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’