As part of our judicial review submission, and in our correspondence with the PSA, we summarised the reasons why doctors and associates are fundamentally different and must be regulated in different ways.   

History of doctors versus AAs and PAs  

The profession of doctor has a longstanding, ancient, history (see the ILO definition). The profession is well-understood by the public and is part of national culture and tradition. AAs and PAs, by contrast, are relatively recent, and began work in the NHS in very small numbers in 2002-04 to assist doctors in delivering specific aspects of patient care. Public understanding of their role is poor (see Annex 1).    

Entry qualifications and training requirements of doctors versus AAs and PAs  

Doctors complete a minimum of 5 years’ training (a 4-5 year medical degree and first year foundation training) but most thereafter complete another year of foundation training and then 3-7 years of speciality training. For AAs and PAs, the entry requirements, competition for entry, duration of training and pass rates are far less stringent. Whilst AAs must have a biomedical/biological/life science undergraduate degree or be a registered healthcare professional with 3 years clinical experience, PAs do not need a scientific undergraduate degree. Both then complete only a 2 year AA or PA training programme ie. far less comprehensive than the training a doctor receives in their first 5 years.

The training is now regulated by the GMC, but many associates who were already qualified or in existing programs keep practising without validated training.

Limits on the registration of doctors versus AAs and PAs 

Doctors are limited:

• initially by only being ‘provisionally’ registered on finishing medical school, so only being able to undertake the first stage of training (F1), and
• then by only being a doctor on a specialist register with specialty training of 3-7 years, in order to apply to certain specialist NHS roles and have private medical insurance.

There are, in contrast, no limits to the initial registration, or provision for specialist registration, of AAs and PAs: once they are trained as above, they are registered.   

Independent/dependent nature of practice 

AAs and PAs are ‘dependent practitioners’ – i.e. they can only work under, and are dependent on, the supervision of a doctor. 

Doctors are independent autonomous professionals exercising their own clinical judgment, even when supervised (albeit they are truly autonomous once accepted onto a specialist register). 

Post-qualification training pathways 

NHS doctors follow post-qualification training pathways (both during foundation and GP or speciality training) that have a long-standing history, are highly structured and well understood. This enables them and others to understand their expected competence. That framework also informs decisions about competence in relation to doctors practising outside that pathway.

There is no post-qualification training pathway for AAs and PAs, rendering it extremely difficult to identify their expected competence.

Arrangements for assessment of competence, appraisal and revalidation 

Doctors follow a formal system of annual appraisal and revalidation, overseen by the GMC, encompassing a review of scope of practice or competence progression. A doctor undergoes a range of performance assessments by supervisors before being signed off as competent on tasks/procedures.

There is as yet no system for appraisal and revalidation of associates, and no nationalised system for signing them off as competent at any given skill. The GMC’s intention is that PAs and AAs will be revalidated every 5 years and that revalidation will not examine their SoP (“It isn’t the role of the regulator to determine how PAs are deployed or whether their scope of practice remains general or becomes specialised. Our revalidation model needs to be flexible enough to incorporate all PAs and AAs, whatever their scope of practice”: Revalidation approach for physician associates and anaesthesia associates, GMC Executive Board Paper 19 December 2022, §21).   

Effect of these differences 

As a result, doctors and associates belong to fundamentally different professions and to adopt the regulatory approach used for doctors in relation to associates is misconceived as a level of principle. 

The professions differ fundamentally in terms of their likely levels and areas of competence and their ability (and that of members of the medical team working with them) to identify and understand their own competence and its limits, impacting on the ability of other doctors to delegate/supervise them and the ability of patients to give informed consent.  

Our legal team have been working very hard but we are short of funds.

The differences between doctors and associates are stark, and to claim that the same regulatory model can simply be copied and applied to both is a fallacy.   

The GMC should have paused, reflected and reconsidered it's decision not to define clear, enforceable limits.

It did not and we expect the PSA to act on behalf of the public they serve.

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