This June may finally bring some clarity to the physician associate controversy, as the Leng safety review is published. But given the strength of feeling on both sides of the debate, the next steps will be far from simple. Here, Eliza Parr looks at what outcomes GPs can expect from the review findings
A few months into his new role as health secretary, Wes Streeting launched an independent review into the safety of physician associates. The controversy surrounding the PA role had become a ‘toxic debate’, he said, and a review was necessary to ‘establish the facts’.
Mr Streeting gave Professor Gillian Leng, a former consultant in public health medicine who was previously chief executive of NICE, an unenviable task – to decide whether PAs and anaesthesia associates (AAs) are safe and effective members of NHS teams.
The review is expected to report in two months, and it’s hoped this will offer a clear way forward for the deployment of PAs in NHS general practice and other settings.
But what will the outcomes of the review be? And who is Professor Leng listening to? Here, we answer some of the key questions surrounding this oft-cited and eagerly awaited review.
What is the aim of the review?
The principal question the review seeks to answer is whether the PA role is safe and effective as a member of a multidisciplinary team, across all tasks, roles and settings.
In a recent engagement session for GPs and other professionals who work with PAs, Professor Leng offered more information about how she will answer this. Based on her response to this principal question, there are three ‘secondary questions’ which could lead to a variety of outcomes (see image).
Professor Leng has offered no hint yet of where she will stand on these questions, emphasising the need to stay neutral and listen to all sides until the review concludes. It’s likely some doctor leaders would like to see the review push for complete discontinuation of recruitment to the PA role. Indeed, the RCGP’s position is that they completely oppose a role for PAs in general practice.
But concluding that PAs are ‘never’ safe and effective, and that recruitment should be therefore discontinued, seems an extreme outcome, especially given the number of other potential conclusions set out above.
Professor Leng told doctors this week that she is ‘very much keeping an open mind’, but suggested that medical leaders will need to be able to ‘draw a line’ under all the controversy.
‘How might medical leaders support the implementation of the review findings? Because there is no point going through all of this process if we don’t manage to draw a line under what’s happened and move forwards with some consensus, whatever the review concludes.’
Given the ‘toxic culture’ surrounding this debate – which Professor Leng promised to ‘call out’ – it will be impossible for the final review to please everyone. Whether either side will be able to ‘draw a line’ under under it remains to be seen.
Does the Government have to listen?
The Department of Health and Social Care (DHSC) has said Professor Leng’s recommendations will ‘inform’ the NHS workforce plan, which will help deliver the 10-year plan for health.
But there is no official obligation for DHSC to accept and act on the review findings. Professor Leng says there is no ‘formal mandate’ for this, but she is ‘assured’ the Government wants to accept her recommendations.
‘I’m assured that they don’t have any preconceived notions or ideas about what I am going to say, or indeed what I should say. And I think everybody is hoping that we can come to some agreement around the future,’ she told doctors this week.
So Mr Streeting won’t be compelled to listen to the review – but ignoring it wouldn’t be a great look. He commissioned the investigation himself, and Professor Leng, with years of experience at NICE, is well-known for her evidence-based approach to improving care. While some may disagree with her conclusions, they will be hard for the Government to argue with.
What evidence is the review based on?
Professor Leng’s team has sought to gather views from PAs themselves and the staff who work with and supervise them, as well as patients.
Evidence includes:
- A survey of PAs and those who work with them – over 8,000 responses
- A systematic review of studies on the safety and effectiveness of PAs
- A call for any data from GP practices and other providers (e.g. safety audits) – 87 responses
- Externally-led focus groups with patients.
After analysing all of these responses, the review will also speak to some ‘experts’ in the style of a ‘select committee inquiry’. Following this, Professor Leng will make her recommendations around the beginning of June.
What have organisations like the RCGP and BMA told the review?
As expected, the RCGP and the BMA were both critical of the current deployment of PAs in their submissions.
In January, the RCGP told Professor Leng that there is ‘no role’ for physician associates in general practice. This position was based on GPs reporting ‘specific’ examples of patient safety ‘being compromised by the work of PAs’.
And this week, the BMA revealed that its own submission to the review includes over 600 concerns reported by doctors about the safety of PAs and AAs, many of which took place in general practice. These reports included PAs having ignored or missed postmenopausal bleeding, raised PSA results, and deep vein thrombosis.
The BMA also urged the Leng review to rename the physician associate role and set a national scope of practice, among a raft of other recommendations. This was based on a survey of over 16,000 doctors and medical students, of which 95% want to see a scope of practice which clarifies what PAs can and can’t do.
These submissions are only one part of the large swathe of evidence Professor Leng will be digesting and drawing from. And of course, the review will have received evidence in favour of PAs, from organisations and healthcare professionals who do indeed think they operate safely and effectively.
But the opinion of reputable organisations like royal colleges and professional bodies will undoubtedly hold weight for Professor Leng. Supervision by doctors is an essential part of the safe deployment of PAs, and so organisations representing them are unlikely to be ignored.
Has deployment of PAs been paused during the review?
The NHS did not implement any interim safety measures during the review, despite calls from medical leaders to do so. The BMA repeatedly demanded a pause on recruitment and ‘immediate adoption’ of its own scope of practice for PAs. ‘You don’t fly a plane under safety review, you ground it,’ the union has regularly quipped.
Despite the Government’s inaction, the review and controversy surrounding the role has in fact impacted on the deployment of PAs, according to Professor Leng. She told doctors at an engagement session this week that associates coming out of training ‘can’t find roles’ and as such employment has essentially been ‘halted’.
‘Although recruitment hasn’t been halted, there aren’t really many jobs for people to go into, so employment has been halted. So although there wasn’t a formal decision, in practice people are struggling to work, and that is very difficult for some people. If we’re being human for a moment, you’ve got people coming out of training and no roles to go to.’
So in effect, the PA project has, at the very least, slowed as a result of the increased scrutiny. But without proper directives or backing from the Government, employers could be at risk if they make employment decisions based on these safety concerns.
Pulse recently reported that GP practices have begun facing legal claims of discrimination from physician associates. An organisation representing PAs claims that hundreds have lost their jobs or been ‘treated unfairly’ as a result of GP practices implementing the RCGP or BMA’s ‘restrictive’ scope of practice documents.
Will the safety review set a national scope of practice?
The Leng review has been clear since its inception that it will look into scope of practice. And Professor Leng has recognised that this is ‘obviously the area people are most exercised by’ – which she has heard ‘loud and clear’.
‘Probably what I hear most about are concerns that there’s no sense of a ceiling of practice, and that these roles might extend and become, effectively, a doctor,’ she told healthcare professionals this week.
So the review will definitely have to take a view on PA scope of practice – whether they should have a ‘ceiling’ on their practice, and where this might come from. But the review suggested in January that it will not cover a detailed scope of practice by setting, and will instead look at if and when an ‘enhanced’ scope of practice may be necessary.
Professor Leng could however recommend the national adoption of scope guidance already produced by medical organisations. She recognised this week that the royal colleges have ‘done a whole load of really useful work’ which she is ‘absolutely drawing on’.
‘I can’t say definitively at this point whether I’m going to support all the scopes of practice that have been developed by the royal colleges […] I’ll need to take a view on that and conclude in the final review.’
The GMC, in its own evidence to the review, also suggested that royal colleges and specialist professional bodies are best placed to set scope in their own specialty areas, as they have ‘the level of clinical expertise required’.
Given the GMC’s refusal to itself set scope for the role – which came under its regulation in December – Professor Leng may also decide royal colleges are best suited for this job.
But the review could also conclude that no scope is needed, and that the Physician Associate Registration Assessment (PARA) is sufficient as a guarantee that they have the necessary competence on qualification. But this conclusion would not go down well with medical leaders.
Will the review set out GP supervision responsibilities?
How physician associates should be supervised is a tricky issue for GPs, many of whom may want the Leng review to provide some clarity.
NHS England has been clear that all work undertaken by PAs ‘must be supervised and debriefed with their supervising GP’. But there are no detailed requirements for the exact level of supervision GPs must provide, and it will therefore vary from practice to practice. Some may debrief with a PA after every session, once a day, or less regularly.
The RCGP has urged supervising GPs to make time each day to ‘hot review’ all the cases a PA has seen that day, with all notes being signed off by the clinical supervisor. But there’s still concern from many doctors around their medico-legal liability if PAs under their supervision make mistakes.
A GMC case from 2017, spotlighted by Pulse last year, suggested that doctors may sometimes need to duplicate the work of PAs in order to avoid being pulled up for inadequate supervision. The GMC was clear afterwards that single tribunal outcomes do not set precedent for future decisions – but the case nevertheless worried GPs.
So a recommendation on supervision from the Government-commissioned may help to clear up some of this confusion. One attendee at Professor Leng’s engagement session this week questioned the point in the role if they have to ‘duplicate everything they do’, given the ‘legal precedent’ that supervising doctors are held accountable ‘when a mistake is made’.
It seems Professor Leng disagrees with this. ‘The legal precedent and the bit about supervision, I think needs to be untangled in relation to what does supervision mean? I don’t think it means duplicating what’s done.’
Ultimately, decisions about fitness-to-practise are made by the GMC and the MPTS – but the Leng review’s conclusion on this tricky issue will surely be influential.
Will the PA title change back to ‘physician assistant’?
So far, Professor Leng has remained tight-lipped on many issues surrounding PAs and where she will stand. But this week, she hinted that her review could recommend a name change for the role.
Medical leaders have pointed out that ‘physician associate’ is confusing for patients as it blurs the line with doctors. How are the general public to know what an ‘associate’ is? Many have pointed out that ‘physician assistant’ – which was the title used for the role in the UK until 2013 – would more accurately represent their qualifications and competence.
When asked whether the current PA title could change, Professor Leng said this is an issue which has ‘come across quite clearly from the relatives of people that have been involved in deaths related to the role of PA’. One high profile case from 2022 involved 30-year-old Emily Chesterton who died after seeing a PA at her surgery – her family have since said that Emily thought she was seeing a GP.
So Professor Leng has promised to give a view on both the name of the role and their identification, for example through uniforms. And she also suggested a name change is entirely possible, inviting ideas from doctors, despite the legal barriers.
‘Now, of course, the name of Physician Associate is set in legislation, and it’s not going to be straightforward to change it. But people do seem to feel quite strongly about it, so if you have any thoughts, then let me know.’
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