There is ‘no evidence’ that physician associates (PAs) add value in GP practices, according to a new academic review intended to inform the Leng inquiry.
Earlier this week, a ‘rapid review’ of UK-based research on PAs was published by GP and primary care academic at the University of Oxford Professor Trish Greenhalgh, in a bid to ‘inform’ the ongoing Government-commissioned review of the profession.
It warned that the available research on PAs is ‘sparse, of variable quality, has important gaps and parts of it are out of date’, and that there is no evidence which ‘directly examines the safety of PAs’ clinical decisions’.
While the current research appears to indicate support for the use of PAs to ‘complement’ MDTs in hospitals where ‘adequately supervised’, it suggested that PAs ‘appear to struggle in primary care’.
This is because the role is ‘more autonomous’ and ‘decisions are more uncertain’, and Professor Greenhalgh highlighted that there is ‘some evidence suggesting that [PAs] may generate unanticipated inefficiencies’.
‘There is no evidence that PAs add value in primary care and some evidence suggesting that they do not,’ she concluded.
The rapid review, which is not yet peer-reviewed, looked at literature published between January 2015 and January 2025, and identified 46 ‘empirical’ papers on PAs, of which half were ‘judged to be trustworthy, generalisable and relevant to the Leng review’.
Professor Greenhalgh undertook the review in order to inform a discussion which took place last week between herself and Professor Gillian Leng, who is leading the Government-commissioned inquiry.
Her review found that ‘very few PAs’ have been studied in primary care, and the ‘limited and out of date’ evidence base ‘does not currently support the claim that PAs are effective as GP substitutes for seeing undifferentiated patients’.
Professor Greenhalgh also highlighted the need for more studies on safety incidents related to PAs, warning that the current lack of such evidence could be ‘misinterpreted’.
‘The absence of evidence of safety incidents in a small number of studies appears to have been misinterpreted by policymakers to mean that there are no safety concerns with the substitution of doctors with PAs. This is an error of logic which, if not corrected, is likely to cost lives.’
According to Professor Greenhalgh, the key research gaps are:
- Ascertaining what PAs are doing;
- Informing the definition of a national scope of practice;
- Identifying and examining safety incidents;
- Estimating cost-effectiveness;
- Informing system-wide workforce planning;
- Improving career development options;
- Learning from other countries.
On national policy surrounding PAs, the rapid review said: ‘Policy and systems research indicates a mismatch between national policymakers’ settled belief that PAs have already been shown to be effective, safe and efficient substitutes for doctors and the views of professional bodies and front-line staff that they have not.’
Other findings on primary care
- A single study found that consultations by PAs working under a doctor’s supervision appeared to be slightly cheaper than consultations by doctors even taking account of longer consultation length, but the input and cost of the supervising doctor was not included in the calculations (nor even measured).
- In some settings, especially primary care, PAs were unclear about their scope of practice, underconfident in performing the role expected of them, and stressed from having to continually explain their role to other staff.
- Introduction of PAs into general practice occurred as part of a wider expansion of staff roles and has led to challenges in optimising this skill mix;
- Large quantitative studies in English general practice have cast doubt on the assumption that introducing a wider mix of staff necessarily improves the efficiency of care or the patient experience.
Professor Greenhalgh concluded: ‘I hope that this rapid systematic review, and the Leng Inquiry more generally, will help bring the various stakeholders together to work towards a more evidence-informed position from policymakers, academics and the professions on this contested topic.’
The Leng review, led by president of the Royal Society of Medicine Professor Gillian Leng, is due to be published in spring this year.
It will consider whether PAs are ‘safe and effective’ members of the multidisciplinary team, examining their scope of practice as well as cost-effectiveness and supervision.
Ahead of publication, the Government has refused to commit to interim safety measures regarding PAs, despite pressure from the BMA.
Appointing our PA was definitely a good decision.
Certainly more skilled than recent victims of RCGP “training”, who struggle to recognise common diagnoses despite a detailed knowledge of NICE guidelines and eco-zealotry.
Employing 3 PAs rather than 2 Salaried GPs for the same money most definitely adds value. Being prepared to work full time, unlike most salaried GPs, helps both with continuity, and developing skills that part-timers struggle with.
Funny how NHSE introduced PAs without any evidence of effectiveness or safety. Would have been an inconvenient truth.
Strangely I can’t find any reference to Dave Haddock on the GP register, so I’m unsure how he’s qualified to comment on PAs versus recent GP trainees.
I bet you can’t find me either.
Only change is by mass shifting if GPs to Australia and Canada and this will help in appointing more PAs in practices and soon no GP appt. or like hospital with 18wks target in news.
I believe this website is for benefit of GPs and not PAs. If you have sympathy for PAs, fair enough but then please leave this site as this is not for PAs. I am sure Dave Haddock is a PA hiding as a GP
Appointing a PA was good decision as filled your pocket by replacing a partner for free labour sponsored by NHSE.. Patient care is a sad joke for bad apples / They will be act by covering up PA errors and poor care or let us say ARRS care-till GMC registers them.. Normally safety checks are done before flying an aircraft and not loading them with passengers and trying it later on. That is how big sad joke this is for the passengers-read patients.
Why is it that medicines have to go through fairly rigorous trials before being made available in the cardinal interest of patient safety?
If physician assistants were to be trialled for safety and cost effectiveness first in a GP NHS setting, then perhaps we would be much less concerned about their existence. But why has this not been done PROPERLY already?
Would I want to take a drug that had not gone through various stages of the due process? Of course not.
Would I want my family to be seen by a PA?
Depressing comments from doctors, some named, others anonymous, making personal attacks only proves that PAs are being scapegoated and bullied. I hope Professor Leng reads your comments and understands the same tactics are used by BMA and to its shame the RCGP. Nowhere is there a positive plan to help our NHS cope with elderly demographic ahead. We desperately need clinicians like PAs and nurse practitioners to work in teams with GPs to manage the workload. The problem is few young doctors want to be GP partners- as I was. I understand the reluctance but don’t blame those that keep our primary care alive just. Of course practices employ nurse practitioners and PAs( who become valued long term staff) rather than locums- they are better at looking after those patients who need time and empathy. Doctors are not thinking calmly here and it threatens all new doctors ahead in their early years training as making mistakes of any sort ( you know the ones doctors don’t admit) leads to trial by tabloid- that is the key flaw in this PR disaster and it will come home to roost soon.
How many PAs does it take to change a light bulb? None, because they’re all too busy slaving away for Dave Haddock 😉