What comes next after the extraordinary general meeting on physician associates at the RCP?

On 13 March an extraordinary general meeting (EGM) of the Royal College of Physicians (RCP) debated five motions on the use of physician associates (PAs) in the NHS.1 Four of the motions, relating to their scope of practice, accountability, evaluation, and how PAs affect the training opportunities of doctors—not just those in formal training programmes—were supported by both the RCP and the Faculty of Physician Associates (FPA). What generated considerable controversy was motion 5, which called for caution in the pace and scale of the rollout of PAs ahead of full regulation being in place.

RCP senior leadership decided to take an active stance opposing motion 5 rather than a neutral one, a move that was always going to be a high stakes risk, and so it turned out to be. This was a missed opportunity for senior leadership to show people they were not taking “sides” and were simply facilitating fellows across both sides of the debate to have their say and allowing consensus to emerge. Instead, it created a clear division between the RCP leadership team and the fellows in the audience.

A flash point was the way the RCP chose to present summary data, rather than the raw data, of the survey conducted to understand the impact of PAs on the members of the RCP who are unable to vote. When the raw data were finally released, they showed that non-consultant medical staff have not found PAs to improve either their working lives or their access to teaching and training opportunities. The RCP’s misrepresentation of the data and the subsequent fallout have been significant. Both the registrar and deputy registrar announced their resignations2 and the president of the RCP Sarah Clarke issued an apology for the “confusion”—a word which arguably is better replaced with “misrepresentation”.3

The results of the actual vote on the five motions were released several days after the EGM.4 The turnout of voting fellows was 31.9%, with motions 1-4 each passing with over 95% support. For motion 5, 78.7% voted in favour of limiting the pace and scale of rollout of PAs.

So where to next? Well, it is important to remember why fellows were so concerned as to trigger an EGM in the first place. Regulation for PAs is not yet in place. Legislation that puts the General Medical Council (GMC) in charge of regulating PAs has passed, but this won’t happen in practice until the end of the year. Evidence has come to light that in the absence of defined scope of practice for PAs, employers have used PAs as a workforce substitution for doctors.5 Some trusts have gone so far as to enable PAs to prescribe medications and request ionising radiation, both of which are against the law for staff not on a professional register.6 Given that there is evidence of poor practice and risk to patients, problems must be resolved prior to the massive expansion in the number of PAs outlined in the Long Term Workforce Plan.

We offer some suggestions for future directions following the meeting.

• Firstly, there needs to be an investigation into the conduct of the EGM. The RCP leadership team needs to repair its relationship with members and fellows. The debate has revealed some of the fault lines in the organisation, particularly the gap between the perceptions of the leadership team and the reality of the working lives of most doctors, which, as the survey revealed, have been made considerably worse by the introduction of PAs. A governance review is already under way, but to regain trust requires a more targeted investigation by someone both skilled and independent into how the process of the EGM was handled.

• Secondly, a full investigation of what has gone wrong with the implementation of PAs must be undertaken. Unless failings are clearly understood, the underlying problems cannot be fixed. This includes defining what the scope of PAs should be and what other mechanisms might be needed, beyond inclusion on a formal register held by the GMC, to ensure patient safety. This also would include a review of all existing literature and a review of the conflicts of interest of relevant authors.

• Next, action is needed to prevent potential harm to patients. Until the PA voluntary register is transferred to the GMC, the FPA and the RCP are the de facto regulators of PAs. To restore the faith of the public and the medical profession in PAs, every instance of possible illegal practice and patient harm must be examined and those responsible need to be held to account, including any senior managerial staff who have enabled or colluded in PAs carrying out responsibilities they’re not qualified for. There are examples for the RCP to follow here. The Nursing and Midwifery Council, for example, has just announced that it will look at introducing proportionate regulation for advanced nursing practitioners, where there are similar problems of lack of consistency around responsibilities and scope of practice being defined by employers.7

• Lastly, the RCP needs to be more democratic. The byelaws of the college need to be amended so that the voices of the membership are heard. The expansion of PAs affects more members than fellows (in terms of training opportunities, rotas, etc) so it does not make sense that members were not able to vote. There is a flaw in the overall process of what modes are available for members to express their views on critical topics to leadership. Transparency into the workings of the RCP would also be improved by reviewing the byelaw that allows council meetings to be done in private—an odd quirk in an era where parliamentary proceedings are telecast live and NHS England’s board meetings live tweeted.

Arguably there was an opportunity here for the RCP to show real bravery and leadership. It could have acknowledged the possibility of patient harm and taken active measures to prevent it, without being forced to do so by its fellows. Yet here we are.

If there is a desire to rebuild relationships then the steps above need to be taken to help calm concerns and show that the RCP is listening. The role of the college cannot be to implement government plans without question, but to work to ensure patient safety stays paramount along with maintaining standards of education and emphasising the value of physicians in healthcare. This is undoubtedly a test for senior leadership. The members and fellows are watching closely. Time will tell whether the RCP’s verbal commitment to “listening” is genuine. The legacy of the senior leadership will be dependent on their actions going forward.