Big questions: How will GMC regulate PAs and what next for GP funding (and protests)?

Maya Dhillon takes on November’s talking points – what will GMC regulation of physician associates look like, and what is next for GP funding (and related protests)

What will physician associate regulation look like?

Friday thirteenth, unlucky for some, blah blah blah. There’s a lot of jokes to be made, but essentially the point is: regulation of physician associates (PAs) by the GMC starts on Friday 13 December. With an independent review into the role announced by the health secretary last week, it seems odd that we are on the precipice of ‘welcoming’ them into the fold, which begs the question: what will initial regulation look like?

The GMC has not yet released the results of its consultation from March which sought views on how to regulate the profession. ‘Scope of practice’ was strictly off limits, but the regulator asked for input on: 

• Standards of curricula;
• Requirements for inclusion on the GMC register;
• How concerns will be dealt with;
• How appeals will be handled;
• The process for setting PA registration fees;

Speaking at the Pulse LIVE conference, GMC chair Dame Carrie MacEwen explained that the reason the consultation response has taken so long was because many respondents ‘did not actually respond to the technical questions about regulation that it posed but instead opined about the role of PAs’. She expressed that the role of PAs has already been set out in the law.

The ‘scope of practice’ remains one of the most controversial parts of the soon-to-be-regulated role. In lieu of the GMC providing a scope, different organisations have drawn up their own. The BMA published ‘first of its kind’ guidance in March, and last month the RCGP published guidance that ‘severely limits’ PAs’ current practice.

The GMC has said regulation will ‘benefit patient care’ but has consistently refused to set out a scope of practice for PAs. When asked by Pulse editor Sofia Lind at Pulse LIVE whether the regulatory body would take other scopes into account, Dame Carrie reinforced that the GMC would not be looking at a general scope of practice, adding that this is not a feature present in other healthcare regulatory bodies for other professions. She explained that PAs will need to have ‘individual’ scopes of practice given that they will work in a variety of different roles.

However, following the conference, the GMC provided Pulse with an additional statement, in which it said it would refer to ‘any relevant guidance produced by royal colleges and other expert bodies.’ Following that, the BMA called for ‘full transparency’ from the GMC about their position on PA scopes of practice. The union claimed that the regulator had refused to share its submission to the RCGP’s consultation on scope, and said it had been ‘forced’ to submit a Freedom of Information request for the information. It argued that doctors deserved to know where the GMC stood on the RCGP’s scope proposal, given that the College cannot enforce their guidelines.

And, although regulation begins on 13 December, PAs and anaesthesia associates (AAs) will have until December 2026 to register. The ‘two-year transition period’ will ‘allow PAs and AAs to complete the necessary steps for registration while continuing to work’, the GMC has said. Only a ‘small’ number’ will be invited to register this side of the year. This means that if a concern is raised about an unregistered PA, the GMC will not be able to do anything about it itself until that PA is registered.

The Government-commissioned independent review into PAs and AAs is welcome, but long overdue. With the results due to be published in the spring, that still leaves us with several months of PA regulation ahead of its report. What happens if the review finds that PAs cannot and should not work with undifferentiated patients, or agrees that they should not work in GP practices? If PAs are already being regulated, it will muddy the waters in what is already a difficult and worn battle, and make it tricky to enforce any limits.

What’s next for GP funding and protests?

Being shafted financially is not a new phenomenon for general practice. How many times have we heard the phrasing ‘expected to do a lot more, with a lot less’?

The 2024/25 contract was dismal for England’s GPs (and arguably worse in the devolved nations). So dismal in fact that it kick-started the long journey towards collective action. Given that we are nine months on from the imposed contract first being presented by NHS England, you would be forgiven for forgetting how it was we got there. But still in August, when asked by Pulse what the priorities were for engaging in collective action, our snapshot survey showed that ‘increased overall funding’ was the most important concern. The want for a new contract, a re-evaluation of funding, was clear.

Collective action rumbled on throughout September and October; with neither any major upsets, nor developments. The expansion of the ARRS to include GPs (announced on the eve of collective action) was clarified. Health secretary Wes Streeting also committed to further funding beyond 2024/25 but did not confirm whether this would be core contract funding. He also asked GPs to ‘stand down’ their collective action.’ Minor occurrences, but nothing of note for either side resulting in substantial change.

And then came the Budget. While the NHS as a whole was given a £22.6bn funding boost over two years, GPs were given an almighty kick in the teeth. They became one of the few areas to be worse off after the Budget, as a result of the hike in employers’ National Insurance. GP practices were refused funding to cover the NI rise because the Treasury classifies them as private sector organisations. Yet at the same time, they are not eligible for NI reimbursements, because they are also… public sector. 

This ‘cruel anomaly’ loophole was even picked up by national media. When pressed about the impact of the Budget on GP practices, the Prime Minister ensured that funding arrangements would be set out ‘by the end of the year.’ At the time it was unclear whether Sir Keir Starmer meant the calendar or financial year, and Number 10 did not respond to a request for clarification. Last week, health secretary Wes Streeting indicated that GP funding allocation was being discussed over the ‘coming weeks’ but it was unclear if that was the full 2025/26 funding envelope or just a solution to the NIC drama.

Nevertheless, when the England LMC conference rolled around last week, it was inevitable that funding would be a core matter. GPC England chair Dr Katie Bramall-Stainer opened the conference talking about the letter she had received from Mr Streeting about the ‘potential implications’ of the Budget on practices. She reminded attendees that while the recognition of the NI hike was good, it should not distract from ‘the prize’ of the next contract. 

Dr Bramall-Stainer also reminded GPs to continue collective action as a way to keep the heat on the Government. This was echoed when LMC leaders voted in favour of taking ‘more significant’ industrial action. There was an acknowledgement that collective action had been powerful so far, but an escalation was necessary to ensure the change needed to secure the future of general practice. The use of the words ‘industrial action’ – rather than ‘collective action’ – in the motion is a departure from the current state of affairs, and implies that GPs are thinking of taking measures that will break their contract – which collective action does not do. 

And the strength of feeling on the matter is not isolated to England, with Scotland’s LMCs having today voted in favour of a ballot of the profession regarding industrial action.

On top of potentially looking at industrial action, England LMCs also voted through an emergency motion for a special conference to be held, looking specifically at how to tackle the NI hike. Given that the aforementioned motion effectively gave the GPC a mandate to ballot on industrial action, this motion was not necessarily needed in order to address finances. The vote only required support from a third of the 102 present LMCs, and around 40 voted in favour. 

With potential industrial action now on the horizon, as well as the special conference on the NI hike (which could be before the New Year) it is clear that GPs are fed up with the lack of funding. Despite being promised a ‘reverse’ in GP underfunding by the new Government, there is still a distinct lack of understanding, respect and clarity regarding GP finances.