Key takeaways
Defining roles builds trust in patient care
Clear boundaries between doctors and associates protect safety and confidence.
Robust governance is key to team safety
Structured supervision ensures clarity, safety, and accountability.
Regulatory reform is on the horizon
The Leng Review proposes clearer titles and stronger governance.
Redrawing the regulatory lines
The Leng Review and the roles of physician associates and anaesthesia associates
The Leng Review commissioned by the Secretary of State for Health and Social Care (DHSC) and led by Professor Gillian Leng CBE has been published yesterday.
The review focuses on two main issues:
A review of the safety and effectiveness of physician associates (PAs) and anaesthesia associates (AAs) working as part of a multidisciplinary team; and
Consideration of changes necessary to improve confidence in the roles.
As part of the review, the views of patients and the public were also obtained. This included the families of patients who died where their deaths were linked with allegedly inappropriate care. The families reported that had they known a doctor had not been consulted, they would have sought further medical advice.
A summary of the issues considered in the Leng review are:
Confusion over titles: The families expressed that confusion between the role of a PA and doctor was an important contributory factor in their relatives’ deaths. Patients assumed they were seen by a doctor. The review highlighted that there was little use of specific methods to identify PAs, aside from badges.
Role substitution: The review surveys found that PAs were sometimes filling in gaps in medical rotas when capacity was limited in local services without considering the comparatively limited training of the PAs. This potentially exposed patients to unnecessary risks.
Lack of confidence within the profession: Concerns have been raised in relation to the PA role by doctors of all grades. This again relates to a lack of distinction between the roles carried out by PAs and doctors, despite the limited training undertaken by PAs. This issue is said to be exacerbated by the GMC being chosen to be the PAs regulator.
We have seen a number of legal issues arise where the roles of PAs and AAs have been scrutinised at inquests or during the claims process.
The Leng Review found that “the evidence on safety and effectiveness was inconclusive and was informed largely by low quality studies. It did not provide a convincing picture that the role of either PA or AA was so inherently unsafe or ineffective that it needed to be discontinued” and “there was no evidence of widespread loss of trust from patients and the public, although significant concerns have been raised”.
The review has suggested 18 recommendations. The key recommendations include:
Positioning of the role: Physician associates to be renamed “physician assistants” to place the role as a supportive and complimentary member of the medical team. Anaesthesia associates should be renamed as ‘physician assistants in anaesthesia’ or PAA and should continue working within the boundaries set in the interim scope of practice published by the Royal College of Anaesthetists.
Initial deployment in secondary care: Newly qualified physician assistants should gain at least 2 years’ experience in secondary care prior to taking a role in primary care or a mental health trust.
Identifying the role: Standardised measures, including nationally recognised clothing, lanyards, badges, and staff information should be employed to distinguish physician assistants from doctors.
Teamworking and oversight: The physician assistant role should form part of a clear team structure, led by a senior clinician, where all are aware of their roles, responsibilities, and accountability. A named doctor should take overall responsibility for each physician assistant as their formal line manager (“named supervisor”).
Regulation and accountability: The GMC requirements for regulation and reaccreditation of physician assistants and physician assistants in anaesthesia within Good Medical Practice should be presented separately to reinforce and clarify the differences in roles from those of doctors.
Implications for patient safety
The Leng Review has essentially reiterated:
The importance of transparency and trust in that clear identification of a PA or AA is important in circumstances where patients are likely to seek alternative care if they are not seen by a doctor.
The integration of new roles must not reduce clinical oversight, regardless of workforce shortages, patient safety and effective care remain crucial.
There is now an opportunity to redefine PA and AA roles to increase public confidence in the role and improve patient safety. The 18 recommendations do not aim to remove PAs and AAs, but ensure that their work is safe, effective, supervised and within a regulated healthcare framework.
Please contact our legal team if you require legal advice or support in relation to clinical governance, patient safety or professional regulation arising from the issues identified in the Leng Review.
This article was co-authored by Saida Khan
