The Leng Review – a critique

At the time of writing Physician Associates (PAs) have been operating in the UK health service for over 20 years. PAs receive similar training as a doctor but delivered in a more intensive way over a shorter period of time. PAs have the same clinical and history-taking skills as a doctor but their focus is on core common presentations, whereas doctors have to learn the pathology of the full range of clinical presentations.

PAs are an established profession in the USA where there are over 1 million doctors and c.180,000 PAs and globally there are many equivalents across many countries. There have never been any significant issues with PAs in the UK until 2022 when the BMA was taken over by a populist pressure group called Doctors’ Vote (now rebranded to Doctors United). DV systematically put forward their own candidates for all representative positions within the BMA and effectively took over the organisation within one year. DV/BMA started to campaign against their PA colleagues citing (unfounded) safety concerns. The DV/BMA also started a series of strikes which resulted in a substantial pay increase when Labour came to power in 2024. They kept on campaigning against PAs and Health Secretary Wes Streeting decided in 2024 that he would commission a review looking into the safety and effectiveness of PAs. He hoped it would resolve the issue.

The Leng Review

Professor Gillian Leng was appointed to lead the review. Dr Leng is a medical doctor who was former Chief Executive of NICE. She was touted as an impartial, evidence-led clinician and the ideal person to impartially review PAs and make recommendations where appropriate. The review became known as the Leng Review and it was eventually published in July 2025. The review has resulted in large numbers of PAs losing their jobs and multiple, ongoing legal cases. The Leng review has been criticised for being biased and making recommendations without an evidence base. Here we discuss some of those aspects:

Leng states that “there is no definitive evidence that Physician Assistants (PAs) are safe in primary care, nor is there conclusive evidence that they are unsafe”. This sentence highlights Leng’s inappropriateness for the role.

PAs are safe

First we need to understand a bit about scientific evidence. If we wish to prove a theory that all swans are white, what we do, in science, is write a null hypothesis that is the opposite; so we say “not all swans are white”, then we try to disprove the null hypothesis by trying to find non-white swans. It seems a bit crazy, I know, but the reason it is done like this is because it is harder to prove a positive than disprove a negative. Every single scientist knows this is the basis of scientific methodology. So if you are trying to prove that PAs are safe, then you look for evidence that they are unsafe. Leng says confidently that there is no conclusive evidence that they are unsafe. Therefore PAs are safe! It is as simple as that.

What is concerning is that Professor Leng is meant to be an eminent scientist. Yet she provides very public evidence of an inability to understand basic scientific method. One can only speculate as to an explanation for this. Is she incompetent, is she trying to manipulate non-scientific readers or does she have some kind of special insight outside the accepted orthodoxy? Who knows?

Recommendations without evidence base

The next thing is she makes recommendations which are not evidence-based.

She wants to rename “Physician Associates” to “Physician Assistants” because she witnessed consultations where PAs introduced themselves as PAs and the patient still thought they had seen a doctor. She did not like the “Physician” part of the term Physician Associate because it was “confusing” and more of an “American” term. However, she then proceeded to keep the “physician” bit and change “associate” to “assistant”. She claimed, without quantitative evidence, that patients did not like “associate” and they felt “assistant” was better.

She also said patients felt it was “too grandiose” – but that specific phrasing has usually come from one particular family who have been in the media talking about PAs. Was there any data that was published that showed the number of patients that said it was grandiose and which warranted an entire name (and role) change? And “grandiose” is very subjective. Personally as a Physician Associate myself, I have never thought of the term as in any way grandiose. Dr Leng has allowed her own subjective bias to influence her thinking with this issue and in attempting to clarify a “confusing” term she recommends one that is equally “confusing”. A better recommendation would be a patient education campaign that clarifies Physician Associates and how they are different/work with doctors.

Leng takes sides

Furthermore Dr Leng would have known that the term “Physician Assistant” has been used to bully and belittle PAs for years, and she chose that term. In doing so she sided with the bullies. She then goes on to try and change the role to fit the name. She seems to like the idea of PAs being subordinate assistants to doctors, rather than medical professionals working alongside doctors. This is a demotion of the role.

Despite finding no evidence that PAs are unsafe, Dr Leng goes on to recommend changes as if PAs are unsafe. For example, she recommends PAs do not see “undifferentiated patients” or “make diagnoses”. In doing so she pretty much destroys the PA profession. Dr Leng’s recommendations in this regard are the reason why so many PAs are now in employment tribunals having been laid off by their employers.

PAs spend their first year studying clinical examination and reasoning, they have the same training a doctor has in that regard. Pareto’s principle states that 80% of effects come from 20% of causes and this applies in full measure to patients presenting with medical issues. You do not need to be a fully qualified doctor to make a lot of diagnoses, that is why a lot of GP surgeries use nurses to diagnose common ailments. Having PAs means you can use PAs to deal with a lot of medical presentations and then use more highly-qualified doctors to deal with the more complex presentations.

PAs are trained to escalate to seniors when they are unsure about a diagnosis. The safety comes from being part of the team. Dr Leng makes a lot out of the Emily Chesterton case in her analysis. Emily Chesterton’s case, a highly emotive one, has been exploited by the British Medical Association in their campaign against PAs. Emily Chesterton’s case is one case resulting from a fatal misdiagnosis in 20 years of having PAs in the UK. UK doctors, by contrast, fail to diagnose 310 fatal PEs every year. Dr Leng has unfortunately shown herself to be biased by an emotional story rather than empirical evidence.

Dr Leng’s recommendations regarding undifferentiated patients is explained by her on the basis that PAs spend less time in education than doctors. In fact, PA education is much more intense and intensive than medical school and uses much more sophisticated teaching methodology.

She gives no actual explanation for what undifferentiated is or any quantifiable way that stopping PAs seeing undifferentiated patients will actually increase patient safety. Although it is probably fair to say that reducing the medical workforce (the consequence of her review) is likely to reduce patient safety.

Dr Leng goes on to recommend that oversight for future faculties should lie with the Royal College of Physicians (and other Royal colleges). The issue here is a historical one. Originally the Faculty of Physician Associates was part of the Royal College of Physicians and everything worked very well. Then politics got involved and Doctors’ Vote activists essentially took over the RCP and pushed through an anti-PA vote which means the FPA was disbanded. The result is that the RCP is now politically anti-PA. It is simply not right to appoint a blatantly anti-PA body to have any oversight of PAs because they will clearly put vested, political interests before the best interests of patients.

The Leng Review – a waste of public money?

Why did this review even need to be done? The USA has 1 million doctors and 180,000 PAs, of course PAs are safe and effective. There were issues with PAs, there are issues with Drs but demoting the PA profession is not the right solution for anyone – PAs, Doctors or patients. PAs are safe, PAs are effective, Leng’s recommendations are a retrograde step without evidence.

The great sadness is that the PA role has become politicised. Rather than recognise this fact Dr Leng has unfortunately sided with the activist members of the medical establishment who are anti-PA. She has allowed her own bias to influence her and then used what scientific evidence she can find to justify her thinking. The Department of Health & Social Care was likely complicit in this as well as a Leng Review with anti-PA recommendations would be politically useful at a time when negotiations were on-going with junior doctors over pay.

In hindsight, appointing a medical doctor to take on this role was the wrong decision because they were never going to be able to be truly independent. Now the Leng Review, which was promised as a resolution to the issue of Physician Associates in the UK has instead lead to multiple redundancies, qualified PA students being unable to find employment and general chaos.

UPDATE: In a bizarre twist Dr Leng has now been appointed to work for the Department of Health & Social Care to “support implementation of (her) recommendations”. Given that Dr Leng has been behind the laying-off of hundreds of PAs from General Practice and secondary care leading to multiple employment tribunals this is a little bit like employing the fox to guard the hen-house. Dr Leng’s great legacy to the NHS would seem to be the slow death of the Physician Associate profession in the UK.

NEWS: Checkout the AAPA critique of the Leng Review. We have a full article on it here.