Our lawyers have now formally written to the Professional Standards Authority (PSA) – the statutory body that oversees the GMC – presenting evidence that the GMC failed to meet at least six of the PSA’s own regulatory standards when it introduced regulation for Physician Associates (PAs) and Anaesthesia Associates (AAs).
The PSA is being invited to consider a huge dossier of evidence showing why the GMC’s approach to associate regulation fell short of the PSA’s standards. These standards insist on risks to patients being identified and managed
This should be a real cause for concern to the PSA, especially as they have repeatedly pointed out that the GMC does not assess risk the same way that every other PSA-accredited regulator does.
We believe the GMC is still not regulating PAs and AAs properly or safely – even after the Leng Review. Professor Leng’s recommendations were welcomed by the GMC but not a single one of them has been implemented. For reasons that are unclear, the PSA did not look into this when it last reviewed the GMC. That has to change.
We have therefore asked the PSA to carry out another, urgent formal review of the GMC’s compliance with its standards, to examine exactly how the GMC believes it is addressing the risks to patients posed by PAs and AAs, and to tell us what it intends to do about it.
We are enormously grateful to our legal team for their work. You can read the full letter here.
None of this is cheap, and we rely on donations to continue.
What is the PSA?
The PSA is the statutory body whose job is to protect the public by setting principles for regulation and holding regulators like the GMC to account when they fail.
The GMC likes to present itself as untouchable; but it isn’t. The PSA exists precisely for moments like this – when a regulator has priorities other than patient safety. And it has already shown it is very interested in PA and AA regulation.
But in December last year it reviewed the GMC’s performance, over the period when PA and AA regulation was introduced, and concluded that the GMC had met all of its 18 standards of good regulation.
That report, though, was astonishingly superficial. The single biggest new responsibility the GMC had taken on was waved through with barely a glance – something that is difficult to understand given what has subsequently emerged.
Where the GMC has failed
We believe the GMC has breached multiple PSA standards – it has
- Failed to identify and manage risks by properly consulting stakeholders.
- Failed to ensure patients receive honest, usable information.
- Inappropriately applied policies designed for doctors to non-doctors.
- Failed to address repeated concerns raised by coroners.
- Failed to implement the Leng review in any meaningful way.
- Failed to keep its own standards under review as risks became obvious.
Standard 5 – the GMC refused to ask the only question that mattered
PSA Standard 5 requires regulators to consult stakeholders to identify and manage risk before setting standards.
The [GMC] consults and works with all relevant stakeholders across all its functions to identify and manage risks to the public in respect of its registrants
The GMC did just the opposite.
It refused to consult on the single most important issue about PA and AA regulation: whether there should be enforceable and meaningful limits on what PAs and AAs can do?
As we heard in court from Professor Melville, the GMC had already decided the answer to that in advance. There would be no national scope of practice and no national boundaries. So its 2024 consultation was carefully crafted to focus on processes, training mechanics and fees, but did not ask about limits on practice.
And when it subsequently introduced new guidance, such as “Supervision Practice Advice”, it also avoided consultation.
Meanwhile, evidence was piling up from Royal Colleges, from coroners, from clinicians on the ground, all recognising that unbounded PA practice was dangerous.
Rather than assess risk, the GMC started with the attitude that PAs could decide for themselves what they were competent to do, an approach which is fundamentally flawed. They also ducked the issue of informed consent, even as coroners repeatedly found that patients did not know they were being treated by associates rather than doctors.
Standard 1 – patients are being misled
The [GMC] provides accurate, fully accessible information about its registrants, regulatory requirements, guidance, processes and decisions
Patients routinely assume that PAs are doctors. They are not.
Yet the GMC imposed no meaningful obligation on PAs to clearly explain who they are, what they are not, and what limits apply to their role. Ironically, medical students are held to a higher standard of disclosure than registered PAs.
In roles that are novel, poorly understood and associated with real safety risks, the failure to ensure clarity leaves patients exposed and doctors professionally vulnerable.
The GMC’s own CEO, Mr Charlie Massey, admitted as much to the recent Health Select Committee
“I’m sorry… that we weren’t clearer about distinguishing between those roles. With the benefit of hindsight we should have gone further.”
Mr Massey would be aware that the AAPAO, the government order covering PA regulation, gives them the duty to keep standards under review rather than peering mournfully into the retrospectoscope.
Standard 2 – treating PAs like doctors is unsafe and irrational
The [GMC] is clear about its purpose and ensures that its policies are applied appropriately across all its functions and that relevant learning from one area is applied to others.
PSA Standard 2 requires policies to be applied appropriately across functions. But the GMC applied doctor-designed regulation to non-doctors.
Doctors and PAs are not interchangeable. They differ in background, academic depth, training length, diagnostic autonomy and professional development. Doctors progress towards independent practice. PAs never do. They are dependent practitioners by design.
Yet the GMC’s framework does not set any limits. Regulating PAs as if they were doctors while refusing to define what they may and may not do is reckless. Parliament intended the GMC to protect the public. Allowing role creep without boundaries does the opposite.
Standard 4 – the GMC refuses to listen to experts
The [GMC] reports on its performance and addresses concerns identified about it and considers the implications for it of findings of public inquiries and other relevant reports about healthcare regulatory issues.
PSA Standard 4 requires regulators to address concerns and respond to findings from inquiries and reports.
Coroners’ Prevention of Future Death reports are about system failure, not isolated error. But the GMC did not revisit its assumptions about scope of practice in the light of these reports.
But the biggest failure to comply with Standard 4 has been the lack of implementing the recommendations of the Leng review. Professor Leng’s recommendations were unambiguous:
- national scopes of practice,
- no independent management of undifferentiated patients,
- clear medical supervision,
- named doctors holding responsibility,
- transparent role titles and patient communication.
But the GMC has done nothing.
Standards 6 and 7 – failure to keep standards under review
The [GMC] maintains up-to-date standards for registrants which are kept under review and prioritise patient and service user centred care and safety.
The [GMC] provides guidance to help registrants apply the standards and ensures this guidance is up to date, addresses emerging areas of risk, and prioritises patient and service user centred care and safety.”
The GMC is supposed to keep standards current and responsive to emerging risk.
Instead, PA guidance remains abstract, vague and detached from real clinical practice. Reams of ethical slogans, but no operational limits. It tells PAs how to behave, but not what they may safely do. And as the risks have become obvious, its standards have remained static.
In conclusion – the PSA needs to act
There is a clear need for the PSA to scrutinise in detail the GMC’s approach to the regulation of PAs. Everyone accepts that urgent change is needed. Yet so far the PSA has meekly given the GMC a green light while ignoring concerns from clinicians, colleges, coroners and patients.
We ask the PSA to look again at whether the GMC has adhered to its standards, and this time to actually look properly.
Not at process, box-ticking and fees, but at whether the GMC has actually done what regulation exists for. Protecting patients and supporting safe medical practice.
Some of the evidence in our dossier only came to light because our judicial review forced the disclosure of documents and exposed a decision-making process that had previously been kept out of public view.
We are grateful to all our supporters who have made this work possible. If you are able to make a further donation to us it will help us reach our goals. We are persistent and committed.