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GMC case in focus: How GPs should supervise PAs

GMC case in focus: How GPs should supervise PAs

Every month, the Doctors’ Association UK looks at a GMC case that has implications for the profession that is either topical or from recent history. This time, we look at the case of Dr Steven Zaw, a secondary care doctor who was suspended for ‘inadequately supervising’ the PA under his authority, which provides a useful perspective for GPs on the role of these healthcare professionals

Most doctors will be aware of the controversy surrounding the physician associate (PA) role. NHS England has stated that PAs should work as valued members of the wider multidisciplinary team (MDT) as they are trained to examine, diagnose and treat patients. This has led to fears that they are being used in lieu of GPs and specialist doctors.

However, PAs are not doctors; they must always work within a defined scope of competence and, most importantly, be supervised appropriately by doctors. NHSE has laid out plans to train an extra 60,000 – 74,000 doctors to support the predicted 10,000 PAs in the NHS by 2036/37.

The GMC has opened a public consultation about how to configure PA regulations. However, this consultation does not address PA scope or standard at all. For doctors then, it is unclear what their responsibilities are to the PAs with whom they may find themselves working.

Or is it so unclear? The Medical Practitioner Tribunal Service (MPTS) thinks not. In 2017, Dr Steven Zaw was assessed for his care of four patients in a period lasting from November 2012 until December 2014: three patients during his employment as a clinical fellow in acute medicine at St George’s Healthcare Trust; and one patient during his subsequent employment at Northwick Park Hospital. The MPTS relied on an expert (Dr I) and – in the case of Patient C, one of the four patients – the evidence of Ms G, who is a PA. (The tribunal referred to the PA as ‘Dr G’*. For the purpose of clarity, we will refer to her as ‘Ms G’.)

Patient C presented to hospital with suspected meningitis and was seen by Ms G. Ms G said that a PA ‘would do the bulk of what a junior doctor could do, but could not independently prescribe for patients.’ In her oral evidence, Ms G stated that once she had completed her assessment, she was expected to liaise with the department registrar who would action any of her requests. From this evidence, the tribunal was satisfied that Ms G had limited responsibilities, and required ‘authorisation’ from a registrar before carrying out any work that went beyond those responsibilities – that registrar being Dr Zaw. 

Most of us would agree with the PA role that Ms G described. However, what does ‘authorisation’ look like? The tribunal went on to consider this and found that although Ms G – the PA – had taken a history from the patient, a collateral history should have been taken by Dr Zaw. By not doing so, he had failed in his duty. 

Furthermore, Dr Zaw did not examine the patient – Ms G had. But the tribunal again considered that Dr Zaw had failed in his duty because he had not also examined the patient himself. Following further criticisms that Dr Zaw had not prescribed antibiotics promptly enough, nor organised a CT scan, the tribunal also found that with respect to Patient C, Dr Zaw had failed to supervise the Physician’s Assistant (‘PA’) on his team – note the term ‘assistant.’ It was his failure to supervise the PA, as well as his care of two out of the other three patients being found below an accepted standard, that contributed to his 12-month suspension, and later erasure from the medical register. 

The role and responsibilities of a supervising doctor regarding PAs appear to have therefore been established. Dr Zaw failed in his duty as a doctor for inadequately supervising Ms G, and this contributed to the suspension of his medical licence. Why Dr Zaw did not fulfil these duties was unexplored by the tribunal. Perhaps he was busy seeing other patients. Maybe, as most of us might think, he assumed that Ms G, employed by his Trust as part of the medical team, was there for the very purpose of taking patient history and examining them. Why have Ms G in post if all of her work needs replicating? 

DAUK, the BMA and others have debated the appropriateness of the GMC as a regulator of PAs. This is further called into question with a catastrophic failure in the live public consultation as to what the scope and standards for a PA look like. The GMC is looking to others – namely employers – to do that. We know currently that employers are not necessarily stipulating any of this, least of all the supervising responsibilities of doctors. PAs may have a role to play in patient care, but all doctors out there need to read the Dr Zaw judgement and take the necessary measures when working with PAs to protect their medical licence. The GMC – and your employers, for those in secondary care – may not do that on your behalf.

Doctors’ Association UK (DAUK) is a non-profit professional association run by volunteer NHS doctors, which advocates for the medical profession and the wider NHS. 

We want a better and fairer process for all, including our patients, and will be reviewing the GMC case of the month for Pulse. Our aim is to generate debate, honest reflection and raise awareness. 

Contact DAUK if you have a case you think should be reviewed.

* Please note, it has been pointed out that this PA has since become medically qualified, and this is why the tribunal referred to the witness as ‘Dr’



Please note, only GPs are permitted to add comments to articles

David Church 19 April, 2024 9:42 pm

Why should NHS need to train extra doctors to support the additional 10,000 PAs ?
Surely the whole point was for PAs to be supporting Doctors?
What on earth are people thinking of here???

David Church 19 April, 2024 9:51 pm

So, the PA can take a history and examine the patient, but nobody, not even the doctor supervising the PA, can diagnose and prescribe without repeating the history-taing and examination.
What then is the point of a PA if all that they can do is pre-emptorily repeat the history-taking and examination that the Doctor must do themselves?
There must be a better solution to this for everybody.
In the meantime, however, no PA must themselves or anybody else call them ‘doctor’ or try to pass them off as a ‘Doctor’, (no, not even if they have a PhD, it is still dishonest misrepresentation).
Someone at the MPTS has crossed a line and should demonstrate the 3 ‘R’s please.

James Weems 21 April, 2024 11:47 pm

PA role obsolete then if their job needs doing again by a doctor.
Here’s a plan.
Restore doctor pay.
Make more posts available.
Scale down PA role.
Fund the doctor led model.
Increase efficiency and get more patients seen by the right person first without any faffing around.

a S 23 April, 2024 12:14 pm

The art of being a good GP is taking a good history and examination. Then the diagnosis and management will follow. Anyone can google the management once the dignosis is clear.
How can I advise/check someones history and examination without going through everything myself with the patient. Asking my advise on someone else’s history and examination is like building a house on sand.

Waseem Jerjes 24 April, 2024 11:18 am

The escalating reliance on Physician Associates (PAs) in the healthcare system raises substantial concerns about the dilution of medical expertise and the potential risks to patient safety. While PAs are undoubtedly capable and trained to perform a variety of tasks within their scope, they are not a substitute for fully trained, qualified physicians. In simple words they are not medics. The fundamental issue with integrating PAs as stand-ins for doctors is that PAs require constant supervision and authorization from physicians to execute their duties, which can burden doctors and divert their attention from more critical tasks. This additional supervisory requirement not only increases the workload of physicians but also introduces risks of miscommunication and oversight. Moreover, the case of Dr. Steven Zaw highlights the severe consequences of inadequate supervision, where a doctor’s career was jeopardized due to the failings in managing a PA’s responsibilities. The incident underlines that the solution to shortages in healthcare should not be to substitute real medics with less qualified non-medical personnel but to address the root causes, such as improving medical training capacities and retention of healthcare professionals. This strategy would ensure high standards of patient care and safety without compromising the quality with makeshift solutions.

Centreground Centreground 24 April, 2024 3:54 pm

The GMC should be accountable in my opinion where it is fully aware it is agreeing to regulate a professional group and stating the history and examination needs to be repeated by the supervising doctor knowing full well that these resources in time and capacity to undertake this do not exist in the NHS .
From my perspective the GMC should be vicariously liable on these grounds alone and GMC individuals involved in PA regulation being introduced to the GMC should be named in the same way as doctors -we are all entitled to our opinions .

Marilyn Monroe 24 April, 2024 7:24 pm

Utter feckin chaos..a whole profession has been created, its regulated by the GMC, and the GMC hasnt decided what they do yet?? WTF?? I was looking for a GP job the other day in the West Midlands..not many around but quite a few looking for PA’s. One really caught my eye “ you will be seeing and managing patients presenting with undifferentiated undiagnosed illness…along with a group of 10 other PA’s in our practice” ..around the same time the ad was up the whole PA issue blew up in Pulse, I went back to look a day or so later and it had been taken down. Yeah there are practices employing good old fashioned Drs, maybe you work somewhere like this, but there are some mega practices that have embraced this wholeheartedly and these Dr GP jobs are now gone. Few months back I got an email about training in palliative care “now available for GPs” , initial funding had been for allied staff only, but it was under subscribed so they decided to let Drs attend too. This is happening NOW. I fear pandoras box has been opened and a consultation by the GMC is two years too late. Primary care delivered by Drs is dying. It will take years to play through, many practices still run the old fashioned way, but I can tell you as a locum who worked/works all over central and western England, its dying. The GMC are complicit and the RCGP have been utterly useless. Just a year or so ago they were arguing for 6 year GP training and they as good as rubber stamped a drop to two. Chaos, a dogs dinner. You keep thinking UK general practice cant get any worse and yet month by month the system manages even more stupidity. Lets have a consultation about it. Yeah next week. Cool