The Leng Review: recommendations for Physician Associates and Anaesthesia Associates
As discussed in our previous article, there has been widespread concern in the sector surrounding the role of physician associates (“PAs”) and anaesthesia associates (“AAs”), with increased scrutiny when it was announced that the General Medical Council (“GMC”) would be responsible for their regulation from December 2024 (with the professions having a two year transition period). On 20 November 2024, the Health Secretary, Wes Streeting, announced a review to consider the safety and effectiveness of the PA and AA roles and their contribution to multidisciplinary healthcare teams, with the review designed to help inform the new workforce plan and wider government policy. The independent review was undertaken by Professor Gillian Leng CBE (“the Leng Review”) and was published on 16 July 2025; it remains to be seen whether this will help to ease tensions in the sector which is also awaiting the outcome of the judicial review brought by Anaesthetists United against the GMC (see below).
The Leng Review - Findings and Recommendations
The Leng Review states that it gathered evidence from various stakeholders through a variety of methods, including formal research, national data sets, local audits and surveys to PAs, AAs and those that work alongside the roles and patients. The review explains that national bodies such as the Care Quality Commission (“CQC”) analysed mentions of PAs or AAs from Coroner’s Prevention of Future Deaths reports, whistleblower files and the Learn from Patient Safety Events System, and at a local level NHS trusts provided a five-year breakdown of ‘never events’ by professional group. Furthermore, the review had input from expert panels which examined international models for these roles.
The review sets out the evidence considered both in primary and secondary care, highlighting where limited evidence exists to point either way i.e. towards safe or unsafe practice, and includes positive patient testimonials from their interaction with PAs and AAs. It sets out challenges in the sector, in particular in respect of changes to doctor training, which it considers have contributed towards the unease surrounding the role of PAs especially. In conclusion the review makes a number of recommendations regarding the integration of the roles of PAs and AAs in the sector and future development of such roles.
Importantly, the Leng Review has recommended that the title of PAs be changed to ‘physician’s assistant’ (a title originally held by PAs when the role was introduced), with AAs referred to as ‘physician assistants in anaesthesia’, to position the roles as more supportive of doctors, rather than independent practitioners. The review recorded that the term ‘assistant’ is used successfully in the majority of other countries employing similar roles, with good acceptance of the role by doctors. To address concerns around the identification of PAs in particular, the review recommends the introduction of standardised measures, including national clothing, badges, lanyards and staff information, to distinguish PAs from doctors. Other recommendations include being part of a clear team structure led by a senior clinician, with a named doctor taking overall responsibility for each PA as their formal line manager (‘named supervisor’). Notably, PAs should not see undifferentiated patients except within clearly defined national clinical protocols and newly qualified PAs should gain at least two years’ experience in secondary care prior to taking a role in primary care or a mental health trust.
Further recommendations include that PAs and AAs are also to be given opportunities for ongoing training and development, including the ability to take on relevant added responsibilities such as prescribing, through a formal credentialling programme. The recommendations also go further to introduce the position of ‘advanced physician assistant’ and ‘advanced physician assistant in anaesthesia’, which PAs and AAs can become after demonstrating sufficient skill and experience to warrant a higher pay band, stating that the roles should also have the opportunity for career progression. The Leng Review has also appended recommended template job descriptions for each stage of the PAs and AAs role.
Recommendations for the wider system set out in the Leng Review include: that the requirements for regulation and reaccreditation of PAs and AAs in the GMC’s publication ‘Good Medical Practice’ should be presented separately to reinforce and clarify the differences in roles from those of doctors; that doctors should receive training in line management and leadership, and allocated additional time to ensure they can fulfil their supervisory roles; and that safety systems should routinely collect information on staff groups to determine system-level issues in multidisciplinary team working.
Response to the Leng Review and legal action
Following publication of the Leng Review, the Royal College of General Practitioners (“RCGP”) has stated that they continue to oppose the role of PAs in general practice but have said they will consider the recommendations of the review. The Royal College of Physicians described it as a “thoughtful, detailed and thorough review of a very complex issue” and that it was clear that “reform is urgently needed to ensure safe multiprofessional teamworking in the NHS, and [they] welcome a strong focus on national consistency, patient safety, collaboration and clarity of role and scope”. Whilst the British Medical Association (“BMA”) has characterised it as an “inadequate response” to “a patient safety scandal”, stating that there are large gaps where patient safety recommendations should have appeared and that it “ignored the most urgent demands of the medical profession” which was a nationally agreed scope of practice.
As previously reported, the BMA filed judicial review proceedings against the GMC in relation to the use of the single term “medical professionals” to describe both doctors, and, PAs and AAs, which the High Court dismissed on 17 April 2025. The BMA contended that the terminology, used in the GMC’s guidance, would imply that PAs and AAs are qualified doctors, when in reality, they have limited medical expertise, however, Mrs Justice Lambert stated in her judgement that “the use of shared standards was logical given the overlap in work undertaken by doctors and associates and the need for regulatory concerns affecting all three professions to be considered against the same standards.” The BMA’s concerns in this regard appear to have been reflected in the recommendations of the Leng Review to some extent.
While the BMA was unsuccessful in their judicial review against the GMC, Anaesthetists United has also brought legal action against the GMC for its failure to effectively distinguish between doctors and associates. The High Court heard the matter on 14 and 15 May, and 9 June 2025, with the judgement expected to be handed down before the end of Summer.
Looking Ahead
As the sector digest the findings of the Leng Review and determine the next steps, and we await the outcome of the judicial review against the GMC, the debate surrounding the regulation of PAs and AAs continues. With the recommendations including concessions on all sides, what appears to be agreed it that reform is needed sooner rather than later. It remains to be seen whether the recommendations will represent the ‘new’ way forward to ease tensions between the roles and alleviate patient safety concerns. We will continue to monitor developments, and our team is on hand to assist with your regulatory enquiries.
Co-authored by Areesha Qureshi, Solicitor Apprentice
