less noticed, but equally worrying) a Health Care Assistant was described as a “nurse”. Other additional roles staff, with far less than professional levels of training, including “care navigators” were described as “highly trained.”

The angry response, mainly from doctors on X/Twitter prompted an almost immediate retreat on June 16, with @BDCFT posting “We have been made aware of mistakes in our ‘It’s a GP Practice Thing’ campaign. We are updating materials to ensure they are accurate and use correct titles for colleagues in General Practice teams.”

But this half-hearted response, with no apology, intensified the anger of doctors who were convinced that the misleading posters were not mistakes, because they would have had to be signed off by senior staff including doctors.

Two days later an updated response on @BDCFT website tried again to convince sceptical doctors that such large mistakes really had been made in error. This time there was a limited apology – to the unfortunate PAs whose photographs had been used – but to nobody else:

“We are writing in response to colleagues who have raised concerns about our local ‘It’s a GP practice thing’ campaign. Unfortunately, serious but genuine errors in our campaign have placed valued colleagues under significant pressure from negative comments on social media.

“We would like to make it explicit that these colleagues did not intentionally misrepresent their roles; they consented to be photographed for the campaign in good faith and the errors were ours. We would like to issue a sincere apology for those colleagues whose roles have been mistakenly misrepresented.”

However there is a credibility gap when @BDCFT claims not to know how such a glaring gaffe on such a highly sensitive subject could have been made, claiming: “We are undertaking a rapid internal review to understand how this mistake has happened and ensure it does not happen again in the future.”

Since the whole point of the campaign was supposedly to explain the role of PAs, it makes no sense that such misleading posters could have been drawn up in the first place, or that correcting the errors relied on just “one of our clinical leads”. We are expected to believe that nobody else involved with signing off the posters noticed the misrepresentation, so despite the issue being flagged up “we had not updated all our campaign resources.” 

RCP President resigns

The day after the  retreat, Dr Sarah Clarke, president of the Royal College of Physicians (RCP) announced she will step down following pressure from senior college officers and fellows over the way she and her leadership team handled the PA debate, not least in the RCP’s March Emergency General Meeting (EGM) – only its second such meeting in 515 years.

The EGM was shown slides by the RCP leadership that gave 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.

Dr Clarke’s statement made no mention of PAs, or of her support for the RCP’s Faculty of Physician Associates, set up in 2015. The statement claimed she would “step aside, […] following a challenging time for the college.”

But the challenging times are still very much alive: more than 80 RCP fellows declared a lack of confidence in the college’s leadership over its handling of the PA debate, and five senior officers wrote to the college to demand Dr Clarke’s resignation because she had ‘lost the confidence of the RCP membership’.

The pressure to draw a firmer line between fully qualified doctors and PAs with much more limited qualifications (and a 100% pass rate in many courses) will continue as the RCP finds a new President.

RCGP call to halt PA recruitment

On the same day as Dr Clarke explained her departure to the RCP Trustees, the Royal College of General Practitioners (RCGP) announced a toughened stance on PAs, urging GP practices across the UK to: 

“halt the additional recruitment and deployment of PAs into general practice until PAs are regulated and practices are in a position to implement the RCGP’s forthcoming guidance on scope of practice, induction and supervision.”

This recommendation is based on ‘concerning findings’ from the RCGP’s recent consultation, which surveyed over 5,000 GPs and found that a massive 80% believe the use of PAs in general practices has a negative impact on patient safety.

The RCGP has further advised partners in practices that are already employing PAs to ensure they do not see undifferentiated patients and that daily supervision time is built into timetables. 

However this new guidance is in conflict with NHS England’s guidelines, which makes it a condition of funding to cover appointment of PAs that they must “provide first point of contact care for patients presenting with undifferentiated, undiagnosed problems.” (page 91)

The RCGP survey found that

“60% of respondents with experience of working with PAs said that they act as the first point of contact for potentially serious conditions,” but worryingly “25% said no time was scheduled for regular supervision, meaning PAs could only speak to their GP supervisor in gaps between appointments.”

RCGP chair Professor Kamila Hawthorne said: ‘Our intention is not to disparage the individuals who are working as PAs in general practice or their profession, but to address and act on the concerns that more and more of our GP members have been raising.’

The Royal College is also opposed to the registration of PAs being handled by the same body, the General Medical Council (GMC), that regulates doctors. 

However, “recognising that GMC regulation is well advanced, and now in legislation, the College will continue to work with the GMC to ensure there is clarity over the differences between doctors and PAs.”

This latest toughening of the RCGP’s stance on PAs follows months of pressure from disgruntled GPs who were uncomfortable with the way in which a new group of “medical professionals” had been allowed to threaten the jobs of fully trained GPs and potentially undermine the safety of services.

BMA steps in

Meanwhile there are tight cash constraints on GP practices, and NHS England is offering extra funds to subsidise PAs and other additional roles – but not to employ GPs (who are increasingly facing  unemployment). The result has been increasing pressure on the BMA to take more proactive measures to block any further moves that threaten to substitute cheaper, minimally-trained, PAs for fully-trained GP members.

New BMA advice now states that sessional GPs’ job descriptions should not include supervising non-doctors unless this is “expressly and mutually agreed;” and that GPs should not be expected to sign prescriptions, request investigations or make referrals based solely on the clinical assessments made by ARRS staff.

The union adds that if a sessional GP does agree to supervise multidisciplinary team/ARRS roles as part of their agreed job plan, they must be allocated sufficient time to safely perform this role, and receive appropriate supplementary pay.

The BMA has published a national scope of practice which (like the latest RCGP guidance) makes quite clear that PAs should never see ‘undifferentiated’ patients in a GP setting. 

However this has not gone down well with those PAs who have a more inflated idea of their skills and importance. Pulse magazine has reported threats by PA representatives to take legal action against GPs who implement it in their practice.

Legal challenges to GMC

As we go to press this quick-fire succession of events has been followed by the announcement that the BMA is to mount a legal challenge to the way the GMC has handled the question of regulating physician and anaesthesia associates, resulting in a “dangerous blurring of lines for patients between highly-skilled and experienced doctors, and assistant roles.”

There is, indeed, no logic in the GMC being the regulatory body, since the postgraduate qualification of PAs and AAs makes their status quite unlike doctors, and much more akin to the other non-medical professionals like Occupational Therapists, Physios and Radiographers, who are all covered by the Health and Care Professions Council (HCPC). 

However there is an anomaly in the positioning of the PAs on the Agenda for Change pay scales. They are grouped in with nursing and other professional staff, not on a doctor’s pay scale, despite having just a 2-year qualification they jump straight in at Band 7, above the starting grade for other professionals after they complete three year courses.

The whole way this has been handled, and the eagerness with which NHS England is now openly favouring the employment of cheaper (but not cheap) PAs/AAs rather than doctors, give grounds for suspicion of ambitions to undermine the authority of fully-trained doctors.

The BMA is taking an important stand, and opposing the GMC using the term “medical professionals” in its materials to describe all of its future registrants – both doctors and associates.

BMA council chair Professor Philip Banfield announced the launch of the judicial review claim at the BMA’s Annual Representative Meeting in Belfast. He said:

“PAs are not doctors, and we have seen the tragic consequences of what happens when this is not made clear to patients. Everyone has the right to know who the healthcare professional they are seeing is and what they are qualified to do – and crucially, not to do. …

 “The central and solemn responsibility of the GMC is to protect the public from those who are not registered qualified doctors, pretending to be doctors.”

The BMA legal challenge is additional and complementary to the challenge to be waged by anaesthetists, who are also angry at the failure of the General Medical Council (GMC) to do its job and protect and defend the medical profession, and who raised a staggering £50,000 in a few days to take the GMC to court.

Anaesthetists United describe themselves as “a group of anaesthetists (doctors trained in anaesthesia) that are unhappy with the way the medical establishment is selling patients and the profession short.”

Their crowd funding page, headlined ‘Stop misleading patients’ explains:

“Physician Associates and Anaesthesia Associates are a new profession. They are not doctors, they do not have the same training as doctors, but are being permitted to take on many of the roles doctors have traditionally fulfilled. The press have reported on troubling cases

“And the General Medical Council, the body legally responsible for doctors’ regulation, has now been given the responsibility of regulating Physician/Anaesthesia Associates too. 

“We think patients deserve better; they should be cared for by doctors when necessary, should know who is and is not a doctor, and there should be separate regulation underpinning this. And we’re ready to take action.”

The biggest worry is that:

“the GMC have steadfastly refused to say what an Associate can, or cannot, do to support patients. The precise term for this is their ‘scope of practice’. The GMC have even refused to hold a consultation on it, despite a statutory requirement for them to do so.”

Anaesthetists United boasts that “We are the group that convened the Extraordinary General Meeting of the Royal College of Anaesthetists, which led to a sea change in the way the medical profession, and the public, have looked at the whole issue of Associates.”

It is possible that strongly-worded representations from top lawyers will be sufficiently forceful to push the GMC into accepting our proposals. But if not, then the next step is court action.

Whichever government takes over on July 5 will inherit this brewing row.

Ministers will be keen to find ways to ensure the skills and dedication of around 2,000 PAs who are already working in the NHS are not wasted: but they need to ensure that finding a role for PAs with just 2 years of postgraduate training does not come at the expense of further weakening the already over-stretched medical workforce, putting patients at risk, and further undermining public confidence in the quality of services they receive.


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