Scope of Practice guidance – Chaos at the GMC and GDC. What on earth is going on?

The safe delivery of medical and dental care to the UK population relies on effective teamworking with leaders delegating tasks to qualified and competent colleagues with a range of professional registrations. In both medicine and dentistry, a number of registrant groups can practice autonomously within a defined Scope of Practice (SoP). Why is it so hard to sort out an SoP for new registrant groups or to revise existing SoP guidance?

There is chaos in the medical world concerning regulation and the Scope of Practice of Physician Associates (PA) and Anaesthesia Associates (AA). This group follow a 2-year postgraduate training and are not currently regulated. Plans are in place for the GMC to become their regulator, but the legislation has not made its way through Parliament yet. The GMC has consulted, but at the time of writing has not released its report or the data from the consultation, in spite of pressure from high profile doctors like Rachel Clarke (author of ITV Breathtaking) and many others on X (Twitter). PA roles are being advertised and filled with enthusiasm introducing massive risk to patients. One big part of the problem is that many different authorities (Royal Colleges, The BMA and NHS Bodies for example) are all developing differing Scope of Practice guidance for PA/AA and how they should be supervised.

The Royal College of General Practitioners (RCGP) and the Royal College of Physicians (RCP) have previously wholeheartedly supported the introduction of this group of healthcare professionals into primary and secondary care. Recently RCGP changed its position RCGP changes position on Physician Associates working in general practice

Unfortunately, and perhaps not surprisingly the introduction of these currently unregulated practitioners has been welcomed by commissioners, hospital trusts and GP practices because of the cost advantages in the long term. PA have been appointed as practitioners to fill rotas and to cover the tasks previously delivered by doctors. Job adverts have appeared describing the role profile of PAs providing services far beyond their training and competence, let alone beyond their anticipated SOP - Remember these practitioners are not yet registered! Patient safety and risk management has been conveniently set aside. It has been widely reported that PAs are ordering Ionising radiation investigations which is illegal and prescribing medication, which is also illegal. In spite of protests, authorities seem not to care.

Patients do not know the difference between these practitioners and doctors. Stories emerge of patients suffering harm following wrong decisions by PAs. Sadly there have been some disasters Misdiagnosis: Bereaved mum calls for physician associate role clarity - BBC News Lobbying by GPs has forced a reversal of the RCGP’s decision to support PAs working beyond their Scope of Practice - whoever thought that was a good idea? RCP has revised its position under pressure from fellows to limit its support to a nationally agreed Scope of Practice rather than its previously stated position to support local variations. Very recently the Royal College of Surgeons in Edinburgh has called for a pause in the regulation of PA/AA while the Scope of Practice of PA/AA is sorted out Further position statement on Physician Associates | Royal College of Physicians of Edinburgh (rcpe.ac.uk). The Faculty of Forensic and Legal Medicine has raised a robust objection to PA examining children where abuse is reported or suspected SWG (fflm.ac.uk)

Common sense seems to be breaking out, however inconvenient it may be to those who are trying to save money and undermine the authority and experience of doctors.

But what is happening in dentistry?

There is a long history of effective teamworking where Clinical Dental Technicians, Dental Hygienists and Dental Therapists and Dental Nurses deliver care within their competencies either under prescription or autonomously under direct access. This works very effectively and safely because there is a clearly defined Scope of Practice for each registrant group. The current Scope of Practice guidance was reviewed in 2013 and is in need of updating.

In 2013 the GDC enabled Dental Care Professionals to operate under Direct Access within their scope of practice Layout 1 (gdc-uk.org) and in 2023 NHSE took steps to enable DCPs to provide a course of treatment within their scope of practice by removing the necessity for a dentist to see the patient in order to raise a claim for NHS treatment. This was part of a wider policy document developing the role of DCPs within dental teams. NHS England » Building dental teams: Supporting the use of skill mix in NHS general dental practice – long guidance

The GDC has been working on its new Scope of Practice guidance since 2019, engaging with stakeholders and seeking comment via a formal consultation. The thrust of the updated Scope of Practice guidance is a significant shift away from the prescriptive list-based approach of the 2013 guidance to a more permissive and empowering guidance. This is described by the GDC as a “principles-based approach”. The Council was told this would be published in September 2024.

But where has the revised/updated Scope of Practice gone? Typically, when the GDC consults on a significant change in guidance it collates the responses, shows them to the GDC Council and then publishes the outcome report on the GDC website. The Scope of Practice guidance is different. The consultation on Scope of Practice took place in October 2021. Since then, the draft has disappeared into the GDC. Secret Council meeting have considered the guidance but no report of that has been published nor has the guidance and supporting documents been published.

The draft guidance in the consultation required registrants to be “trained competent and indemnified” to perform any particular task provided it was within the boundaries of a particular registrant group. That leaves the indemnity providers with the impossible task of having to determine an individual’s competence before offering indemnity for that task. No sensible indemnity provider will be able or willing to do this. It is not for the indemnity industry to do the GDC’s work for it. I am sure most indemnity providers will have made this point in their response to the consultation.

What is going on? Rumour has it that the GDC was on the point of publishing its new SoP but that has inexplicably been pulled. What are the GDC registrant members of Council doing? Are they rubber stamping the decisions and actions of the Executive or are they challenging the decisions or is the GDC finally listening to stakeholders that say the principles-based approach will create more problems than it will solve? As Private Eye might say “we should be told”.

NHS risk managers must appreciate that PA/AA raise the risk profile unless they are properly guided as to their scope and above all properly supervised. Regulators must get a grip, because ultimately the Scope of Practice Guidance is there to protect patients.