2025 in review: Where has the Leng review left PAs in general practice?

As 2025 comes to an end, Pulse looks at the big issues in general practice this year. Maya Dhillon asks: What did the publication of the Leng review mean for the role of physician associates in general practice?

This time last year, doing the 2024 round-up, we wrote about ‘the rise’ of the physician associates (PAs) in primary care. This followed our investigative series looking at what the influx of PAs meant for GP recruitment, how effective they were in practice, which areas were most likely to hire them, and more.

Our investigation made it clear that there was a deep fear over patient safety and doctor ‘substitution’. What was less explicit this time last year was what the future held as the debate moved from whether PAs should be working in general practice at all, to how the role would be defined, restricted or reshaped. In November 2024, health secretary Wes Streeting announced an independent review into the safety of the role, led by professor Gillian Leng – former consultant in public health medicine and chief executive of NICE. 

Given that (the controversial) GMC regulation of PAs and anaesthesia associates (AAs) had already begun by the new year, it was difficult to envision how any recommendations from the review might be implemented.

Different member organisations submitted evidence to the Inquiry. In January, the RCGP told the Leng review that there was ‘no role’ for PAs in general practice with concerns surrounding misdiagnosis and diagnostic errors, inappropriate prescribing, and lack of communication to patients and colleagues. The Government also requested GPs to give practice-level data to help assess the safety of the role.

The BMA made more than 30 recommendations to the review, which included a renaming of the role and setting out a national scope of practice. Subsequently, the union published over 600 reports from doctors of ‘shocking testimony’ about PAs working in the NHS as part of its submission. Some of the more serious reports in general practice included PAs having ignored/missed postmenopausal bleeding, raised PSA results, and deep vein thrombosis.

Ahead of the review’s release, GPs were told by Professor Leng that they could expect ‘certainty’ from the report, with the aim of it feeding into a wider refresh of the NHS long-term workforce plan due in the summer. It was also trailed ahead of the report’s publication that it would recommend a change in the ‘physician associate’ title to avoid patient confusion.

Speaking at Pulse LIVE Birmingham in June, Professor Leng told GP attendees that her research had shown that PAs were introduced to the NHS ‘without clear vision’. At the time, she was unable to share the review’s final recommendations, but she suggested that a lack of ‘definitive data’ meant she could not draw an absolute conclusion on the safety of the role in general practice. We featured her address and subsequent Q&A on an episode of Pulse in Focus: The Podcast for GPs, which you can listen to here. 

When the review was eventually released in mid-July, the PA role was not abolished, but eight recommendations were made pertaining to PAs – all of which the Government accepted. The immediate changes were:

• Adoption of the new title ‘physician assistants’ (the Leng review team has since confirmed this will require a change in legislation, so will not be as imminent);
• PAs must not triage patients nor see undifferentiated patients;
• Supervisors/managers to work with PAs to realign their roles to activities outlined in the review.

Other changes, such as establishing credentialing, career development routes and professional standards for PAs, were accepted, but would require more planning and infrastructure ahead of implementation.

Professor Leng had previously said that her findings would not please everyone, and she was right. The RCGP maintained its position that PAs should not work in primary care; chair of BMA council Dr Tom Dolphin said that the measures did not ‘adequately protect patients’; and the general secretary of United Medical Associate Professionals (UMAPs) Stephen Nash warned that having PAs only treat ‘differentiated patients’ could limit access to care. 

Shortly after, UMAPs announced it was seeking a judicial review against the Government, challenging five of the recommendations. The trade union went on to seek an interim injunction against NHSE to stop it ‘forcing through changes’ to the PA role while the judicial review was ongoing, however this was refused. 

That certainly wasn’t the only legal case surrounding PAs this year. The BMA challenged the GMC’s decision to include PAs and AAs in the term ‘medical professional’ in its standards document Good Medical Practice. The High Court eventually sided with the GMC in April, though the union has since threatened the regulator with new legal action following the Leng review. Anaesthetists United (AU) also brought a judicial review against the GMC over its refusal to set an official scope of practice for PAs. This was dismissed in September, but the group have applied to the judge for permission to appeal against that decision.

But even with the ‘certainty’ delivered by the review, there are still many blurry areas and unanswered questions, for both PAs and GPs. Perhaps the most pressing of these is timing. While the Government accepted all recommendations, no clear deadline has been set for when they must be implemented, leaving practices in a prolonged state of limbo. NHSE has since published FAQs that appear to water down the immediacy and force of the review’s actions for practices, leaving GPs to infer that much is being left to local and varied interpretation; rather than national and standardised enforcement.

This ambiguity is particularly stark around risk and responsibility. NHSE has confirmed that PAs may still be covered by indemnity even if they are practising outside the Leng review and RCGP recommendations, a position that has raised alarm among GPs already concerned about patient safety and medico-legal exposure. For supervising doctors, this creates an uncomfortable contradiction: being told what PAs should not do, while being reassured that indemnity may still apply if they do. Practices have also been advised to seek HR advice when implementing the review’s recommendations.

So, where has the Leng review left PAs in general practice? Still present (though surveys show numbers are dwindling), but more constrained on paper than in practice. They are operating within a role that is tightly defined yet unevenly enforced. The review may have delivered political certainty, but there is still much on-the-ground uncertainty. For GPs, the question is no longer simply whether PAs are safe or appropriate in general practice, but who bears the risk while the system works out how the review’s recommendations are truly enforced.

Want to hear more from our interview with Professor Leng? Listen to our podcast episode from Pulse LIVE Birmingham for clips from the day, discussion and analysis of her findings regarding PAs in the workforce. Listen here.