Today we have written an open letter to the GMC setting out how its approach to the regulation of AAs and PAs blurs the lines with doctors and constitutes a failure to fulfil its legal duties.

We have told the GMC it must cease referring to AAs and PAs as ‘members of the medical professions’, ‘medical professionals’, and in ‘medical practice’.

We have also called for:

  • the replacement of Good medical practice 2024 with two partner sets of standards, Good medical Practice (for doctors) and Good associate Practice (for AAs and PAs)
  • the implementation of our online registers format, which makes clear the registers for doctors and associates are independent

We have told the GMC these changes must be in effect when regulation starts.

*Credit and thanks to twitter user @scuderia_panda who inspired and wrote the letter with support from @LondonAnaesth and the AU team.

Open letter regarding your approach to regulation of AAs and PAs

Dear Professor MacEwen and Mr Massey

In preparation for the regulation of anaesthesia associates (AAs) and physician associates (PAs), referred to collectively as associates, the GMC has published:

  • Good medical practice 2024
  • plans for how AAs and PAs will be displayed on online registers

With these, the GMC is descending into the pitfalls of a multi-professional regulator, blurring the lines between associates and doctors. This is a serious issue that adversely affects patients and public confidence.

We are writing to set out how referring to associates as ‘members of the medical professions’, ‘medical professionals’, and in ‘medical practice’ constitutes a failure to fulfil your statutory duties and must cease.

We call for:

  • the replacement of Good medical practice 2024 with two partner sets of standards, Good medical practice (for doctors) and Good associate practice (for AAs and PAs)
  • the implementation of our online registers format which makes clear the registers for doctors and associates are independent

These changes will satisfy your statutory duties and must be in effect when regulation starts, before the seeds of confusion and conflation are sown.

The GMC’s statutory duties as multi-professional regulator

The Medical Act 1983 sets the GMC’s objectives for “the medical profession” and The Anaesthesia Associates and Physician Associates Order 2024 (the AAPAO) does so for “the anaesthesia associate and physician associate professions” in new and separate objectives. This separation makes clear that the GMC’s pursuit of its objectives in regulating AAs and PAs must not come at the expense of its objectives for the medical profession.

Promote and maintain public confidence

A core objective under the Medical Act is to “promote and maintain public confidence in the medical profession”.  To fulfil this, the public, patients, healthcare professionals and employers must always be clear who is and is not a lawful member of that profession i.e. a registered doctor.

In pursuing regulation of AAs and PAs, the GMC thus has a duty to not give the false impression that associates are doctors or newly registered equivalents. This will mutually benefit the GMC’s separate objective under the AAPAO to promote and maintain public confidence in the anaesthesia associate and physician associate professions.

Propensity for conflation by the public

In considering whether it is giving a false impression, the GMC must put itself in the shoes of patients and the public. This is also required by its duties under the Medical Act and the AAPAO to “have regard for the interests” of patients.

It is critical for the GMC to appreciate that AAs and PAs are unique in being largely unknown to the public and having titles, tasks and patient access routes which make them easily mistaken for being doctors or equivalents. This propensity for conflation is radically different, for example, to the potential for a patient to confuse a dental hygienist for a dentist.

Where the starting point for a patient is a false impression of being a doctor, regulation must address this accordingly. It must also be respected that the public and healthcare professionals will understand terms used by the GMC (and adopted by others) in line with their established meaning and use.

Adoption of terms used by the GMC

When the GMC uses a term for associates, it encourages adoption by others including associates themselves. If that term gives a false impression of being a doctor or equivalent, the regulator is setting bad standards by example and failing in its duty under the AAPAO to promote proper professional standards of associates. Use of the term by others also amplifies the GMC’s failure to maintain public confidence through its own use alone.

It also risks leading to complaints against associates, including accusations of pretending to be a registered doctor, an offence under s 49 of the Medical Act. An associate “who wilfully and falsely.. uses… any name, title, addition or description implying that he is registered under any provision of this Act” commits the offence knowing the term can mislead. Yet the GMC has created a predicament for enforcement, since its own use of the term can be cited as justification, grounds for a defence or even tacit endorsement.

Applying the GMC’s statutory duties in practice

To fulfil its statutory duties, the GMC must therefore pay meticulous attention to never give the false impression that AAs or PAs are:

  • Doctors
  • A type of doctor going by a different name
    • including anaesthesia associate or physician associate being the name for a grade of doctor, specialised doctor or advanced doctor
  • Equivalent to a doctor
    • but with a different title, e.g. because of educational background

‘The medical professions’

It is enshrined in law that AAs and PAs are not members of the medical profession, but their own distinct, named professions. In legislation, as in common language, there is only one medical profession: the medical profession.

In Good medical practice 2024 (GMP 2024), however, the GMC pools the three distinct professions together into one group. It does so by mis-stating and rewriting its objectives in law for “members of the medical professions”.

“The medical professions” is a new term of the GMC’s invention that does not reflect the will of Parliament. By using the plural i.e. multiple medical professions, an equivalence to the medical profession (and therefore doctors) is implied, especially when considering the propensity for conflation by the public.

The GMC’s distinction that an associate is a member of ‘the medical professions’ and implicitly ‘a medical profession’, as opposed to ‘the medical profession’, is a subtlety which, if appreciated at all, is a recipe for confusion not clarity. The GMC thus gives a false impression that associates are doctors, a type of doctor or equivalent to a doctor.

‘Medical professionals’

Throughout GMP 2024, AAs, PAs and doctors are referred to collectively as ‘medical professionals’ and individually as a ‘medical professional’. This contradicts established meaning among healthcare professionals and most of the public, for whom a ‘medical professional’ is exclusively a doctor (as a member of the one medical profession). Describing an associate as ‘a medical professional’ thus gives the false impression they are a doctor, a type of doctor or equivalent to a doctor.

This is demonstrated by healthcare professionals using the term ‘MAP’ or ‘medical associate professional’ for an associate, out of necessity of distinction from a ‘medical professional’. Accordingly, ‘healthcare professional’ not ‘medical professional’ is the commonly used umbrella term for a professional in healthcare.

The GMC calling an associate a ‘medical professional’ also contradicts definitions in legislation and risks unacceptable confusion. ‘Registered medical professional’ is defined for the purposes of The Abortion (Northern Ireland) (No. 2) Regulations 2020 and ‘responsible medical professional’ for the purposes of the Armed Forces Act 2011. Doctors are included in these definitions and associates are excluded.

‘Medical practice’

Requiring that associates follow ‘Good medical practice’ implies they are in medical practice and by logical extension: medical practitioners; engaged in medical practice; and practising medicine.

Each of these terms is used by The Medical Act†, health care professionals and most of the public to mean exclusively medical doctors or their practice. GMP 2024 thus gives a false impression that associates are doctors, a type of doctor or equivalent to a doctor, and may lead to associates falsely describing themselves in terms such as ‘registered medical practitioner’.

We presume the GMC do not take a view that associates actually are in medical practice, as this would contradict its published position that “unregistered medical practice is against the law” and its historic lack of enforcement against unregistered AAs and PAs. In any case, as highlighted, such a view would not justify public use of the term.

† The Medical Act in various parts and circumstances: enables the GMC to perform specific functions “relating to medical practice and practitioners”; permits registration based on a qualification that entitles the holder to “engage in medical practice”; requires for registration a certificate that the holder has  “lawfully being engaged in medical practice” or satisfaction they are “entitled to practise medicine”; places prohibitions on “medical practice” and where a person may “practise medicine”; and refers to “general medical practice” and “specialist medical practice” as legislated by The General and Specialist Medical Practice (Education, Training and Qualifications) Order 2010.

Further conflation resulting from Good medical practice 2024

GMP 2024 addresses associates as ‘you’ and states:

  • You must provide, propose or prescribe drugs or treatment (including repeat prescriptions)
  • You must follow more detailed guidance on:
    • Protecting children and young people and 0-18 years: guidance for all doctors
    • Leadership and management for all doctors
    • Personal beliefs and medical practice
    • Good practice in prescribing and managing medicines and devices, if you prescribe
  • To maintain your licence to practise, you must continuously engage with local clinical governance systems

This paints a clear and false impression that associates are doctors, a type of doctor or equivalent to a doctor. It falsely implies associates will have a licence to practise (only given to doctors) and is ambiguous enough for many to conclude associates not only have a legal right to prescribe but a duty under GMP 2024.

Our solution to Good medical practice 2024

We call for GMP 2024 to be replaced with two partner sets of standards:

  • Good medical practice (for doctors)
  • Good associate practice (for AAs and PAs)

Good associate practice will mirror the same high professional standards in Good medical practice, save for those which must be amended or removed as they cannot apply to associates.

The GMC must never describe AAs or PAs as ‘members of the medical professions’, ‘medical professionals’ or ‘in medical practice’ and Good associate practice will respect this.

Good associate practice will include (or link to) additional standards because current guidance from the GMC and the Faculty of Physician Associates is inadequate for the unique challenge of regulating associates and fulfilling the GMC’s statutory duties.

The additional standards will be drafted based on the principles that associates:

  • Must follow a specified and explicit scope of practice, as set by a professional body with appropriate expertise.
  • Without being asked, must tell patients their professional title, the name of the doctor supervising them and how they are meaningfully different to a doctor.
  • Must record their job title and the name of the doctor supervising them in all written documentation and give these, without being asked, when speaking to colleagues unfamiliar with this information.
  • Must follow GMC guidance governing how their title and role is displayed or described, based around a comprehensive list of examples of what is and isn’t acceptable. The list must address associates being confused for Associate Specialists.

(Attempting to keep one publication for all registrants requires unnecessary complexity and confusion that would effectively create two sets of standards anyway, and requires losing ‘Good medical practice’ as a title and expression that holds value in maintaining public confidence in, and standards of, doctors.)

Online registers

At present, the GMC website hosts a register search function that at a glance clearly identifies to the public the registers it is required to keep by law. ‘The medical register’ is used as the common name for the register of medical practitioners and a brief definition of it as “a list of doctors” sits prominently next to the search function.

Current GMC website

Duty to keep a distinct register of associates

Article 5 of the AAPAO requires the GMC to keep a single register of associates which must be divided into two parts only, one for AAs and one for PAs. This can only be satisfied by keeping a new register of associates (and only associates), distinct from the register of medical practitioners.

Published plans in GMC news articles

On 24 October 2023 the GMC announced it would not operate separate online registers and that associates would be “displayed on the medical register”. On 8 March 2024 it did not declare a change to this plan and published partial depictions of “how our public facing registers will look” including the search function.

GMC partial depiction of its new register search function

The only logical conclusion is that the GMC plan to unilaterally redefine ‘the medical register’ as not being the register of medical practitioners but a different list (possibly all GMC registrants) that newly includes associates. In combination with keeping existing webpage titles and headings including ‘Search the medical register’, this is how associates will be displayed on the medical register.

Failure to meet the GMC’s objectives

‘The medical register’ has great public recognition, with widespread understanding that anyone on it is a lawfully registered doctor who meets strict qualification and other requirements. Any attempt to redefine what the medical register is, or discard reference to it, would debase valuable currency that maintains public confidence in the medical profession.

A member of the public using the planned search function is likely to correctly appreciate that a PA or AA has a different name of profession to a doctor. However, it comes with the false impression that a PA or AA is a type of doctor going by a different name or an equivalent to a doctor, since they are displayed on the same medical register.

Although welcome and beneficial in certain contexts, associates’ GMC numbers having an A prefix does not in any way help address this false impression. Nor would simply changing the title to ‘Search the registers’ because the separate registers in law for doctors and associates are still not identified or explained, and do not reflect the will of Parliament.

Consequences follow too for patients not even consulting the online registers. For example, an associate may tell a patient misleadingly “I am on the medical register” or “I am GMC-registered just like a doctor”.

Our format for online registers: simple and clear

To fulfil the GMC’s statutory duties, the online registers must make it clear to the public at a glance that:

  • the medical register of doctors is preserved
  • there is a separate register of associates with its own entry and qualification requirements
  • associates are not doctors, a type of doctor, equivalent to a doctor, or required to hold a degree in medicine

We propose our format depicted below

Our proposed online registers format

Putting matters right

We have spelled out the practical, ethical and legal issues with your approach to regulation of AAs and PAs. These issues are entirely unnecessary and can be simply resolved, as demonstrated by our proposed solutions.

The GMC rightly expects doctors to “put matters right, if possible” and we urge you to do the same in the interests of patients and the public. We are encouraged by the fact you are open to feedback and changing your regulatory plans for associates: “We’ve listened and have responded to feedback about our approach to regulation, and we will continue to do so”.

We trust this signals a willingness to engage constructively with Anaesthetists United on this matter, without undue delay or recourse to further action on our part. Things must be put right before regulation starts and irreversible harm is established.

Accordingly, we request, via email and in a timely manner, acknowledgement of receipt followed by a response that addresses the issues and practical next steps.

Yours sincerely

Dr Richard Marks FRCA

On behalf of Anaesthetists United