GMC case in the spotlight: How GPs should manage PA

Every month, the British Medical Association looks at a GMC case that has an impact on the profession that is topical or from recent history. This time, we look at the case of Dr Steven Zaw, a secondary doctor who was suspended for ‘improperly supervising’ a PA under his authority., which provides an important perspective for Doctors on the role of these health professionals

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

However, PAs are not doctors; they must always work within the defined scope of competence and, most importantly, be properly supervised by doctors. NHSE has set plans for train 60,000 – 74,000 more doctors supporting a predicted 10,000 places in the NHS by 2036/37.

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

Or it is so unknown? The Medical Tribunal Service (MPTS) thinks not. In 2017, Dr. Steven Zaw he was assessed for his care of four patients between November 2012 and 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 work at Northwick Park Hospital. The MPTS relied on the expert (Dr I) and – for Patient C, one of the four patients – the evidence of Mrs G, who is a PA. (The court referred to the PA as ‘Dr G’, for unknown reasons. For the purpose of clarification, 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 the PA would ‘do most of what a junior doctor can do, but she couldn’t prescribe to patients on her own.’ In her oral evidence, Ms G said that once she had completed her assessment, she was expected to contact the departmental registrar who would deal with any of her requests. From this evidence, the court was satisfied that Mrs G had limited duties, and needed ‘approval’ from the registrar before performing any work that exceeded those duties – that registrar being Dr Zaw.

Most of us would agree with the role of the PA that Mrs G described. However, what does ‘consent’ look like? The court continued to consider this and found that although Mrs G – PA – had taken the history from the patient, the 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 – Mrs G did. But the court saw again that Dr. Zaw failed to fulfill his duty because he also did not examine the patient himself. Following further criticism that Dr Zaw did not immediately prescribe antibiotics, nor arrange for a CT scan, the court also found that regarding Patient C, Dr Zaw failed to supervise a Physician Assistant (‘PA’) on his team – note the word ‘assistant’ .’ It was his failure to manage the PA, together with his care of two of the other three patients being found below the acceptable standard, which contributed to his suspension for 12 months, and later deletion from the medical register.

The role and responsibilities of the supervising physician regarding PAs seem to have been established. Dr. Zaw failed to fulfill his duty as a physician by not properly supervising Ms. G, and this contributed to the suspension of his medical license. Why Dr. Zaw did not fulfill these duties was not investigated by the court. Maybe he was busy seeing other patients. Perhaps, as most of us can imagine, he assumed that Mrs G, employed by her Trust as part of the medical team, was there for the purpose of taking patient histories and examining them. Why has Ms. G posted if all her work needs to be copied?

DAUK, the BMA and others have debated the suitability of the GMC as a regulator of PAs. This is further questioned by the catastrophic failure of public consultation on what the scope and standards of PA look like. The GMC looks to others – namely employers – to do so. We now know that employers do not necessarily specify any of these, at least among all of the physician’s managerial responsibilities. PAS may have a role to play in patient care, but all doctors out there need to read Dr. Zaw’s judgment and take the necessary steps when working with PAs to protect their medical license. The GMC – and your employers, for those in secondary care – may not do this on your behalf.

The Medical Association of England (MAUK) is a not-for-profit professional association run by volunteer NHS doctors, who advocate for the medical profession and the wider NHS.

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

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