Independent inquiry finds serious governance failures at the Royal College of Physicians of London

These quotes, from a 45-page report published by the King’s Fund,1 summarise the findings of an independent inquiry into the events surrounding an Extraordinary General Meeting (EGM) of the Royal College of Physicians of London held on 13 March 2024. By the time the inquiry began in May 2024, several college officers, including the president and registrar, had resigned. The college is currently operating with an interim president and has promised to learn from the inquiry and heed its recommendations.

A group of fellows had called the EGM in March to challenge the college’s position on physician associates. The background to this challenge and various versions of what happened before, during, and after the EGM are well documented.23456 Briefly, in September 2023, several fellows were concerned that plans for physician associates to be regulated by the General Medical Council (GMC) and overseen by the Royal College of Physicians had not taken insufficient account of patient safety or the knock-on impacts on the workload and training opportunities for doctors. In November 2023, they triggered the college’s formal process for an EGM, seeking a full and frank discussion of these issues at a time when Parliament had not yet passed the Statutory Instrument for regulating physician associates. The King’s Fund inquiry has now found, college officers responded in ways that were perceived as sluggish, inconsistent, possibly manipulative and, at times, unprofessional.

Crucially, delays in setting up the EGM meant that by the time it was held, the Statutory Instrument had already been passed by Parliament. As the inquiry found, “had the EGM been held before that point, the concerns raised would have been fed into the parliamentary process and may have affected the passage of the legislation” (page 18).

The missed opportunity to influence Parliamentary discussion on the role and regulation of physician associates in a way that reflected the concerns of its membership is among the most serious issues faced by the college in its 500-year history. The NHS has set a target of expanding the number of physician and anaesthetic associates to 10 000.7 A February 2024 survey by the British Medical Association of 19 000 doctors found that 87% felt that the way physician and anaesthetic associates currently work always or sometimes risks patient safety, and 80% were concerned that an associate they worked alongside sometimes or often worked beyond their competence.8

The UK GMC will begin regulating physician and anaesthetic associates in December 2024, after the Statutory Instrument came into force in March 2024.9 On 26 February 2024, the House of Lords debated the legislation only because several peers had tabled amendments. Nicholas Francis Markham, the responsible minister, said that those consulted favoured what was proposed, naming the Royal College of Physicians, among others.10

That statement was technically true, but as the King’s Fund report documented, it is far from the whole story. When the EGM was finally held on 13th March 2024 (delayed beyond the eight week maximum set out in college bye-laws), a series of motions overturned the college’s former supportive position on physician associates—but by then, it was too late to influence legislation. The King’s Fund report rejects arguments made at the time that this delay was necessary to enable discussions to take place within the College Council.

The inquiry’s findings of failure of leadership, disjointed governance, lack of engagement with members’ and fellows’ concerns, allegations of manipulating data, and a culture that sometimes included “shouting and the use of intimidatory language” (page 5) led the King’s Fund to recommend various actions. These include a further inquiry into the governance structures, specifically how the lay and clinical Trustees interact and how the Board of Trustees interacts with the Council.

This recommendation reflects a tendency for inquiries into governance failures to view solutions in terms of fixes to governance structures.11 This is clearly needed and should be informed by a proper systems analysis12 to understand the problems. However, it is also necessary to examine whether the behaviour of individual leaders meets an acceptable standard.

An inquiry into college structures may turn up new insights. But the King’s Fund report already provides compelling evidence that the college’s leadership presided over a culture that was toxic and unprofessional, while promoting policy that was in opposition to its values and the views of its fellows and members. It will take time to come up with new, more effective, structures but, given the evidence that Parliament may have been misled, we respectfully suggest that those who held the highest executive and board-level oversight roles during this period might consider their positions.