Dark days for the Royal College of Physicians of London

The Royal College of Physicians of London (RCP) was established over 500 years ago to uphold professional standards in medicine, but now seems bent on lowering them. Senior officers appear to have engaged in Orwellian tactics to try to push through physician associate (PA) roles with scant attention given to patient safety. In the wake of an outcry over how the college has handled the PA debate, particularly after a contentious emergency general meeting (EGM) held earlier this month,1 an independent inquiry is urgently needed to investigate the questions of governance that face the college.

Chief among these questions is the college’s ability to represent and advocate for its members’ views on PAs. The college took on hosting the Faculty of Physician Associates in 2015—a time when the PA role was constructed primarily as assisting doctors. At that point, nobody was talking about this new staff group substituting doctors.

But by 2023, PAs—whose numbers are set to expand rapidly in the next few years2—were being used in a wide variety of roles, including joining hospital doctors’ rotas and seeing undifferentiated patients in general practice.34 Given that PAs do not yet have a clearly defined scope of practice, the college’s close association with their training and certification has started to look like a wanton blurring of boundaries between doctors and non-doctors.

This association has also raised questions about senior officers’ neutrality on the debate. The day before the EGM, the RCP’s president Sarah Clarke published a firmly worded personal opinion on PAs in The BMJ.5 In rapid responses to the article, I and others raised questions about whether conflicts of interest had been fully disclosed, and a revised conflict of interest statement confirming that the college receives income from the Faculty of Physician Associates was retrospectively added.5

I was one of 20 fellows who had requested an EGM so that we could debate matters relating to PAs, including five motions for fellows to vote on. But the format and running of the EGM, tightly controlled by senior officers, meant that full and frank discussion of critical topics—patient safety, the training of the next generation of doctors, and potential financial conflicts of interest—did not occur.

The college had commissioned a survey of more than 12 000 members (holders of the MRCP qualification) in advance of the EGM, but only a selective “summary” of these findings was presented, which conspicuously failed to convey the widespread concern the raw data revealed about aspects of the PA role. We were shocked at senior officers’ refusal to release the full survey results until after an online vote on the EGM motions had closed.1

In the days following the EGM, college officers bowed to pressure and released the full results of the member survey6; an online vote of fellows carried all motions of concern overwhelmingly7; and there were demands for an independent inquiry.

This unfortunate chain of events has been, in the words of a BMJ columnist, “a masterclass in how not to engage with your membership.”8 Two of the college’s senior officers have stepped down,910 but the gulf between what remains of the college’s senior executive and the doctors they are meant to represent has probably never been wider. Indeed, on 25 March, the college president, who was standing for re-election uncontested, was given a distinctly frosty reception at the annual general meeting.

Many doctors are left with misgivings as to whether the college has met the standards of professionalism, transparency, and candour expected of the institution that is meant to represent us. There are questions about whether the structures and processes of college governance need reform—for example, by allowing council a deliberative role rather than expecting it to rubber-stamp decisions made by a handful of senior officers. An independent inquiry to investigate these questions should be commissioned urgently, conducted thoroughly, and published promptly.

Perhaps the one positive outcome has been that RCP London is now in no doubt as to the views of its members (over 2000 of whom responded to the survey6) and its fellows (over 4000 of whom voted on the EGM motions7). Doctors’ key concerns are clear: PAs’ scope of practice (and the implications for patient safety), supervision and accountability, candour (patients are not always aware that the person seeing them is not a doctor), loss of training opportunities for doctors, how PA roles will be evaluated, and the need to proceed cautiously when rolling out a role that has not yet been shown to be safe or cost-effective.

RCP London has announced that it is committed to honouring the result of the fellows’ EGM vote and taking account of the views of its members. It therefore needs to put measures in place to limit the pace and scale of PA rollout until crucial safety critical questions have been answered. It also needs to openly welcome an independent inquiry into how fellows’ concerns about PAs were addressed by senior officers.

The reputation of RCP London is already precariously low. If the examination of what went wrong either does not happen or turns into a face-saving exercise, public trust in this once revered institution could plummet even further.