Leng Review Webinar - Physician Associates

Gillian Leng (00:52)
Good evening, everybody. Well, welcome to this webinar. It's just on 7 p.m. and we've only got an hour. So I think I'm going to start on time. This is one of a series of five webinars that are part of the review into the role of physician associates and anesthesia associates. And this evening, you should all be physician associates. It's your session. We've had some questions pre-submitted.

but I'll come to those shortly. First thing to do is to run through the agenda and how the evening is going to run. So if you could have the next slide.

So I am Gillian Lange. I'm leading the review. I have a background in medicine. I specialised in public health and then worked at NICE for just about 20 years, just over 20 years. So lots of experience of looking at evidence and contrary to what some may think, much of what NICE guidelines are based on was not a series of excellent randomised control trials. I'm used to mixed...

mixed evidence and how you interpret that and how you draw conclusions, often in quite challenging scenarios. And as I'm sure you'll all testify, this is at the moment quite a challenging scenario for you all. I have Stephen Nash with me as a co-host to help out with the questions. And I'm just going to turn to him briefly to say hello.

Stephen Nash (02:22)
guys, my name is Stephen Nash. I'm a physician associate that's worked in acute med, cardiothoracics and general practice. My role here today is as the General Secretary of United Medical Associate Professionals, which is the trade union that represents medical associate professionals in the UK.

Gillian Leng (02:38)
Thanks, thanks, Stephen. And also here in the background, we have members of the review Secretariat from the Department of Health and Social Care who are providing me support along the way and they are managing the technical things like moving the slides, sorting out questions, et cetera. Two main things to do this evening. The first is for me to give a brief overview of the review, the process, how it's working, the evidence that we're looking at and the planned timeline.

And then after that, the most important bit is the Q &A ⁓ session because you don't want to listen to me for an hour. So the Q &A is to give you the opportunity to ask questions and make any comments.

So we've moved on to the slide, which is about asking questions. And obviously, any question should be relevant to the scope of the review and focused on the physician associate part of that. Feel free to ask whatever's on your mind. And if you want to, you're more than welcome to ask questions anonymously.

use the Q &A function rather than the chat because the chat's not operational and the Q &A gives us the functionality of up voting questions which is quite helpful. But in terms of the anonymity, be aware that at a previous session sometimes people were taking screenshots of the questions and they've since been posted. Nothing terrible has come of that but if you are concerned about your anonymity,

ask questions without putting your name. And in order to prioritise questions, and I'm keen that you do that so that we can logically work through those that have had the most votes. In order to do that, please use the arrows next to the questions. So you'll see an up arrow. If you click on that, it will vote up the question. If you click on the thumb, that will like it, but it won't count and it won't vote up the question. It also means

So I'm told that if you hover over that, you might be able to see the name of the person who liked it. So again, if you're cautious about your protecting or anonymity, then beware of doing that. There are some questions already in the Q &A. They are ones that we've made up. They are questions that have been sent in advance. And of course, you're welcome to vote those up too. And as I said earlier, I'm going to respond.

in the order in which you voted for them, unless there's an obvious repeat or something similar. And if I don't know the answer, then I will get back to you. And Stephen is going to answer the questions to avoid me having to do too much multitasking. Please don't include personal information, private, privileged information in the questions because we can't read those out. And of course, keep them polite and know inappropriate language.

And that's the process for questions. And if we can have the next slide, I'll just give a bit of background about the review. So there's a document on the gov.uk website that gives detail of the scope of the review and some updates about evidence, et cetera. But in a nutshell, the question that the review was asked to consider was, the roles of physician associates and anesthesia associates safe and effective?

as members of a multidisciplinary team across all tasks, roles and settings. We were told very early on to make sure that AAs were not muddled with PAs. You have different types of training. You have different ways of working, different settings, et cetera. So although there will be one report at the end of this, there'll be separate sections that relate to AAs and PAs.

So simple question, but obviously not quite so simple to answer. And the line across the middle is there to indicate that there could be a spectrum of answers. It isn't going to be black and white. The evidence isn't black and white. And there could be at one end of the spectrum, things that should never be done. And that might be never working in a particular environment. That might be never doing any of these roles.

I'm just giving you the full spectrum to be clear that there is all up for consideration. So there's a never end and there's an always end on the right where things are considered ideal, well done, should be expanded. And then in the middle areas where things might need to be modified to improve safety, effectiveness, wider confidence in the roles. So question, evidence and a spectrum potentially of answers.

and to give you a very brief progress update on some of the things we've been looking at. There's the next slide, please.

If you've been following the review, you'll know that we had a call for evidence. It's closed now and we've had 87 responses. Now that might sound to you like not very many, but that is 87 organisations that have responded. Therefore, clearly within each organisational response, there have been a whole host of documents that has been submitted.

I haven't got the number for the total number of things within that 87, but it's quite a lot. So a big task for the team at the moment. I've been going through those things firstly to classify, make sure they are in scope of the review, then work out whether they are some research study, audit data, or perhaps just the scope of practice or a policy document. They need to be classified.

things that look like research that are data driven evidence, we will then assess them against quality criteria. In an ideal world, we'd have high quality randomized control trials. And I know that's unrealistic in this scenario, absolutely. So we will look at the best available evidence and therefore we're using standard quality criteria for assessing evidence.

We also launched a survey which closed on the 30th of March. We ended up with over 8000 responses. It was. Aimed at physician associates and anesthesia associates and those that work with them. It wasn't intended to be a blanket survey of everyone in health care, and I know that there are some questions that have already been asked about the survey that are in the Q &A, so I shall not say anymore at this point, but we can.

We can come to that. I have done a series of visits. I visited three acute trusts face to face. I also did one virtually, which took less travel time, much easier. And I think I learned quite a lot. Not the same as being there, but it was useful. And I visited several practices, general practices that use physician associates.

However, short of spending several years going around everywhere, it was going to be inevitably limited engagement, which is why I'm also doing this series of webinars to give me a chance to speak to a wider group and for you to ask questions. And I've got a slide on the webinars shortly. Sorry, I haven't quite finished that slide. Sorry, what's happened?

There we go, that's it. And systematic review. We commissioned a systematic review from King's College in London. We've received that in draft. It looks both at national and international data. Some of you will have seen in the BMJ perhaps that there was a review published recently, led, authored by Trish Greenhage. It's pretty good.

Well done review. It's been peer reviewed. in the BMJ and we will look at that. It wasn't commissioned by the review though, just to be clear, because it's slightly ambiguous if you read it. We didn't commission that one, but we will look at it. And the other piece of evidence that isn't on this list is getting feedback from patients. And we've got some independent patient facing organisations running focus groups for us so that we get feedback from.

on patients who have been ⁓ exposed to, it doesn't sound quite the right phrase, but have been treated by, had consultations with, whatever phrase you want, physician associates. won't just be random patients, they will be people that have interacted with you. Right, now the next slide.

So evidence overview, this is to try and illustrate how it all comes together. It builds in a rather cumbersome fashion, but let's start. The first block is all about the data that we've collected. So if we can have the first bit, that's the bit. So research evidence, data that might come from trusts, it might come from CQC and the survey plus other surveys. So there's our own survey plus other surveys. We're going to...

pull all of those together into some key elements which looks like, next bit please, looks something like this, something like this. As I said at the beginning, separated by AAs and PAs. PAs I definitely want to split by setting. Primary care and secondary care is the high level split. If there's enough data, which there might not, but if there's enough information to split secondary care into some of the specialty areas,

then that would be interesting to look at. I'm sure you'd agree, but we'll have to see how much data there is and if that's worthwhile. And then of course, looking at the key things that the review was asked to consider. Safety, effectiveness of the role, potential subgroups within that, if possible. The patient perspective, cost and cost effectiveness, where we possibly can. Having worked at NICE for 20 years, you'd expect me to include that.

It's probably not going to make a huge amount of difference, but I think for completeness, we need to do that. And then any separate issues around education and training. So that's the data element. alongside that, we're also getting some softer intelligence, if you like. So if I can have the next box, that's feedback from stakeholder groups, from experts visits. So informal, softer feedback.

Pulling all of that together will hopefully refine the themes that were identified at the very beginning. So if I can have the next box. So at the very beginning, people said you need to look at education and training. What are the requirements? You need to look at day to day working, things that relate to supervision, scope of practice, staff ratios, identity and naming. And I'd be interested this evening in your thoughts around that part, the identity and naming.

how well you think it works as it is at the moment. And if you have any other ideas, you could vote up on, ⁓ use the voting system for that, we? Regulation and governance and what best practices and so that will be refined. That was what we were told at the beginning. And then to bring it all to a conclusion, having got through this, I'm reserving the opportunity to talk to some independent experts, partly

people who are ⁓ international, but others too. This won't be key stakeholder groups, it will be experts to help then shape the recommendations. And the timing that I'm working to at the moment is to get the recommendations, the report out for June, because it's really important that this feeds into the new workforce plan that the government is producing. It's got to do that. And it's quite tight, this timeline.

but we've got to get it into the workforce plan. And I absolutely appreciate that you guys are all living through a lot of uncertainty at the moment and that it's very difficult for you and there's nothing worse than uncertainty. So what you need is a conclusion from this review and then whatever it says, it'll be better and you can move forward with that. Human brain doesn't like uncertainty.

And the next slide, please.

So just a summary of today, engagement webinars with five key groups. It was four. I wasn't originally planning to do a separate one for anaesthetists, but they felt very strongly that the AA role is important, that I'd spoken to the AAs and that they would like to have ⁓ opportunity to talk to me as well. So that's been added in. I've already done the one for AAs and I've done one for other healthcare professionals.

I'm speaking to resident doctors tomorrow. As I said already, focus groups with patients and the aim of all of this is to hear your questions, hear your thoughts. You can just put comments into the Q &A if you wish, we'll note them. Want to understand your views, make sure you feel better informed and it will very much, your perspective will very much help contextualize all that data and inform those themes.

So we will review all the questions that come in, even if we don't have time in this hour. And we are recording the session and we'll make it available after we've gone through all of them so that they're all available at the same time.

So there's one final slide which has some suggested questions for discussion, but don't feel restricted by this. This is just in case you needed prompting, which I'm sure you won't, but how would you like to see your future role positioned? What do you feel about career progression and development? What would you like to see? Hopes regarding future of regulation. What is good day-to-day supervision like that means

everything is done appropriately and safely and what do you think about a national scope of practice? Is it helpful? Now on the right of this slide I wanted to put a little white man person thing walking on a tightrope because that's how I feel doing this review. There are quite strong perspectives, quite differing perspectives and I've been very careful to listen to all those perspectives but not to be

drawn into any of the various camps. So that's why I'm walking a tightrope. But I'm also walking a tightrope because as I hear things, I'm learning more about the roles and beginning to formulate ideas. However, I don't want to indicate where the review might conclude because that will set hairs running. So I'm being

If you think I'm being cagey, I probably am because I don't want to say too much about where this might go. You know, a lot of this is managing messages, communicating well and clearly. So if I'm cagey, I apologize, but it's deliberate and is to manage that message because we have to land this review well. We have to make sure that whatever comes afterwards is

is not leaving you in this toxic environment that I know some of you feel at the moment. I know it isn't like that for everyone, but certainly a number of people have reflected that to me. So that's the end of my slides and we can probably take them down. You can get a better view of me and Stephen and we will, I will refresh the questions so that I can see the upvoted ones.

But I think I'm going to hand over to you, Stephen, to actually read out what's at the top.

Stephen Nash (19:39)
Yep, good evening. So ⁓ this first one, I'm not going to read out the name because I don't think it will be contained in the recording, but there's a physician associate has asked, will the review be addressing the RCP and BMA advisory guidelines? My trust are using these to essentially phase out PAs across multiple departments.

Gillian Leng (20:00)
⁓ In terms of addressing the advisory guidelines, I'm not going to formally comment on what they say. However, I will make the recommendations that I think need to be made. And the expectation is that the organisations that you've listed on here, plus others in the stakeholder group, will follow them. I've got government backing to take this forward.

This relates to the point I made about landing this well. I've got to be really astute, really engaging with all these organisations so we get buy-in and support moving forwards because we can't have individual organisations putting out different things. We've all got to be on the same page. ⁓ I'm reasonably, fingers all crossed, but reasonably confident that people are

are engaged and supportive of the process. And that's all I can hope at this point.

Stephen Nash (21:02)
Okay, I think this second question probably ties in a little bit with that. So another PA said, I'm worried that the damage to our profession, sorry, our professional reputations is already done and there's no coming back from this. What do you think needs to be done to repair our reputation as a profession or should we all be looking for a new job?

Gillian Leng (21:26)
And that's got 44 votes. So that's obviously something that we relate to. That's a feeling. Yeah. Yeah. Yeah. Yeah. It's interesting. I spoke to some PAs today in a trust. I won't say which one, but where they were working, they seem to be highly valued in the teams that they were working. And it was quite encouraging for me.

Stephen Nash (21:30)
the

Gillian Leng (21:54)
because you can get a sense, can't you, that it's awful everywhere? But it obviously wasn't for this group. Now, as I said at the beginning, I can't tell you what the review is going to say. I certainly haven't written it yet. imagine, so this is a scenario. Imagine we look at all this evidence and imagine it shows that patients like and value your time. Imagine that there's

positive comments from those that have submitted evidence that we've got no evidence that there's a safety issue. Imagine we've got positive evidence base that will be published. That's going to help if that's what we get to repair your reputation. They'll be there in black and white in a report and the conclusions of the review, whatever they say, it will provide a definitive position for you.

to move forwards, you will have some security from a positive report.

Stephen Nash (23:02)
Okay, I think this is, I don't know whether we just covered this one, but I'm not sure whether it's gonna be in the remit of the review. I might just try and tweak it slightly, because it's got 39 votes. But the question is, if the government is to scrap the physician associate profession, are we going to get compensation for our fees or other pathways into medicine? I think that the general feeling here, Professor, is one that

If we, if this is a done deal, for example, with the sheer volume of some of the detractors, there's a lot of people here that are concerned that they've done everything that's been asked of them, but they're potentially going to be detrimental as a result. And will the review consider if it does find that there is no space for physician associates or anesthesia associates, how they, the people that actually answered that call are compensated?

Gillian Leng (24:02)
can't make any guarantee about compensation or fees. I can, again, if we're in that scenario, because I was just talking about a scenario where it's all rosy. And this is scenarios because I haven't written the review yet. But if it is the worst case scenario from your perspective, I feel strongly enough to indicate in a report like that, that there's a trained profession in the NHS.

and that we need to make use of that profession in the NHS, even if it doesn't continue, you know, it would be unhelpful to not either redeploy, retrain or, know, redundancy is clearly an option, that bearing in mind we need staff in the NHS would feel... ⁓

A waste. So I can make comments. I can make comments about, you know, retraining, but it's not it's not within my gift to make that happen.

Stephen Nash (25:15)
Okay. ⁓

I'm just looking at the list here. There's a couple that are quite similar. the next one, I guess, is the, and I think actually this leads off quite nicely from what we were just speaking about because I think over the last two years there has been kind of a lot of noise about the physician associate role. And so the next question is, is the review team aware of the BMA document which tells its member how to answer the PA survey and what action has been taken regarding this? I think that you could probably, there's a few more questions along that. ⁓

that vein as well. ⁓ You know, so it's clear that the BMA, RCP and RCGP have used poorly powered and misleading surveys, often with significant numbers of people who haven't worked with PAs to determine policy and guidelines. What action is the review taking to review these surveys, including methodology, validation and conclusions reached before basing in any analysis on them? I think without trying to flood you with questions, there's a few like that. And I think what people are looking for is

is really a sense of how, I was gonna say data validation, quality control, like we've had to put up with a lot of speculation from people who don't really know a lot about us and how is the review determining what to listen to or is it based on volume?

Gillian Leng (26:36)
It's not based on volume, so it's not going to be like a referendum. So the X number of people say this, 51 % say something or other and we're out of the EU. It's not that. However, you're right to flag up the issues in relation to surveys. I was made aware, I can't remember who alerted me to it, but the BMA document. And I have contacted the BMA.

And I can't undo anybody that's responded as they have in relation to this, but I have have alerted the BMA and they were going to follow it up. I don't know how that that's the best I can do, but the more the more relevant question is how am I going to handle the survey data from both the survey that the review put out and the others? And just just so you.

you know, you're aware, I really wanted this survey to be different, to focus on PAs and AAs and those people that worked with them. felt that would give me a clear perspective about how well things worked from that little group. It wasn't intended to be a blanket survey so that everyone in the NHS could tell me their views. I thought that that's going to be hearsay. It's got to be people who've worked with you.

And ideally, there would have been a clever way of sending it out just to those groups, perhaps through trusts. Tried that, it wasn't possible, unfortunately. Tried other routes to send it out. And in the end, it is what it is. You'll have seen it. And some people have said, why didn't you ask for identifiers? We considered that. We didn't go for identifiers because we were concerned that people might not reply because they felt that...

they could be identified. That leaves us with data that leaves us with ⁓ that leaves us with issues about potentially ⁓ potentially how do we interpret the feedback that we've had? So ⁓ we did. We have specifically asked, have you worked with a PA or an AA? Unless people have actively lied, we will know that we can exclude people who who don't.

work directly with you. And apart from that, there might be some technical ways that we can look at to see to see who these where people are coming from. Are there clusters that seem inappropriate? Easier said than done, but we will see if there are any technical ways. We'll also triangulate data will look for lots of duplications. I've seen the answers that the BMA group has encouraged everyone to take. There was. ⁓

different example but there was some data I was shown recently that said things like this group does well on safety, there was something else that was positive, so two positive metrics but then there was a lot of concern associated with it and it just didn't work. So you know there are ways of triangulating what you're seeing to try and work out whether people have been gaming. We will do our best and if

it's inevitable that the survey is going to have to come with caveats that any analysis is going to be included but with caveats around how valid it is. We'll also look at other surveys again, again ⁓ taking the potential bias into account. Not ideal. That's all I can say. I wish I had a magic wand but there isn't one.

Stephen Nash (30:26)
I think that goes back to that original question, doesn't it, if there are such entrenched positions from these organisations that you've got to land this with, where does that leave you? Because that's a very difficult place to be.

Gillian Leng (30:40)
as far as I understand it, that the BMA document that suggested how people should vote was not mandated centrally, if that makes any difference. Yes, it wasn't a centralized policy.

Stephen Nash (31:01)
⁓ I will move swiftly on. So ⁓ because that one I'm sure we could we could flog that particular dead horse for a while. ⁓ Will the Leng review include recommendations regarding the future workforce plans for physician associates which are expected to be released as part of NHS E DHSC annual report?

Gillian Leng (31:27)
As I said, when I was going through the plan, the recommendations in the review will feed into the government's workforce plans, which are not the same as the NHS England workforce plan that was published before. So expecting a new workforce plan, which is good. I'm not quite sure about this annual report that's referred to. I'm not sure what that means, but rest assured that the review will feed into future work plan.

Stephen Nash (31:57)
So I think there's two workforce plans. there not? ⁓ This is here, landing in between the two of them, is it? I can't remember. The review team discussed it recently about where this would feed into. So it's for Department of Health and Social Care one, but not necessarily for the other stakeholders. Is that right?

Gillian Leng (32:23)
I will have to get back to you on that. I don't remember the detail, afraid. I'm sure I should. If anybody in the team knows the answer and wants to add it in somewhere.

Stephen Nash (32:34)
Just from the Department of Health, there are two annual reports, the DHS, the annual report and the NHS England annual report. They don't typically comment on workforce numbers. They are just sort of like any organization, annual reports with accounts, etc. And there are two reports that are planned to be published this year, the 10 year plan for health, which is sort of sets the vision for the health system. And then the long term workforce plan, which you could consider as one of the enablers or delivery mechanisms for that 10 year health plan.

We will feed into both of those, but obviously the main part, the main thing that is most relevant to this review or the other way around, the thing that's most relevant to the long term workforce plan is this review. So we will feed into that long term workforce plan and any recommendations will be considered. It's obviously up to ministers whether to fully adopt or not to Jill's recommendations, but they will be fed into the long term workforce plan. That is a long term workforce plan refresh which will replace the long term workforce plan published by NHS England in 2023.

Excellent. Next question then Professor. Will the review consider, I just want to check, I just want to read this one before I read it out loud if that's alright.

Gillian Leng (33:36)
Thanks. ⁓

Stephen Nash (33:50)
Okay, so will the review consider that other non-doctor roles such as ⁓ ACPs are not being restricted and are equally qualified? Would the review consider their model of deployment in the NHS as a solution to PAs, for example, speciality specific credentialing pathways to ensure patient safety and standards whilst allowing local scope?

Gillian Leng (34:13)
Yes, I was reading that question while also listening to Lily. Is this a question mostly about how PAs are able to develop their careers? Is that the credentialing part? So to build a portfolio, to build a scope of practice, is that what that's referring to?

Stephen Nash (34:34)
I think there's two elements to this question. There seems to be an element, you know, first of all, why are physician associates being focused on when there are other ⁓ professions out there working at a similar level? ⁓ And then equally, I think it's comparing the way in which ⁓ there is kind of a post qualification development programme for ACPs to be able to gain advanced knowledge in a given speciality.

So I think they've put here, for example, speciality specific credentialing pathways and thereby, know, scope is an interesting debate at the moment, isn't it, and how it's formed. But the idea that scope for every other professional is individualized with a base scope of practice at the point of qualification. If we're going to continue as PAs, is that post

qualification scope and credentialing in a speciality, something that will solve some of the questions about post-qualification training and scope.

Gillian Leng (35:41)
Thank you. So, yeah, yeah, yeah. So, just a brief reflection on why do we think PAs particularly are being focused on and not some of these other ACP roles. And I think it's because partly, I mean, there's a number of reasons, but I think it's partly because other professions have started out more separately.

Stephen Nash (35:42)
Yeah, worthy,

Gillian Leng (36:09)
and have grown and evolved to be doing some of the things that doctors traditionally do. Whereas I would say physician associates were always designed to be there to do the roles, some of the roles that doctors do and therefore to be a help and support. And I think it's that that means that there has been challenge from within the medical profession where they see some of their

They see competition sometimes, I think it's fair to say. I think that's what it stems from. And I think that's probably why there's resistance to further development, why there's resistance to a wider scope of practice, because then the sense is, your roles are growing more and more into those that are similar to the doctor role, the traditional doctor role.

I think it would be very odd to move forwards with a professional group such as the PA with no opportunity to develop. I mean, that's not how professional jobs are constructed. It's not how any type of job is constructed. You have to grow and develop. I think, you know, and that's not me speaking is me. That's me reading, you know, reading the evidence, reading around. It's just a fact that that's how other roles.

work on this, the credentialing is clearly a mechanism to ensure that. And it's interesting that in the US, you probably know this, but in the US where the roles began, they are now, they're now having a pathway specifically from PA to MD with a dedicated route to do that. And I don't know whether, whether there's a, yeah.

whether there will ever be any enthusiasm to have that here. But at the moment, I think if you wanted to study medicine, you'd need to go into...

to the beginning?

Stephen Nash (38:11)
Yeah,

so there's no crossover course at the moment. you know, a physician associate stays a physician associate and then they gain their proficiencies in their specialities. And then if they want to go into medical training, they go back to being medical, you know, undergrad or post-grad training and then they would go in as an F1.

Gillian Leng (38:37)
Okay, well thank you. We should move on, shall we, to the next one?

Stephen Nash (38:41)
Yeah, just reloading my screen. So I saw this one come up earlier. I think it's going to quite difficult for you to answer because it's a piece of string question. Will PAs job market reopen to them in both primary and secondary care across the UK? Because currently there are no jobs despite my years of experience. I cannot find one. I have a family to support and it's had a massive impact both on my finances and mental health. I think this is probably indicative of actually the hundreds of PAs that have

you know, we've got a thousand plus graduates right now who haven't been able to get a job post-qualification because of the campaign. And then on top of that, we've got the people that were made redundant. And ironically, most of the people that have been made redundant had years and years of practice and precedence. Very few were new PAs. And so you've got some of the finest now out of work that can't actually retain or regain employment. And I think that's why

you're going to get these questions here is because people want to know that they can hang their hat on on waiting a little while to wait for the review to publish.

Gillian Leng (39:45)
I I really feel for everyone in this position, it must be ghastly. And I feel a huge responsibility because as you say, people are waiting for the review. So I think that the job market will reopen if I come out with some positive recommendations. But I think people are cautious at the moment about recruiting in case I don't. So I do need to get on with this. It goes back to the point I made earlier about being

being in limbo, being in a state of uncertainty is difficult at the best times. But when there are no jobs around, it's awful. I it really is awful. And although I said we've got to do June because of the workforce plan, I've got to do June because there are not a June or as soon as possible because there are people and people's lives on hold and it really matters.

Stephen Nash (40:38)
So originally, I think we talked about preliminary results in one of the updates. I haven't seen that mentioned recently and I don't want to add any additional pressure after what you've just said, but is there likely to be preliminary results at any stage that would start to show a direction so that employers could have a bit of faith if it was going in a positive direction?

Gillian Leng (41:03)
can't say definitely. I've been thinking about it and whether it's sensible to do that or not. So there's an option, you know, get everything nicely written up, everything justifiable, polish it all off and publish it. Or there's an option to ⁓ have ⁓ the early considerations, early findings without a fully polished background material.

and I will need to take wise counsel on that and talk to people in the department who are in government as to whether that would be helpful.

Stephen Nash (41:42)
I mean, certainly from a trade union perspective, if it was looking positive, preliminary results would probably help me in my job role, but I'm not going to use that to put any pressure on you regarding that one. That's fine. Thank you very much. I just want to refresh.

⁓ So has the impact on PA's mental health and wellbeing been considered in the review? The user goes on to say this is destroying our lives when all we've done is try our best to be the best clinician we can be.

Gillian Leng (42:17)
Yeah, and you know, be absolutely assured that a lot of people say very good things about how committed and dedicated as a group you are. And I know you probably hear the bad things, but there is also a strong voice in support. In relation to impact on your mental health, it's not part of the review because I'm looking at safety and effectiveness, but as I've

hopefully indicated I am aware of the impact that it's having on you and hopefully everybody is getting support locally if needed and the trusts and or wherever you happen to be working or offering support.

Stephen Nash (43:03)
Okay.

think we may have covered this slightly before Professor but is the review looking at the governance of other non-doctor professions so that PAs are not subject to unfair restrictions or regulations which are not expected of other non-doctor professions?

Gillian Leng (43:25)
in the comments. ⁓

Yes, in part, but not in a huge amount of detail because it kind of goes beyond the scope, but certainly looking at regulation where it's relevant across the board.

Stephen Nash (43:44)
Okay, well was a nice quick one for the second. Yeah, I know, right?

Gillian Leng (43:46)
That was not

And I noticed the questions we're getting down to are not so popular are they compared to the beginning ones where we had lots of votes.

Stephen Nash (43:56)
Yeah, there was a few that disappeared there, I wasn't sure where they'd gone. So regarding safety data, what comparative data will be used? My concern is that the nature of health care is that there is always risk of adverse events and outcomes. There's been an intense effort from some to reveal any adverse patient outcomes associated with PAs. Will there be an analysis of safety data of other roles such as resident doctors or ACPs, for example, to compare?

if not why and how can you compare safety of PAs if you don't analyze safety events associated with other roles? And I think so just to sort of caveat this a little bit is that I think there's a fear of using anecdote to drive fear for our profession and we've seen significant efforts and recycling of certain tragedies for that and I think that's where this is generating from is trying to find an evidence base

with which to be able to actually look at something and see whether it's safe as opposed to just because there was a binary incident that occurred. It does that write us all off. And I think that's where the fear comes from here.

Gillian Leng (45:10)
Yeah, and I get that. So we're looking at as much safety data as we can. much of the published research has included safety within the considerations. again, none of this is an exact science, but safety has been considered in the published research. In an ideal world, I'd probably want to have a comparison that was a team, a multidisciplinary team with PAs.

with a multidisciplinary team without PAs. It's really hard to do this on a profession by profession basis. Healthcare is all about working in a team and it's sometimes, you know, clearly one individual's fault, but more often than not, it's all part of the system. It's a system failure and that's something I've discovered when trying to get hold of patient safety data is that

that it's not easy to get it by individual because the reporting is designed not to do that, not to target people. And I know what you're referring to in relation to high profile cases, but you read into those and you can see that all of them have multi-professional input to them. It's not just one person and having worked as a clinician myself, having been a patient, everybody makes mistakes, don't they? Everybody makes mistakes.

So again, all I can do is look at the data that we've got, take into account the bias that is there, and to draw whatever valid conclusions I can or I can't. I think having a whole set of different types of information will give a reasonable picture. It's not perfect, but that is why I'm.

drawing on lots of different sources rather than writing it's just our survey or whatever because none of this is perfect. yeah, to answer specifically that I'm not doing a one-on-one comparison because much of this is about working in teams.

Stephen Nash (47:26)
Yeah, no, think that's fairly answered. The next one is more of a statement actually. So clear career progressions would be helpful, for example, with extra training, considerations around pay bands and being able to prescribe in the future, teaching, etc. I think this goes into the fact that, you know, over the last five years, there's very much been a ⁓ stall in how PAs progress post-qualification.

And will your review cast any sort of comment or light on potential ways for PA's to progress within the profession?

Gillian Leng (48:06)
was flagged early on as one of the themes. If you remember that lovely slide that built up, there was a theme there about progression or not because that matters. I think I said before, didn't I? I can't think of another healthcare profession that can't progress. I do think that as healthcare evolves, and I thought about this a lot after 20 years at NICE, I've seen so many new technologies.

being rolled out across the system that all professionals need to evolve and probably more than we ever imagined. So I shall stop waffling and just say yes to that.

Stephen Nash (48:53)
think this is we're gonna end up going backwards slightly here because following the review if parties do not agree with the outcome will there be any consequences for those who disagree and who continue to bully, belittle and harass PAs in particularly online?

Gillian Leng (49:11)
Well, the first bit about parties do not agree with the outcome. That goes back to my point about working with the stakeholders as I go along about sharing information as I go along. I'm keen to share the data part that ⁓ is being collected with all stakeholders because that's not the same as giving advanced warning of the recommendations, but I think everybody needs to see the data and I need to talk about the limitations of that data.

So let's land this as well as we can. I think we need to all agree to move forwards whatever the review concludes. And bullying, belittling, harassing, know, that should be completely unacceptable. Anyway, it should be unacceptable now, let alone in the future. I know there are various bullying and harassment policies across the NHS. If you can use those then.

then do, it's not acceptable.

Stephen Nash (50:13)
So there's this interesting ⁓ one come through here. ⁓ So having worked both in the UK and the United States, the PA role is better understood by the general public in the States as the role continues to grow as internationally, will the review look to suggest ways we can educate the general public about the PA role and the work that we do? I think that's really important actually, because I think just on my own spin on that comment is that actually

I can't remember the last time there was a significant public campaign to increase awareness of the multitude of roles that you're now likely to see in a healthcare environment. I think PAs have suffered as a result of that. And so I'd be interested to know myself whether the review is going to suggest, you know, some PR for PAs and AAs going forward.

Gillian Leng (51:00)
I think we're supposed to have in this country, we're supposed to have more different roles in healthcare than anywhere else. I went to one of the trust visits I went to with the team, we arrived at the reception desk and they were having some event and laid out across the desk with name badges and I just thought there were so many different roles here. I'm not surprised, people are confused. I I'm going to turn this back on you Stephen, because I'm doing too much answering. What do you think?

your patients feel about the Name Physician Associates. Do you think it works?

Stephen Nash (51:31)
I I think from, I'm going to be quite candid actually. So when we did our research that we submitted ⁓ to you, we did try and collect some patient data and the general feel of it was that the priority for the patient was, can I be seen in a timely manner? Does the person seeing me have my best interests at heart?

Are they able to provide the care I require? And if they don't, do they know where to send me? And I think the argument about physician associate, physician assistant, I think has become weaponized as a lot of language in this debate has. But I still think and I still feel from the perspective of the patient that what they care about is less what we're called and more than knowing what we can do. And I think if you, there's a question about uniform as well.

know, should we standardise the uniform of physician associates across the NHS? And I mean, good luck with that, because I don't think there's many standardised uniforms across the NHS that patients recognise. if you do that, if you change the name, you've got to start the education process all over again for physician associates and patients. So first of all, what are you going to change our names to? There's a comment about changing it to physician assistants, and that seems to be more of a derogatory thing than a

than a genuine, you let's try and name them differently thing. And I think if we're if we're saying, well, OK, let's change the name now. We've now got to reeducate them that physician associates no longer exist. We've then got to explain to them what what the new terminology is. We've then got to hope that whatever campaign that we run for the next 20 years about the name change sticks better than the original campaign that we used for physician associates.

And then we've also got to hope that it doesn't trigger anyone's feelings, you know, with regards to that they didn't like our names, that there's another campaign in a few years time. And so I don't know, I feel I feel like physician associates are probably more recognised now than they've ever been, grossly because if we've had a very effective smear campaign, so people understand that the role is there, we should probably use the momentum off the back of that to actually clearly educate people, you know, what we now do. And, you know, are we safe and effective? What can we provide?

here's what we do and where we come from. And I would say actually to keep the name the same, I think PA should have some pride in the name now after what we've been through. I do see it as a detriment to a certain degree. don't think I've seen any data that substantiates physician associates confusing. So my thought process on this is that we use the momentum we've got to actually make sure that people know.

who we are now going forward and we have a good campaign off the back of it that educates patients and the wider professions. There's still people that don't understand what physician associates do.

Gillian Leng (54:30)
Yeah, that's good answer. Hold on. I think that probably the best people to educate the public are you guys talking to them. ⁓ There's two parts to the name, aren't there? And I've heard both bits commented on. It tends to be either associate or assistant. There's not much flexibility there. Physician is

Stephen Nash (54:33)
Rehearse that one in front of the mirror.

Gillian Leng (55:00)
I think the legacy of coming from the United States because they talk more regularly about a physician. don't really, well, these patients don't talk about physicians unless they're particular type of patient. Mostly it's the doctor. And in some countries there are doctors assistants, doctors associates, medical associates. There are different ways of that first name, but you've made the point about change is never good.

At the beginning of going out doing visits, asked people, I asked PAs, how did they introduce themselves? And it was usually a variant of, you know, I'll say I'm a physician's associate, I'm part of the medical team, and I'm not a doctor. All clear. But the two problems could then they would often say, so I will say that I'm really clear I'm not a doctor and then the patient will go and say, thank you, doctor, at the end of the consultation, which is not your fault, but that's

That's just what happens. But what does worry you about that intro is ⁓ it doesn't have a snappy way of describing what you do do. So saying I'm not a doctor sort of.

Stephen Nash (56:13)
Yeah, I mean, one of the few professions that currently the guidance suggests that we have to give a list of what we're not rather than what we are and what we do do. And I think this comes with the weaponization of language through this campaign that we've had run against us as well, is that, OK, how do you now describe the role when you can't? What words can you use? Words can't you use? know, there was a question, know, GMC said, well, we're a medical professional. So.

Do we do we say that? Hello, my name is Stephen Nash. I'm a physician associate. I'm a type of medical professional. Well, you know, apparently that may be confusing. So then you go, OK, well, do we do it the way that you described that I'm not a doctor, I'm not a nurse, I'm not an ACP, I'm not a physio, I'm not, you know, the list goes on. And I think I think some of this is a symptom of where we're at with the campaign as opposed to necessarily being a genuine. ⁓

a really genuine issue and I think yes, whether if there has been ⁓ patients that have been confused because someone has said they're a doctor, I think that's actually a GMCable offence. Like if people are doing that, don't hold, especially with what's going on at the moment, I don't hold much tolerance for that sort of behaviour, but is the gross majority of physician associates going around and deliberately misleading people, I don't buy it.

Gillian Leng (57:34)
Listen Stephen, we've got three minutes left. Do want to find me one more question? Okay. ⁓

Stephen Nash (57:37)
Well, we made

So one here asking about whether you've compared with physician associates from USA, New Zealand, Netherlands and Germany.

Gillian Leng (57:50)
Well, the literature review that we commissioned has drawn on international data and there's some quite helpful tables looking at what's been published from around the world. And I certainly want to have some conversations with people from those more comparative healthcare settings as well. think that that will be valuable, but I'm building that in towards the end.

Stephen Nash (58:19)
So will there be something put into place to prevent further harmful publications like the guidelines posted by the BMA or the RCGP? Will there be any sanctions for those involved in publishing harmful documents or articles already?

Gillian Leng (58:35)
don't think there's anything that we can put in place. I'm more working on, as I said earlier, the positive reception to what I say so that it's logical that people can see all the data, that it makes sense, the areas that I've considered and the recommendations. And I really, really hope that we can do a good job of that and move things forward. ⁓ yeah, sanctions, I'm not sure.

I certainly can't make that happen, I'm afraid.

Stephen Nash (59:08)
Do you want one more?

Gillian Leng (59:10)
⁓ Yeah, one more, one more. ⁓ Now answering them so quickly.

Stephen Nash (59:14)
I know. So the GMC Power Map and the FPA curriculum outline the expectations of a newly qualified PA. Of the 300 or so professions within the NHS, only the dental sector has a defined scope of practice that clearly sets out what that group can and cannot do. Ironically, they're also taking, doing a survey currently to see whether they changed that because they found it was detrimental. I've just added that bit in. But however, Universal SOP fails to take into account individual training.

experience post-qualification development and specific skill sets. If a scope of practice were to be introduced, would you agree that it should not only be tailored to the individual specialities, but also take into consideration years of practice and any additional training undertaken?

Gillian Leng (59:58)
That's a long, that's a more complicated question, isn't it, for...

Stephen Nash (1:00:02)
Yep, one minute, no push.

Gillian Leng (1:00:03)
For one minute and I've got to thank everyone. So I will thank the person for that question and I will agree that it's really complicated and you can't just say here's the scope of practice off you go and that's why some will argue that actually you can't have a national scope of practice at all. You can have an initial scope of practice but because people then develop specific skill sets it becomes something that should be set locally. So I get all those points. ⁓

And I'm going to stop there, but thank you so much, Stephen, for reading out the questions and for answering some of it too. And thanks to the team for supporting the webinar. And thank you to everyone who's engaged and added questions and done lots of voting. It's been really helpful. And I'm sorry we haven't quite got through everything, but we will take those points away. And it's been great to engage with you all. And I will do this work as speedily as I can.

Thank you. Good night, everyone.

Stephen Nash (1:01:03)
Thank you very much.