Physician associates introduced to NHS ‘without a clear vision’, says review lead

Exclusive Physician associates (PAs) were introduced into the NHS ‘without clear vision’ and workforce planning, the leader of the independent review has said.

During an interview at Pulse LIVE Birmingham last week, Professor Gillian Leng suggested the rollout of PAs could have been handled better.

Professor Leng, who is the former CEO of NICE, is leading an independent review into the safety and effectiveness of PAs and anaesthesia associates, commissioned last year by health secretary Wes Streeting. The review followed mounting concern among GPs and patients about the use of PAs in primary care, with warnings of patient confusion about their role and their scope of practice.

Professor Leng confirmed to the audience that her findings from the review will report at the end of June or early July.

On the rollout of PAs to the NHS, she said: ‘Any change done well requires a clear vision for what the future state should be like – and I don’t think we have that described. I don’t think that was ever set out.’

In order to achieve successful implementation, Professor Leng said you need ‘vision leadership’, ‘local implementation’ and ‘that workforce-planning element at a local level that properly thinks through “what might a service model look like with a PA in it”.’

She said: ‘With the wisdom of wonderful hindsight, we could have done it a bit better.’

Although she was unable to share what the recommendations of her review would be, she did hint that a lack of available evidence had meant it was not possible to draw a definitive conclusion on safety.

She told delegates: You know, there’s nothing that says PAs are 100% safe in primary care, but there’s equally nothing that says they are 100% unsafe in primary care. There’s a lack of definitive data. But I am confident that we’ve looked as hard as we can.’

She stressed that there are ‘no randomised controlled trials that have been carried out in general practice’, ‘no controlled studies of any sort’, and that ‘the data is relatively limited’.

‘There are bits of data that one can draw upon, but it’s not a comprehensive, perfect evidence base. That didn’t surprise me. I wasn’t expecting there to be a perfect evidence base.’

But she said her 20-year experience of working at NICE producing guidelines without a perfect evidence base had prepared her for determining ‘what needs to happen next’.

‘So on this occasion, I’ve drawn upon patient perspectives, on clinical views, on expert opinions, both nationally and internationally, and looking at the needs of the workforce. So all of those bits of information are being triangulated with the centre, with a core around safety and effectiveness. But there is not not black and white evidence around safety and effectiveness in primary care.’

Among available evidence Professor Leng did highlight benefits of PAs, including that they may even outperform GPs in some areas.

‘There are some studies that show… that PAs are better in some areas than GPs, in others that they’re less effective. Things like referral rates seem to be similar to GPs. PAs tend to have slightly longer appointments. They tend to give slightly more advice – that might be correlated to being given more appointments.’

And she went onto suggest that the level of scrutiny aimed at PAs is unprecedented and potentially disproportionate.

‘I don’t think anywhere, anyone else around the world has looked so comprehensively for information about one particular staff group, and I have to say, I don’t think any other staff group has had this level of scrutiny. It would be interesting to see what happens to other professionals if we try to find data on their safety and effectiveness. It’s quite unusual to have this level of scrutiny.’

She was also firm that PAs are not to blame for the GP unemployment crisis.

She said: ‘There is a short answer to that, and I think the short answer is no. I don’t think they’re to blame.’

Instead, the review found that practices have genuinely hired PAs when they have ‘struggled to employ GPs’.

‘I visited practices that said we would not be open right now. We would not be able to provide a service for patients without PAs,’ Professor Leng said.

On scope of practice, she said she found a ‘striking’ differing perspective between PAs – who were ‘confident that they can do the vast majority of those activities that you might see in primary care’, while ‘the response from doctors was much less supportive of those roles being carried out’.

‘So we saw quite a divide in views on what could be carried out and should be carried out…  and probably the answer is somewhere in the middle.’

Professor Leng concluded: ‘It’s a very tense topic. There are very polarised views around the roles of PAs. So I have tried to get as much evidence as possible, listen to as many people as possible, and I’m absolutely clear that the recommendations will not please everyone, but I’ve taken what I hope is a pragmatic, sensible approach to move things forward.’

The Pulse interview brings the most comprehensive insight to date into what the review has found. Professor Leng had previously promised her review would bring ‘certainty’ around the role of the profession in the NHS. It has also been reported that PAs are likely to be renamed following the review, to avoid patient confusion.

Want to hear more from our interview with Professor Leng? Check out the newest episode of Pulse in Focus: The Podcast for GPs, for clips from the day, discussion of her findings, and analysis of what the final report might recommend regarding PAs in the workforce. Listen here.