Red tape. It’s not exactly the most alluring of subjects, is it? Until, that is, you find yourself swimming in human excrement off the Cornish coast thanks, in part, to the water regulator Ofwat’s toothless oversight. Or screaming at a clip of GB News as its latest anti-vax talking head lets rip about implantable microchips with smirking disregard for any reprimand Ofcom may or may not deign to issue. Or being unable to sell your cladded flat because no one is going to buy a potential deathtrap.
Every regulatory failure has the potential to cause human suffering or loss of life, but in the case of the UK’s medical regulator, the General Medical Council (GMC), the dangers could not be more direct. The GMC exists for one reason alone—to keep patients safe from harm. If it fails in its core duty of ensuring that doctors are practising as they should, then patients may be injured or die as a consequence. The stakes are quite literally life and death—which is why the GMC’s competence, integrity and political independence should be a matter of paramount concern for us all.
You may, then, be perturbed to learn that large numbers of NHS doctors are in active revolt against the GMC. I hope so. I want you, please, to pause for thought at the risks to a grassroots doctor—someone whose entire career could be destroyed should the GMC decide to try to strike them off—in stating, publicly and for the record, that their regulator is unfit for purpose. To be more explicit still, this GMC-registered doctor (7019426) believes her regulator is falling short of the professional standards it expects of doctors. I consider the GMC’s recent behaviour to be at best cavalier, at worst downright dangerous, demonstrating serial failures of candour, transparency and integrity. And though I am painfully aware of the NHS’s atrocious track record of attacking, smearing and crushing whistleblowers, I regard as sacrosanct my professional duty to act in my patients’ best interests. What kind of doctor would I be, exactly, if I chose to keep quiet about grave patient safety concerns out of fear that the GMC might come for me?
Doctors are in uproar over the GMC’s role in the proliferation of a new, little publicised group of staff in the NHS termed “medical associate professionals” (MAPs), the most well-known of which are “physician associates” (PAs). Our anger has been swelling for several years, but this week is crunch time. On Friday 13th December the GMC will, for the first time in its 166-year history (other than a brief period of supervising dentists), regulate a body of healthcare workers who are not doctors. It will start issuing PAs with seven-digit GMC numbers just like mine above (though it insists there will be no public confusion about roles, because it will add the prefix “A” to those numbers).
The GMC will refer to PAs as “medical professionals”, despite this term being synonymous, in the eyes of many patients, with “doctor”. Indeed, the GMC appears to be quietly erasing the word “doctor” from some of its official material. Look on the GMC website, for example, and there the “Duties of a doctor” are now referred to as “The duties of medical professionals registered with the GMC”—the word “doctor" has vanished. Patients needn’t worry about getting confused though. A doctor, says the GMC, is a “medical practitioner”, whereas a “medical professional” might be a doctor, but then again, they might not. Clear as mud? I’m afraid you’re just not paying sufficient attention.
Why does any of this matter? Recalling why the GMC was founded in the first place is instructive. In recognition of the public health harms caused by quacks, charlatans, pseudo-doctors and snake oil salesmen, the Medical Act of 1858 tasked a new body, today’s GMC, with the specific remit of ensuring that the public knew who was, and who was not, a doctor. For nearly two centuries, this remit has served patients well. It ensures that anyone found to have impersonated a doctor can be struck off the register.
With PAs, though, things are more complicated. Originally envisaged as assistants who would increase NHS productivity by relieving doctors of routine and administrative tasks, the first PAs started working in the NHS in tiny numbers 20 years ago. The concept of clinical assistants supporting doctors was both uncontroversial and welcomed. Every doctor I know tears their hair out at the vast tracts of time we are forced to squander on prehistoric IT, labyrinthine admin and a thousand other straightforward tasks that keep us away from the work for which we are trained: diagnosing and managing patients. Having assistants to help with some of those tasks seemed sensible and efficient. But the PA role swiftly evolved. The term “assistant” was replaced by “associate” and PAs began to take on more and more of the tasks traditionally carried out by doctors (with a fraction of the training, but nominally overseen by a supervising senior doctor).
Today there are 3,250 PAs in the NHS, with the numbers set to expand rapidly. The 2023 NHS Long Term Workforce Plan has a stated aim of increasing their numbers to 10,000 PAs by 2036. Although rarely stated explicitly, the tacit explanation for the NHS’s growing reliance on this new role is economic: with an increasingly aging and medically complex population, the NHS cannot afford for the same proportions of patients to be treated by doctors.
The medical profession’s opposition to PAs has been dismissed by some politicians as an ill-tempered turf war, nothing more than members of an established profession trying to stop newcomers from encroaching on their traditional territory. Former health minister Jim Bethell, for example, has claimed that doctors who criticise the PA project are bullies whose concerns are “old-fashioned professional jealousy and shop-floor protectionism dressed up in fancy clothing”. Stalwarts of the medical establishment, including the Academy of Medical Royal Colleges, have equally sought to belittle the issue by framing it as an example of social media toxicity, as opposed to something grounded in evidence.
But this is disingenuous. Multiple large-scale surveys of doctors and multiple individual Royal Colleges (including the Royal Colleges of Physicians in London and Edinburgh, of Radiologists, Anaesthetists, General Practitioners and Paediatrics and Child Health) have all formally reported safety concerns about the increasing use of non-doctor PAs in doctor roles, with only the fig leaf of vague supervision from senior medics to protect patients from harm. Those concerns are shared by patients, relatives and several coroners who have investigated patient deaths involving PAs.
The coroner who examined the death of 77-year-old Susan Pollitt at Royal Oldham Hospital in 2023, for instance, explicitly highlighted the lack of any national framework covering the training and supervision of PAs, and the assessment of their competency. Pollitt, who was being treated by a PA, died after an abdominal drain that she didn’t need was mistakenly left in her abdomen for 21 hours. Evidence showed that in the month of Pollitt’s death, the NHS trust which oversees Royal Oldham used PAs to cover nearly 20 per cent of doctor shifts in elderly care. Her husband, Roy Pollitt, who was unaware she was being treated by a PA and not a doctor, believes “she would have lived if the NHS had not used cheap labour”.
Although multiple NHS bodies (the GMC included) insist publicly that PAs are not being used as substitute doctors, this is clearly happening, despite PAs’ more superficial training. In place of five years of medical school, PAs complete a two-year clinical course after a first degree which is usually, but not always, in a science. Graduates in sports studies, English literature and even homeopathy have all successfully completed PA courses, with some universities reporting a 100 per cent pass rate.
One former PA who has since retrained as a doctor, Adam Skeen, sums up the scientific content of his PA course as: “minimal anatomy, a couple of hours of pharmacology, no physiology, immunology, histology, genetics, or microbiology”. He believes PAs have been “sold a lie”, and it is hard not to share his sympathy for the well-meaning individuals caught up in a workforce debacle. Unlike doctors, there is no defined national scope of practice determining what PAs can safely do. In primary care, they have acted as de facto GPs. In hospitals, they fill vacant slots on resident doctor on-call rotas in acute medicine, paediatrics, emergency medicine and even highly complex specialties such as haematology. This year, Liverpool’s Alder Hey Children’s Hospital was forced to admit that a PA had even been involved in carrying out child sexual abuse medicals over a period of four years—but only after a Freedom of Information request forced it to do so.
In June, the Bradford District and Craven health and care partnership, a large NHS body responsible for the health needs of 2.4 million people, appeared to explicitly break the law by putting up posters that misrepresented PAs as doctors to its patient population. “The physician will see you now,” stated the posters, but the member of staff featured and explicitly described as a “physician in Bradford” was a PA, not a doctor. After a backlash to the campaign, the care partnership stated: “We now recognise that despite receiving feedback from one of our clinical leads, we had not updated all our campaign resources… Therefore, the title of physician associate has been incorrectly labelled as physician and although a corrected version of the leaflet was produced, it had not been changed on posters or animations.”
No one is suggesting that doctors never make mistakes (we do), nor that there isn’t a crisis in NHS staffing (there is), but the solution cannot be to mislead the public into thinking they’ve seen a doctor when they have not. Informed patient consent is meant to be enshrined at all levels of the NHS, not compromised whenever the NHS and its political leaders decide it can be.
Doctors who care about patient safety are asking themselves, do standards in UK medicine matter any more? Are the exceptionally arduous hoops through which doctors are expected to jump (entry to a highly competitive degree, five gruelling years of medical school, the series of specialist postgraduate exams of such rigour that hundreds of doctors fail them each year) necessary, or not? If a PA can safely occupy a resident haematologist’s slot on a hospital on-call rota, for example, despite having passed neither a medical degree, nor any Royal College of Physicians’ membership exams, nor any postgraduate haematology exam, then why does a doctor need these qualifications? Why not dispense with all this expensive red tape and be honest with the public that these days, anyone with a PA course can do pretty much anything a doctor can, with no safety repercussions for patients?
This is not an academic question: many recent medical graduates with up to £100,000 of student debt are looking incredulously at the current state of UK medicine and voting with their feet, departing for Australia, where they will earn more and not be summarily replaced by an “associate”. Meanwhile, the GMC insists it will not set any national parameters for what PAs can safely do and will, instead, leave it up to individual cash-strapped NHS trusts to decide how they allow their PAs to practise. As a doctor who, unusually, used to work in another profession, I can personally attest to the remarkable difficulty and complexity of practising medicine, with its unique fusion of science and humanity. Getting a First in PPE (Philosophy, Politics and Economics—not protective equipment) was infinitely easier than my work in palliative care, as were my years working in television journalism.
But don’t take my word for it. Recently, Professor Andrew Elder, the president of the Royal College of Physicians (Edinburgh), penned a pointed paper in the British Medical Journal entitled “Medicine is difficult—there are no shortcuts”. This short piece referred no less than 12 times to the difficulty of the discipline, with Elder writing: “Medicine is difficult, has become more difficult over my 40-year career, and will continue to become more difficult… The visions of future healthcare that have produced this mission to generate more doctors or more ‘associate professionals’ in shorter and shorter timeframes [are] based on a political concept of ‘productivity’ that is alien to those who walk the wards, talk to patients, and see the quality of care, rather than its quantity, as paramount.”
Elder’s words are a sharp rebuke to the GMC’s director of education and standards, Colin Melville, who in March this year proposed “streamlining” the course content of UK medical schools because doctors can always rely on their phones. As he wrote in a blog: “With up-to-date information at our fingertips via trusted sources on our smartphones we don’t need the huge repository in our heads from textbooks and lectures. Content in the curriculum can be streamlined.” The GMC may be comfortable with future UK doctors increasingly relying on internet trawls to guide their practice, but this experienced clinician most definitely is not, and nor are many of my colleagues. Safe medical practice relies on sufficient depth and breadth of training for doctors to be aware of rare as well as common causes of pathology. Inexperienced doctors sometimes forget what conditions they must not miss—the “unknown unknowns” that may prove fatal. Google cannot help them if they've never been taught about condition X in the first place.
The GMC insists that PAs are “an important part of the health system” and that “regulation is a vital step towards strengthening both patient safety and public trust” in the role. The council has also claimed that it will differentiate between doctors and PAs. “Physician associates… are not doctors, cannot replace them, and should never be used to fill gaps in doctors’ rotas. When we begin regulating PAs… later this year, we will expect them to be supervised by a doctor and to practise within their competence,” the GMC stated last month. But for many doctors, this is far from reassuring, representing instead a cavalier approach to the deadly serious matter of maintaining standards in UK medicine.
In March, forced onto the back foot by mounting concerns in the media about PAs, the GMC finally announced a public consultation on their role in the NHS. In May, this consultation closed, but then the GMC went mysteriously quiet. Months went by. We heard nothing. For 97 days in a row, I politely asked the GMC on social media to please release the results of its public survey. Those requests were ignored. Other doctors submitted Freedom of Information requests for the data, which were rebutted by the GMC, which now claimed that its consultation was, in fact, a form of medical “research” and thus beyond the reach of FOI submissions. Then, last week—mere days before GMC regulation of PAs becomes a fait accompli in the face of fierce opposition from doctors—it finally released a redacted version of its survey data. The report has removed all free text public responses which the GMC deems to be “beyond the scope” of its survey (sorry, research) though it does confirm that two-thirds of respondents disagree with most of the GMC’s approach on this divisive issue.
All of this brings us neatly back to the question of red tape and how, safely, to dispense with it. Much like fire hazard regulations for blocks of flats, or maximum permitted effluent levels for our rivers and seas, is the GMC red tape in which I am gladly wrapped as a doctor (because my patients’ safety matters to me deeply) superfluous or necessary? The GMC’s stance has been to obediently follow the lead of the Department of Health on PAs by embracing them as “medical professionals”, while shrugging off any need to regulate them via a national scope of practice. Individual trusts can essentially use PAs as they see fit, with no repercussions from the GMC. For a medical regulator, this seems an astonishing dereliction of duty.
Mercifully, Wes Streeting has now ordered an urgent, independent investigation into the safety of using PAs in the NHS, though this research should have been undertaken before introducing this new role, not two decades later. Meanwhile, the GMC is ploughing ahead with quasi-regulating non-doctors from Friday, all while continuing to bluster, evade scrutiny and wonder why doctors like me, having lost all faith in its competence and honesty, are reduced to publicly begging it to do its job properly.
