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Physician associates: expansion, regulation, and the Leng review
Planned to grow to 10,000, physician associates came under GMC regulation in 2024. After coroners' findings and an independent review, the roles are to be renamed and restricted, but not abolished.
Status note: The government accepted all 18 Leng recommendations on 16 July 2025. The renaming is not yet law: a draft General Medical Council Order 2026 was consulted on from 24 March to 21 July 2026, and as at October 2026 the government was still analysing responses. Using the title physician associate or anaesthesia associate without GMC registration becomes an offence from 13 December 2026.
The stated rationale
The 2023 NHS Long Term Workforce Plan set out to grow physician associates to 10,000 and anaesthesia associates to 2,000 by 2036/37, to expand capacity.
The full cycle
In our view, the UK shows what happens when a role is scaled before the evidence:
Expansion. The 2023 workforce plan set ambitious growth targets.
Regulation. The GMC began regulating physician and anaesthesia associates on 13 December 2024.
Deaths examined by coroners. The High Court’s 2025 judgment in the Anaesthetists United case sets out coroners’ findings in four deaths in which a physician associate was involved, including those of Emily Chesterton (2022) and Susan Pollitt (2023). In the Pollitt case, the senior coroner’s Prevention of Future Deaths report noted there was then no regulatory body with oversight of physician associates, title confusion, no national framework for how they are trained, supervised and judged competent, and a competency sign-off that assessed only the technical skill of inserting the drain, not consent, risk factors or aftercare.
Evidence review. A BMJ rapid review of UK research found that of 29 qualifying studies, none examined safety incidents and only one directly observed clinical competence.
Re-tightening. The Leng review (July 2025) found the evidence “weak” and “entirely based upon observational data”. It recommended renaming the roles “physician assistant” and “physician assistant in anaesthesia”, no undifferentiated patients except under national protocols, at least two years in secondary care before working in primary care, and a named supervising doctor. The government accepted all 18 recommendations.
Courts. Challenges by Anaesthetists United (High Court, 2025) and the BMA (Court of Appeal, 2026) both failed: the courts found the GMC acted lawfully in declining to set national scope limits and in calling doctors and associates “medical professionals”.
The fair reading
We think the coroners’ findings cut both ways: the Pollitt report’s first concern was that there was then no regulator at all, which is different from a failure of proportionate regulation. The High Court accepted as rational the GMC’s view that national hard limits could hold back competent associates. The BMA says confusion over the role has led to “at least 3 deaths”.
Both the Leng review and the BMJ authors found the evidence base weak. As the BMJ authors put it, the absence of evidence of safety incidents is not evidence that the roles are safe.
Who supports it
UK Government (keeps the roles; accepted Leng in full)
GMC (the regulator; defended its approach in court)
Who has raised concerns
BMA: Leng "fails to fully protect patients"; it wants a defined "safe scope" of practice
Anaesthetists United (brought an unsuccessful judicial review seeking national limits on scope)
The Court of Appeal dismissed the BMA's challenge to the GMC's use of the term 'medical professionals' for both doctors and physician and anaesthesia associates in Good Medical Practice. A separate judicial review by Anaesthetists United, seeking national limits on scope of practice, was dismissed by the High Court in September 2025.
Why it matters: The courts found the GMC acted lawfully on both terminology and scope of practice. In our view, change will have to come through policy, not litigation.
Reviewed UK research on physician and anaesthetic associates published from 2015 to January 2025. Of 29 studies meeting its inclusion standard, none examined safety incidents and only one directly observed clinical competence.
Why it matters: In our view, a clear statement of the evidence gap: the authors warn that absence of evidence of safety incidents is not evidence that the roles are safe. Co-author Martin McKee was BMA president in 2022-23.
An independent review found the evidence on the roles weak and based on observational data. It made 18 recommendations, including renaming the roles 'physician assistant' and 'physician assistant in anaesthesia', and requiring a named supervising doctor for each physician assistant. The government accepted all of them.
Why it matters: In our view, a template for how a government re-tightens a role after scaling it ahead of the evidence.
A senior coroner found that an ascitic drain, which a junior doctor had decided to place, was not clinically indicated. The physician associate who inserted it was unaware of local guidance, left it in for 21 hours and directed that it be clamped, which the coroner found was unwarranted. The report also raises the absence of a regulator at the time, title confusion, and a competency sign-off that covered only the technical skill of inserting the drain, not consent, risk factors or aftercare.
Why it matters: Its first concern was that there was then no regulator at all, so it does not show that proportionate regulation fails; its other concerns (training, supervision, the title, competency sign-off) remain relevant under regulation.