In her long-awaited report on Associates, Professor Leng has set out 18 recommendations. The most significant of these is that the title of “physician associate” and “anaesthesia associate” should now be downgraded to physician assistant (PA) and Physician Assistant in Anaesthesia (PAA) –  and alongside that, their role must be redefined. 

Changing the name reinforces that the role is one of being a supportive, complementary member of the medical team and not a replacement for doctors.

Key recommendations include:

• Prohibiting PAs from seeing undifferentiated patients
  
• Ensuring they are clearly identifiable as PAs through badges and uniforms
  
• Setting guidelines on what they can do via national job descriptions
  

But our concern remains: how will any of this be enforced?

Why did it go so wrong?

Leng pulls no punches in her assessment of how senior leaders mishandled the introduction of PAs and PAAs. She highlights that:

• There was no clear vision for these roles, or their purpose and remit
  
• There was no single, consistent voice speaking for the profession
  
• Service models for PAs were never properly thought through
  

As a result, gaps in medical staffing were often filled by PAs without considering their limited training or ensuring appropriate supervision was in place.

She concludes there is no case for continuing with these roles unchanged — major changes are needed if PAs and PAAs are to be safely and effectively embedded in the NHS.

The undifferentiated patient

The biggest safety concern raised was about PAs diagnosing new conditions and initiating treatment – especially when dealing with undifferentiated patients. Getting a diagnosis wrong at this stage can send patients down entirely the wrong clinical pathway, with serious consequences.

Leng recommends that PAs should not see undifferentiated patients, unless triaged into an adult minor ailments stream. These limits will be clearly defined in protocols to be agreed by the Royal College of Emergency Medicine (RCEM) and the Royal College of General Practitioners (RCGP).

We hope both Colleges will consult and publish these protocols urgently.

Career paths for PAs and PAAs

Leng recommends a national framework for PA careers. Newly qualified PAs would:

• Be limited to specific roles and tasks, based on a national job description
  
• Spend at least two years in hospital practice before working in general practice
  
• Be able to access training and credentialing programmes developed with the medical royal colleges
  
• Progress to “Advanced PA” roles through a standardised selection process based on national job profiles
  

Crucially, career progression beyond the Advanced PA level is not anticipated, because the PA role is limited to collaborative, supportive work alongside doctors.

In anaesthesia, this is echoed: PAAs can follow structured development, but always within a defined scope of practice endorsed by the RCoA and always within clear limits, given that their role must remain subordinate to a consultant.

A different model of teamworking

Leng is clear that safe teamworking is not solely about limiting the functions of PAs and PAAs. It is also about ensuring doctors delegate appropriately and have time for activities that require their greater skills and expertise.

The PA and PAA roles must sit within a clear team structure, led by a senior clinician. Everyone in the team must understand their roles, responsibilities, and levels of accountability.

She recommends that:

• Doctors get specific training in line management and supervision
  
• They are given time in their job plans to carry out these responsibilities properly
  
• Any expansion in the PAA workforce must only happen in conjunction with the RCoA, to build safe and effective models of anaesthetic delivery backed by the consultant workforce
  

She rightly notes that robust supervision is essential for delivering safe anaesthesia via PAAs. 

We consider the defined supervision levels set out in the RCoA’s current guidance are a non-negotiable foundation for any future PAA rollout.

Specific considerations for Physician Assistants in Anaesthesia

PAAs should continue working within the boundaries defined by the RCoA’s interim scope of practice. Unlike PAs, they already work in a more closely regulated environment, with clear supervision standards.

Any future expansion in the use of PAAs must be agreed with the RCoA, and must ensure models of care are led and supported by the consultant community.

We think those departments that have implemented their own governance arrangements for PAAs will need to urgently review these in light of Leng’s recommendations.

But who will enforce it?

We support many of Leng’s recommendations.  and hope the government accepts them. But enforcement remains a serious concern, especially at a local level where some NHS trusts have shown a tendency to ignore or sideline College guidance.

We look to both the GMC and CQC to take clear responsibility: the GMC for regulating individual practitioners, and the CQC for inspecting the organisations employing them. Without strong enforcement, trusts may be tempted to bend rules under financial pressure, and patient safety could suffer. 

What about medical training?

Professor Leng makes an important point about postgraduate training for doctors. While long shifts of the past were unsafe, today’s training model has lost all sense of continuity, mentorship, and team identity.

Doctors in training feel isolated. Rotations and shift patterns make it hard to form lasting relationships or find role models. The culture has become transactional — processing doctors like widgets, instead of investing in future clinical leaders.

Final thoughts…

Many feared this would be a whitewash. It wasn’t. This report marks the start of a long road to repair the damage caused by the unstructured rollout of the PA programme.

Anaesthetists United believes that there is a lot of work that needs to be done,  and that the Colleges, clinicians, and regulatory bodies must now take the lead in implementing these recommendations safely and transparently.

We also are awaiting the outcome of our legal case in which Mrs Justice Lambert will consider whether the GMC must set and enforce safe and lawful practice measures to ensure that what PA/PAAs can and cannot do in their day to day work is properly set out.