In their replies to the coroner, following the inquest into the tragic death of Susan Pollitt,  the General Medical Council (GMC) and the Royal College of Physicians (RCP) expose a stark divide on the issue of Physician Associate (PA) practice standards.

The RCP firmly asserts that PA practice scope should be nationally regulated to enhance patient safety, a stance we strongly support. Critically, they say  “System leaders, including the GMC, should take a leading role in developing and overseeing a national scope of practice for PAs.”

We firmly believe this is necessary because: 

• there is currently no national scope of practice – nor is there any prospect of one being adopted or agreed any time soon; 
• even if one were prepared by a Royal College, it would have no legal effect unless the GMC adopted it; and
• it would not be enforceable unless the GMC agrees to enforce it. 

But even if the GMC remains unwilling to develop a full scope of practice, what it absolutely must do is set limits on what PAs can do, so that everyone – patients, doctors and PAs themselves – know and understand the limits of the PA role. 

Exactly the same principles apply to Anaesthesia Associates (AAs). 

The GMC, however, has delivered a response that appears evasive. It may even cause the Coroner to think the GMC is taking actions that it has firmly refused to take, in response to correspondence from us and our solicitors. We urge a careful review of their wording.

For the RCP it was a simple question. They fundamentally disagree with the GMC position with respect to the scope of practice and have committed themselves to actively campaign for limits on PA expansion until safe practices are established. The RCP has not yet said that they will support our judicial review but we are hoping that they will do so in due course. Any encouragement that members or fellows can give them to do so would be very welcome.

Standards, limits and a loophole

Professor Colin Melville’s reply to the coroner, on behalf of the GMC, appears at first glance to be quite encouraging. He acknowledges that patients must always be clear about the role of PAs within the team. He acknowledges too that once regulation begins the GMC will have the power to set ‘standards’ of patient care. He says the GMC supports the work that the Royal Colleges are doing on scope, and confirms that they are encouraging Colleges, employers and others to work together to ensure that all such guidance is aligned and consistent.

And yet, while apparently agreeing with us, he skirts around some key issues. 

His  assertion that the GMC will have power to set the standards of patient care that PAs need to meet seems, at first sight, to be clear and unambiguous. Yet the GMC have already claimed, in their reply to our lawyers, a dubious distinction between ‘standards’ (which they say they can set) and ‘limits’ (which they say they can not). This artificial division allows them to then claim they cannot determine what Associates (both PAs and AAs) can and cannot do. 

To us there is simply no meaningful difference between setting standards and limits. The very notion of a standard connotes a limit because behaviour outside of the standard becomes impermissible. Good Medical Practice is awash with standards that impose limits. And the GMC says it has no problem with setting standards for PAs at the point of qualification through approval of their course curriculum. Its reluctance to set standards kicks in (ironically) once PAs have qualified and start in practice full time. 

But if the GMC truly believes that there is a difference between standards and limits then Melville should have highlighted this, and any implications of this distinction, in his reply to the coroner. Without addressing this point then his reply does not address the very serious concerns the Coroner has raised in a helpful way nor show due diligence. We recommend that the coroner seeks clarification on this.

Royal Colleges, Employers and Scope

We firmly believe, as does the RCP, that scope for Associates should be set nationally. We also believe that the Medical Royal Colleges are best placed to define this, but that the GMC must embrace the responsibility Parliament has decided it should have to set and enforce limits whether or not they appear in scopes of practice. Melville in his response states:- 

The issue of a perceived lack of national guidance surrounding the safe deployment of PAs has been raised in recent months.”

Pausing there, this is simply wrong.  There have been grave concerns for several years which drove the decision to empower the GMC as regulator. 

He adds: 

“Several organisations have been working to develop guidance appropriate to their specialty or responsibility…. We have been supporting the work that individual royal colleges, and the Academy of Medical Royal Colleges, are currently leading on developing a range of guidance on supervision and how PAs can safely develop their skills and competencies over time once they have qualified and registered with us. The Royal College of Physicians is currently consulting on their guidance and the Royal College of General Practitioners plans to do so shortly. We are also encouraging colleges, NHS employers and others to ensure that all guidance being produced is aligned and consistent so as not to cause confusion for employers, supervisors or PAs themselves.

But this support is superficial and will make no difference. We say this because NHS employers can and do ask Associates to act outside the scope of practice that Colleges have set in the past – or  they simply rewrite the text of what has been produced to include ‘enhanced’ (and fundamentally different) tasks that they want PAs to undertake. 

Again, this is something the GMC should be well aware of. It was another reason to give it regulatory powers. We have recently heard Stephen Nash, leader of Associate group UMAPS, pleading for help on this to Channel 4; confirming our concern that not only do employers push Associates on scope but that this is where things go wrong.

And when the guidance given by Colleges and employers is inconsistent, what will the GMC do? If they support the College’s position and adopt and enforce it, this would help. But if they side with the employers, or simply remain neutral, then their ‘support’ of the Colleges becomes empty and meaningless. 

The coroner should press the GMC to clarify these details.

Roles and hierarchy 

Perhaps the saddest remark in Melville’s statement is the question: What was the role of the consultant in overseeing the overall care of Mrs Pollitt?  A question that reveals a catastrophic breakdown of the hierarchy, roles and leadership in hospital medicine. Is the GMC proud of this? Surely the role of the consultant should be clear to all.

But an additional complication was that Mrs Pollitt was under the care of a respiratory consultant, with input from the gastro team, and the interrelationships between the various teams and the Associate themselves may have contributed to the problem. Melville thinks a junior doctor had overridden the consultant. He also argues that the PA themselves was not given proper instructions, without addressing who should have given such an instruction.

If this is what employer-led scope looks like then it requires urgent change.

The legal challenge

Our judicial review of the GMC, over their failure to set lawful and safe practice measures, remains critical. We have submitted the papers to the Court and are waiting to hear back. In the meantime, we remain very short of funds, and are looking for both personal and institutional funding. If every Consultant and GP gave us £100 it would be a great help. Please consider donating. There is a long way to go.