The verdict on the Leng review is positive with caveats (doi:10.1136/bmj.r1482).12 How positive you feel depends on your perspective (doi:10.1136/bmj-2025-084613).3 The rapid introduction of physician associates and anaesthesia associates was, in an era of self-inflicted damage, perhaps the most destructive workforce policy since our focus shifted from the covid pandemic. The wounds of resentment and distrust are deep and will be slow to heal.
The key questions for Gillian Leng to answer were primarily about the safety and cost effectiveness of physician associates (doi:10.1136/bmj-2025-086358).4 Evidence gathered for the review was broad and deep, taking in published research (doi:10.1136/bmj.r441 doi:10.1136/bmj.r1478),56 data from organisations, surveys of doctors and physician associates, and wide consultation with professional and patient organisations, as well as the families of patients who had experienced harm—although some claims subsequently emerged of data either not submitted or not considered by the review team (doi:10.1136/bmj.r1487).78
The primary objective can only be the health and wellbeing of patients and the public. However, in a decade of confused and expedient thinking, controlling costs became the most important metric—with no appreciation of the cost effectiveness of substituting doctors with physician associates. The rush to roll out these new roles gathered momentum from 2015 under the health leadership of Jeremy Hunt, without sufficient evidence of patient safety or benefit.
A year earlier physician assistants, as they were originally known, had rebranded themselves as physician associates. Medical royal colleges supported the expansion of these roles without fully considering the consequences. Therefore, all stakeholders—politicians, senior NHS managers, heads of professional medical colleges, and physician associate leaders—must accept their share of the blame.
It’s taken a grassroots movement of doctors to raise the alarm: firstly, about patient safety; secondly, about the impact on training and career progression among doctors, who are better qualified than physician associates but start off being paid less. Wes Streeting, as the newly appointed health secretary in 2024, walked into a pay dispute with resident doctors. He also inherited a toxic and related row between doctors and their own leaders, physician associates, and politicians. His decision to call for an independent review of the safety and cost effectiveness of physician associates and anaesthesia associates was a sensible one.
Leng’s conclusions are mostly clear and are particularly bruising for physician associates. The name is to be changed back to physician assistants, and different professional staff must be clearly identifiable in any clinical encounter. Confusion in staff roles is potentially harmful for patients.
The newly renamed physician assistants will work only under the supervision of a doctor, will train for two years in hospital before being able to work in general practice, and won’t see “undifferentiated patients” except for specific minor ailments after triage. They can be trained to prescribe but can’t order a diagnostic test involving ionising radiation. Leng has produced template job descriptions for newly qualified physician assistants, and any expansion of that scope, she says, must be under the oversight of the relevant medical royal college.
Scope of practice
Nonetheless, these measures may not go far enough for some critics. Leng hasn’t halted the recruitment of physician assistants. Doctors who already have physician assistants in their teams, the review reports, tend to be more positive about their experience of working with them. The restriction on seeing undifferentiated patients isn’t absolute—and it has the potential to be widened beyond “minor ailments.” The purpose and role of an “advanced” physician assistant, as proposed by the review, is somewhat opaque. Leng expects that these problems will be resolved by further work on multidisciplinary teams and scope of practice involving medical royal colleges and societies.
Crucially, physician assistants remain regulated by the General Medical Council, something that Leng says was out of her remit, albeit in what’s intended to be a more distinct regulatory route alongside doctors. Yet, given that the BMA and the campaign group Anaesthetists United took the GMC to court because of their assertion that GMC regulation was for “medical professionals” and that physician assistants couldn’t be described as such, it’s not clear how the Leng review can help resolve this matter. Physician assistants themselves seek better regulation and more robust research into their implementation (doi:10.1136/bmj.r472).9
The Leng review has gone a long way towards meeting concerns about patient safety and slowing down the physician “associate” juggernaut. However, there was no win-win scenario at the outset, and there is none today. Doctors’ demands have largely been met; however, the disagreement over scope of practice and regulation will continue. The BMA has criticised the review for failing to provide a national scope of practice for physician assistants, and the Doctors’ Association UK remains concerned about the safety implications of allowing physician assistants to prescribe and order non-ionising radiation (doi:10.1136/bmj.r1505).10 The medical royal colleges have so far been supportive.
Leng describes the review as a pragmatic solution that won’t be universally popular. The challenge for the government, which commissioned the review and has unreservedly accepted the recommendations, is to nail down the scope of practice for physician assistants and to adapt the plans for regulation to tackle outstanding concerns. Otherwise, much of the good work of the Leng review will ultimately be undone.
