Independent report

Leng review: further detail on the areas to be covered by the review of physician associate and anaesthesia associate professions

Published 23 January 2025

Applies to England

Background

The Secretary of State for Health and Social Care has established an independent review of the physician associate (PA) and anaesthesia associate (AA) professions, to agree recommendations for the future. It will consider the safety of the roles and their contribution to multidisciplinary healthcare teams.

The conclusions of the review will help to inform the refreshed workforce plan that the government has committed to publish in summer 2025 and wider government policy. The review’s terms of reference set out the purpose and timing of the review.

This document will set out how the review will address the terms it has been set and how it will seek to gather the evidence needed to do this.

General approach

The review will be:

• open and transparent, sharing information wherever possible
• based on the best available evidence and data
• collaborative and inclusive of all perspectives
• underpinned by patient experience
• forward-looking, aiming to address the healthcare challenges of the future

Wider engagement and understanding the issues

The debate around the roles of PA and AA is regularly described as ‘toxic’, with reports of bullying and harassment in the day-to-day working environment and leaders being unwilling to speak up. While this behaviour is clearly unacceptable, the review must understand all concerns raised by the medical profession, by other healthcare practitioners and by the public, in addition to those directly related to safety and effectiveness.

Wider engagement will therefore be an important component of the review, to provide a broad perspective of views, challenges and potential opportunities. It will include:

• a listening exercise with affected families, patients and healthcare professionals
• visits to and conversations with practices and trusts that employ PAs and AAs, aiming to get a geographical spread, to cover a range of settings and examples of best and less effective practice
• thematic workshops on a range of relevant topics such as scope of practice
• written evidence submissions from stakeholders

Evaluating the safety and effectiveness of the PA and AA roles

To address the areas of inquiry set out by the review’s terms of reference, the principal review question is: are the roles of physician and anaesthesia associate safe and effective as members of a multidisciplinary team, across all tasks, roles and settings?

The review will consider all available research, evidence and data that can inform the answer to this question, looking comprehensively at the roles and settings in which PAs and AAs work, including internationally, covering a range of potential activities. This will include the effectiveness and cost-effectiveness of the role within multidisciplinary teams and, where the data allows, the results will be presented by clinical setting, in particular:

• primary care
• the anaesthetic room
• hospital settings

It is important to note that this question about safety and effectiveness is a complex one, influenced by a large number of inter-related factors. As with any complex question, there is unlikely to be a simple yes or no answer. Instead, there may be a spectrum of answers, potentially demonstrating some areas where practice is less safe, others where PAs and AAs are highly effective members of the team and, somewhere in the middle, areas where practice can be improved.

Exclusions from the review

The review will not consider the role of other medical associate professions (surgical care practitioner roles) or pay levels for PAs and AAs. Future requirements for numbers of PAs and AAs is a question for government and the review will be considered as part of the refreshed workforce plan to support the 10 Year Health Plan.

The question of whether PAs and AAs should be regulated, or which body should carry it out, will not be covered as this regulation has commenced. The review will not produce a detailed curriculum for PAs or AAs as this is the role of the regulator.

The review has been commissioned for England only, but there will be ongoing engagement with the devolved governments, which are likely to be interested in the review findings.

Evidence and data sources

The review will draw on a range of available evidence, including evidence from stakeholders and individuals, across the breadth of the review’s scope. Quality and bias of the evidence will be carefully assessed using standard approaches.

Some of the main sources will include:

• NHS England data sources
• published research, drawing on national and international literature
• Care Quality Commission (CQC) data, including on freedom to speak up, whistleblowing complaints and complaints received from the public
• coroners’ reports
• research carried out by various medical bodies
• a bespoke survey to PAs and AAs and to the teams that work with them

In addition, there will be an open evidence-gathering phase, where stakeholders will be invited to contribute. In particular, we will invite submissions that include:

• unpublished research
• trust or practice-level reports, such as those based on audit data or local collection of safety data
• trust-level patient complaints, compliments and feedback

Measures of safety and effectiveness - main outcomes

Ideally the main outcomes measures listed below would be examined, comparing outcomes to relevant comparators. However, it may not be possible to draw many conclusions from national data, which is designed to examine systemic rather than individual failures.

Safety - serious preventable events

Outcomes measures include:

• mortality rates
• ‘never events’, including maladministration of drugs and administration of the wrong gas
• other events, including misdiagnosis or delayed diagnosis; transfer to the intensive care unit (ICU)

Delivery of effective care

Outcomes measures include:

• timely access to a practitioner and patient throughput
• referral rates
• completion of tasks and clinical paperwork
• continuity of care

Reported feedback

Outcomes measures include:

• patient and/or carer satisfaction
• staff experience (PAs, AAs and multidisciplinary team members)

Evaluating factors that may improve safety and effectiveness

Depending on findings from the evaluation of safety and effectiveness, there is likely to be further work to consider a secondary question: what modifications are required to improve future safety, effectiveness and wider confidence in the roles?

The aim of the secondary question is to examine factors that might make the roles more or less safe and effective, and is a crucial part of the review. Several areas have been identified that are within scope of the review (listed below) and others may become apparent as a result of the initial data analysis.

Education and training

The review will cover all elements of PA and AA training, pre- and post-qualification, that appear to impact on safety and effectiveness of the roles and appear to be missing in terms of best practice. This will include any identified variation in training locations and settings.

Day-to-day working

The review will consider supervision and oversight, including best practice for PAs and AAs and optimal staff ratios. It will also consider the scope of practice for PAs and AAs at the start of their working career, including where PAs and AAs might release time for doctors to focus on more specialist care, and if and when an enhanced scope of practice might be appropriate. The review will not cover a detailed scope of practice by setting or for more senior practitioners with bespoke training and experience.

The identity and naming of the PA and AA roles, including their names as set out in statute, have been raised as areas of confusion and these will be considered by the review. Other aspects of identity may include factors such as how PAs and AAs introduce themselves, the uniforms they wear and badges.

The review will look at the impact of roles on the wider multidisciplinary team, including possible impacts upon resident doctors where training opportunities are reported as having been affected.

Regulation and governance

Best practice in regulatory practice for PAs and AAs will be considered, drawing on international examples. This will include setting out who should have responsibility in the health system in relation to setting out guidance and standards on training and working for the profession, to address current confusion in leadership roles.

The review will look at concerns that have been raised about potential confusion caused by regulation of the roles being undertaken by the General Medical Council (GMC) rather than another regulator, and consider any actions that could be taken to avoid confusion for those providing and receiving care. Changing the regulator is not within the scope of the review.

Additional evidence and data sources

To address the question about potential modifications to the role, the following additional sources of evidence will be collected and evaluated:

• current national advice relevant to the review, including information produced by the Royal Colleges, the British Medical Association (BMA) and the GMC
• international reports on training standards for PAs and AAs
• international research and policies relevant to the regulation of PAs and AAs
• a bespoke survey to PAs and AAs and to the teams that work with them

Through the open evidence-gathering phase we will seek robust, high-quality information on:

• scopes of practice set at a local level, including any guidance for how PAs and AAs are used in setting rotas
• local policies for supervision and day-to-day oversight

Summary

The review will need to work at pace to meet its aims and timeframe. The principal question is complex and will require a broad assessment of analysis and data to draw evidence-based conclusions. The evidence-gathering phase of the review will begin in early 2025 and conclude by the end of February.