American Academy of Physician Associates (AAPA) publishes critique of the Leng Review

The highly respected American Academy of Physician Associates (AAPA) has published their critique of the Leng Review and it makes grim reading. Here is the full report:

https://www.aapa.org/download/153276/?tmstv=1761916932

If you cannot be bothered to read all 12 pages, here is a summary:

The AAPA’s response, prepared by doctoral-level research scholars with over 50 years of combined experience, raises significant concerns about the methodology and evidence underpinning the review’s restrictive recommendations.

Key Finding and Central Concern

The Leng Review found no substantive differences in safety incidents or “Never Events” between UK Physician Associates and comparable healthcare providers. Despite this finding, the review recommended limiting PA practice scope, including restricting PAs from treating undifferentiated patients and changing the professional title from “Physician Associate” to “Physician Assistant.” The AAPA argues these recommendations lack sufficient evidentiary support and stem from methodologically flawed research processes.

Methodological Weaknesses

Literature Review Inconsistencies: The systematic review initially identified 47 relevant articles, with 24 excluded using subjective criteria such as small sample sizes or low quality. Of the remaining 23 medium or high-quality studies, many were dismissed without consistent rationale. For example, the Drennan et al. (2015) study, which analyzed 475 patient records and found PA clinical documentation more appropriate than general practitioners (81.6% versus 50.8%), was criticized for using “narrow outcome metrics” despite robust sample sizes. Similarly, the Senft et al. (2019) study analyzing over 861,000 patient records was questioned for case mix adjustment despite showing negligible differences in patient complexity. The review lacks a systematic framework for evaluating bias, sample size adequacy, or statistical power, raising concerns about arbitrary decision-making.

Focus Group Limitations: Patient focus groups conducted by the Patients Association suffered from sampling bias and methodological opacity. Participants were recruited through a convenience sample from a patients’ rights newsletter, with only 23 of 31 participants having actually received care from PAs. This means many comments about PAs were not experience-based, potentially skewing perceptions negatively. The report fails to clarify whether data saturation was achieved, how themes were identified, or provide context for quotations. Vague generalisations using terms like “some” or “most” appear throughout without specific proportions, weakening the reliability and applicability of findings.

Survey Design Flaws: The survey distributed for evidence collection had no verification process to confirm respondents’ NHS affiliation. While duplicate and bot responses were screened, the lack of statistical weighting or margin of error calculations limits generalisability. Significant non-response bias is evident, with only 32% of UK PAs responding compared to just 2.6% of doctors and resident doctors. Without statistical adjustments to correct for subgroup imbalances, the survey results may be skewed and unrepresentative of the broader NHS workforce. The survey’s snowball sampling approach through public channels during what the review itself described as a “toxic” debate environment raises questions about whether coordinated opposition campaigns may have influenced responses.

Secondary Data Analysis Issues: The review characterised national datasets—including coroners’ reports, whistleblower files, and the Learn from Patient Safety Events system—as “inconclusive and largely unhelpful,” despite evidence suggesting PAs provide safe care. Analysis of Prevention of Future Deaths reports from July 2013 to February 2025 revealed no pattern of findings related to PA care, with a notably low incidence rate of 1.43 cases per 1,000 PAs. Comparative analysis of Never Events found no significant differences in rates per full-time equivalent between PAs and resident doctors or nurses. However, the report fails to standardise search periods across professions, examining PAs from May 2023 to February 2025 while using July 2013 to February 2025 for comparators, limiting the validity of comparisons. Additionally, underlying data supporting key analyses was not made publicly available, reducing transparency.

Influence of External Advocacy

The review references public comments from the British Medical Association (BMA), which has historically opposed the PA profession, but does not clarify whether these influenced policy recommendations. It remains unclear whether PA-supporting organizations received equal opportunity to contribute expert testimony, potentially creating an imbalance in perspectives considered.

Response to Key Recommendations

Title Change: The recommendation to rename the profession from “Physician Associate” to “Physician Assistant” lacks evidence that such a change would improve patient understanding of role differences. Both terms use the same “PA” abbreviation. The AAPA argues that communication and education strategies would be more effective than title changes. Survey data shows patients who interact directly with PAs report positive or neutral experiences, while those without direct interaction hold more negative views—suggesting communication gaps rather than title confusion drive misperceptions.

Restricting Undifferentiated Patient Care: The proposal to prohibit PAs from seeing undifferentiated patients except under clearly defined protocols is not supported by the safety data presented in the review itself. The Prevention of Future Deaths reports showed no pattern of concerns related to PA care, and isolated incidents should not outweigh millions of safe patient interactions. Survey responses indicated 90% of PAs feel extremely or very confident in their supervision adequacy and ability to report safety incidents. Additionally, approximately 43% of survey participants felt PAs could take on additional activities, with only slim majorities of GPs (53%) and resident doctors (50%) opposing expanded PA responsibilities. Restricting PA practice could exacerbate existing NHS workforce shortages, particularly given that many healthcare professionals support expanding PA roles to increase appointment availability and reduce wait times.

Positive Aspects Acknowledged

The AAPA recognizes value in recommendations aimed at enhancing UK PA career progression, establishing clear roles within NHS multidisciplinary teams, and ensuring PAs are appropriately credentialed through General Medical Council (GMC) regulation. The GMC began regulating PAs after more than five years of planning, and three in five surveyed PAs believe this regulation will positively impact safety, support, and public perceptions. These measures address legitimate concerns around process and communication without imposing unnecessary practice limitations.

Conclusion and Recommendations

The AAPA critique concludes that while the Leng Review acknowledges no significant differences in safety, effectiveness, or Never Events between PAs and comparator groups, its restrictive recommendations are undermined by methodological weaknesses in literature review, focus groups, and survey design. Secondary data consistently indicates PAs deliver care comparable to other NHS professionals. Rather than imposing constraints that could worsen workforce shortages, the AAPA recommends evidence-based strategies focused on clear role definition, structured credentialing, and enhanced career development pathways. The recently implemented GMC regulation is expected to strengthen governance and public confidence, making premature restrictions on PA practice unjustified before the regulatory framework’s effects can be properly evaluated.