The Leng Review was an opportunity to finally address the many issues which have emerged through the chaotic and unchecked implementation of PA roles.
While no doubt much work has been done by the authors, its recommendations in essence give a green light to the expansion of physician assistant roles yet leave many details sketchy. The review outcome will leave many hospital doctors deeply concerned.
HCSA’s own submission to the Leng Review was clear. We called for:
- A detailed, single scope of practice for all PAs
- Opposition to prescribing powers
- A block on PAs being able to provide care for untriaged, undifferentiated patients
- For only senior doctors to be responsible for delivering direct clinical and overall supervision
- New national guidance to set out how senior doctor supervision should be decided, with their consent, as part of the job planning process
- Assessment by employers to identify capacity for supervision prior to recruiting PAs
- The ringfencing of medical training provision for resident doctors
- The reversion of the PA/AA title to physician’s assistant.
Unfortunately, several of these crucial issues are body-swerved or, worse, ignored by this review.
On central issues – including its own remit to assess the safety, effectiveness and cost-effectiveness of these roles within our NHS – Professor Leng admits the review drew a blank due to the lack of data and an evidence base.
Despite this it ploughs on to lay the groundwork for expansion of the role, as envisaged by the previous long-term workforce plan. While we await a new version of that document in the autumn, the Leng review signals the direction of travel.
There are a few positive recommendations. The review advises that the title physician assistant be used for both PAs and AAs, who it recommends be titled physician assistants in anaesthesia. HCSA’s preference is “physician’s assistant”, which more appropriately defines the role, but it is still an improvement. There are other cosmetic changes designed to better identify PAs, such as a recommendation that uniforms and badges clearly show the difference between assistants and doctors.
It also touches on the call from HCSA to ensure that senior doctors in supervisory positions should receive job-planned time to oversee PAs, as well as management training. But this is a double-edged sword. Leng acknowledges the acute issue of competition ratios for training places, and sympathises with concerns from resident doctors on the impact of PAs on their own development. However, we are told that this was not within the review’s remit.
There is also no indication that employers shall, as HCSA has advised, be required to assess the capacity of senior doctors prior to recruiting to these roles.
In our view, the current pressure on trainers and lack of capacity in the system already poses a fundamental risk to the future consultant pipeline. Training opportunities for resident doctors must be prioritised over the expansion of PA roles.
Perhaps the biggest failings of the Leng review centre on the scope of PAs’ work and their future role in our hospitals. The approach it advocates does little to answer concerns over safety and clinical mission creep.
Headlines seized on the advice that PAs should not see undifferentiated patients except those “with minor ailments”. This should not take place “except within clearly defined national clinical protocols.” This leaves things wholly unclear – we must wait to see the outcome of a future proposed working group to see what this means in practice.
Another recommendation is that limitations be placed on PAs to prevent them performing tasks which should be carried out by doctors – for now.
Leng rejects the idea of applying a consistent national scope in favour of locally defined upskilling via a national certification and credentialling programme. This leaves the door open to employers to continue the clinical encroachment of PAs upon doctors’ work – something that has been so divisive and damaging to date.
Worse, the review states that this system will lead to PAs being granted the power to prescribe, despite the review team’s own evidence showing only 8 percent of hospital doctors agree.
And despite acknowledging that there was no evidence of their cost-effectiveness, Leng goes further – proposing an advanced PA role. This rubs salt into the wound for resident doctors. It raises the prospect that PAs with far fewer years behind them will out-earn them for even longer. It also signals an even greater blurring of roles in years to come.
Far from resolving the conflict over PAs, the review is likely to fuel it. In the absence of clear evidence, it simply accepts that the mass expansion of PA roles is a workforce issue and is inevitable. It also leaves many of the central concerns for hospital doctors at the door of others – the autumn workforce plan, or the Whitty review into post-graduate education.
By advocating against a national scope and for greater powers for PAs, the risk is that many of the impacts doctors have been warning of will come true in future, and on a large scale. The outcome of the training review and workforce plan will signal precisely the size of this challenge to our profession.
In the meantime, HCSA’s message is clear: PAs are not doctors. Any notion of creating a pseudo-medical role through the back door will be opposed.
