Leng Review Webinar - Healthcare Professionals

Gillian Leng (00:49)
afternoon everyone. It's just gone 1 p.m. so I thought I should make a start welcome. It's April the 1st, it's April Fool's Day, I have to say I have got no hidden false facts, I haven't been that imaginative so all that you hear is the truth and nothing but. If we could have the next slide please.

This is to outline what the webinar is going to cover. I am Gillian Leng. I am the lead for this review into the role of Physician Associates and Anesthesia Associates. My background is in medicine. I specialised in public health and ⁓ worked at NICE for 20 years. So a lot of experience of carrying out reviews of controversial topics, which I hope stands me in good stead for this review. I'm here with

⁓ co-host, Jeanette Dixon, who's kindly agreed to join me. Jeanette, would you like to say hello?

Chair AoMRC (01:54)
Hello, I'm Jeanette Dix and I'm currently chair of the Academy of Medical Royal Colleges, which is the membership organization for all of the faculties and medical royal colleges across all four nations. I'm the immediate past president of the College of Radiologists and I happen to be a clinical oncologist and I am part of the external stakeholder advisory group on the Leng Review. Hi.

Gillian Leng (02:20)
Thanks, Jeanette. Jeanette's going to turn her camera off, but I hope she'll still be there at the end of the presentation, because what I'm going to do is give a brief overview of the review, the process we're taking, and the timeline. But I don't want to spend too long doing that, because key for me is to give you the opportunity to make some comments and to ask any questions. So we'll allow plenty of time for that. Also in the background are some of the team.

from the Department of Health and Social Care who are supporting this review and they're in the background to help and hopefully there won't be any technical issues, but I'll turn to them should there be. So next slide please.

In terms of asking questions, please feel free to ask whatever's on your mind and you are able to ask questions anonymously if you prefer. And do use the Q &A function. I don't think the chat function's enabled and we'd like you to use the Q &A. And if you want to, instead of asking your own question, or indeed as well as asking your own question, you can up vote other people's questions and that will help.

Jeanette, prioritise which ones to ask me. We're going to strictly go with that priority order. We're not going to cherry pick. So you might want to choose a similar question rather than ask your own if that's easier. So the voting function is the arrow. There's a thumbs up sign, which means you can like it. The like function won't help prioritise. It doesn't do that. You're very welcome to like questions as well as vote for them.

But please be aware that it sometimes seems to expose your name if you like the question. So be aware of that if you prefer to be anonymous. So remember Q &A and ⁓ the arrow to vote for. Because not everyone is going to be able to attend today's webinar, we are going to record it and we'll share it with colleagues afterwards.

note that if you're asking any particular questions and obviously don't include any personal, private or privileged information in your questions because we won't be able to read those out or indeed any with inappropriate language but everything else very happy to do my best to answer. If I can't then we'll come back to you with a with better answer when we've done some investigation. So the next slide please. This is an overview of

of the key questions that the review is covering. And the main question is about safety and effectiveness. This is what I was asked to look at. Are the roles of physician associate and anesthesia associate safe and effective as members of a multidisciplinary team across all tasks, roles and settings? And it's clear that the issues around AAs and PAs are separate. I've had a lot of feedback in relation to that.

So although it's one review and there'll be one report, those two groups will be separated in the way that I look at them. The line in the middle is there to indicate that there is a genuine spectrum. It might be that there are some things or indeed, you know, it might be that some roles should never continue or parts of that role should never continue.

or the other end of the spectrum, might be that parts of the role or the whole role should be expanded, or in the middle, are there going to be some modifications required to improve safety effectiveness? So I'm very much keeping an open mind. We are in the middle of looking at all the data and evidence that we've been submitted. And then at that point, we'll be able to see where on that spectrum the answer should lie.

In terms of a progress update, we've kicked off a number of areas of inquiry. And if I could have the next slide, please. So these are some of the things that we've put in place. A call for evidence, and we had 87 responses to that call for evidence. That's responses from individuals or institutions. Within that, there's a lot of information. So one response might include.

a whole spectrum of information reports, data, audit information. We are going through that, screening it, screening it in terms of relevance, categorisation and quality. And it might be that not all of those responses make that quality cut, but we will look at everything that we've been sent.

We had a survey that was open for about four weeks. It has now closed. We've had over 8,000 responses. So we'll look carefully at those. I know some people have been concerned that there might be some gaming going on and we will do our best to assess as technically as we can whether it looks like there are duplicate responses. But it's sadly inevitable when you have an open survey that it isn't always as valid as you'd like it to be.

But rest assured that the survey isn't, as you'll see from this slide, the only piece of information that we are looking at. The survey was specifically targeted at PAs and AAs and those who work with them. It wasn't intended to be a broad brush survey, but ⁓ we have had quite a lot of responses and we'll see what we get. Webinars launched.

This is the second webinar and I've got another slide on webinars in a moment to give a bit more detail, but the point of these webinars is to do some wider engagement. Although I've done a number of visits as the lovely purple line says, although I've been out and visited acute trusts and although I visited some primary care centres, I can't visit everybody face to face. I thought these webinars would be a helpful addition to get a wider set of perspectives.

We've also commissioned a systematic review from some colleagues at King's College who've drawn together all the evidence both nationally and internationally. ⁓ Others have also done systematic reviews in these areas and we're looking at those as part of our overview. Some of you will have seen in the BMJ the review recently conducted by Trish Greenhoudge which is very helpful and thorough.

That's not a review we specifically commissioned, but of course it will inform the findings and the conclusions of the review. One other thing not on this slide, but we are also interested in the patient perspective. And we've commissioned a couple of externally led focus groups to give us some views from patients that have had experience of PAs.

Next slide please. Next slide builds in a rather complicated fashion, but it's designed to show, I hope, how all of this fits together. So this is all the bits of data that I've just referred to. Research data, data that we might have received from trusts and primary care, the survey. We're going to put all of that together as best we can and analyse it in the form that's about to appear, I hope. A little table.

So we're going to analyse that separately for AAs and PAs and the physician associates, definitely by primary and secondary care. If we've got enough data to split the settings in secondary care, then we will, but we may not be able to do that. Clearly we want to look at safety and effectiveness because those were key to the review question, but I also want to add in the patient perspective where we can, cost and cost effectiveness where we can and look at

differences in education and training. So that's the data bit. As I've mentioned, I'm also keen to gather softer feedback from talking to people, listening to people and having these webinars. And all of that intelligence will then help us, will help me identify what the key themes are. The table that's now appeared is something

that reflects what I heard at the very beginning of this review. heard that themes around education and training were key, that day-to-day working, things like supervision, oversight, scope of practice, staff ratios for the AAs, all those sorts of things, and regulation and governance were important. That's what I heard at the start. However, it will, of course, be refined and updated as required in the light of all the feedback and the data.

That will hopefully get me closer to an answer, but I'm reserving some space at the end of this process to ask some experts some key questions at the end, running it probably a bit like a select committee inquiry with a two or three experts coming along. And I think there's another little bit just to finish this off. Key questions for discussion with expert panels and then developing recommendations in the light of all this evidence and the timeline.

The timeline for this is June, hopefully the beginning of June. And it's really important that these recommendations are done in time to feed into the wider review of NHS workforce, because there's no point doing that in isolation from everything else. So that's how it will all fit together. And the next slide, please. In relation to today and how we're going to use this input, I've partly described that.

But as I said, we're holding a number of webinars. I did one last week with the anesthesia associates and also this week I've got another one with apart from this one with resident doctors and with the group of physician associates. I've agreed to add a fifth one which you don't see on this slide, which is with anesthetists.

They were particularly keen because of the focus on AA's to have a dedicated session with me. So I will somehow manage to find the time to fit that in too. I don't know if there's any anesthetists in this group, but just so you're aware, that will happen as well. I mentioned the focus group with patients. So we are using these sessions as I've indicated to hear your views, to understand your views about how PAs and AA roles work.

And hopefully you'll go away feeling a bit better informed about how the review is working. But the key thing is to hear your questions and we will review all the questions raised. If this is anything like the last one that I did, we won't have time to answer everything, but we will record them and take those questions away. That emphasizes, again, the importance of up voting so that we do prioritize today.

the questions that we answer with everyone in the virtual room. So my next slide, please. These are some areas where you might want to ask questions, but you don't have to stick to these. For instance, you might want to consider whether there are any areas where you think PAs or AAs can add value for the future.

Do you think there are any changes to the roles? Do you have any views on patient safety? How might medical leaders support the implementation of the review findings? Because there is no point going through all of this process if we don't manage to draw a line under what's happened and move forwards with some consensus, whatever the review concludes. And I emphasize again, I'm very much keeping an open mind. Is there a...

anything that you can give me in relation to the PA and AA roles and resident doctor interactions because that is where I see quite a lot of the tension and any thoughts on a national scope of practice being helpful or not. And there's a little figure on the right of this slide, little white person on a tightrope and I put that there to illustrate how it feels for me because there are lots, well, there are some different perspectives

in relation to the issues and I have to be very careful not to side with any particular perspectives because I really do need to stay on that tightrope and listen to everybody's views. As I go further through the process, obviously my thoughts and ideas become clearer. You might think I'm being cagey in some of my answers, but I don't want to give any sense of what I might conclude.

Now I don't want to set inappropriate hairs running because we haven't got to the end of the process. So I will play to mix metaphors, tight ropes. I will play this with a straight bat. So I think I think that's where we're going to conclude, isn't it? Before we turn to questions. So if you could take the slides down and hopefully Jeanette will magically reappear. And we have some questions on the screen.

Chair AoMRC (16:15)
So the first one, Jill, is I'm a consultant supervising a PA. Will you weight my experience more than the experiences of those who haven't worked with PAs?

Gillian Leng (16:28)
So that's a great question. And the answer is it depends. It depends on the question. If I want a view from a consultant about how it is working with a PA, then absolutely I will wait your experience more. But if I've got a general question, which is about how do health care teams work together, how do medical staff work in general, then I'm delighted to get a broad.

sense of a broad response to that question. So it does depend what I'm asking for and takes me back to the survey that I mentioned because there I was wanting to get that perspective of people that are working with PAs and AAs, but there is a context where broader views are helpful too.

Chair AoMRC (17:14)
The next question is quite a long one, but essentially it's about substitution ⁓ and substitution about cost effectiveness from Luella at Barks. So it's about, it's being argued that people with a two year degree can safely substitute for doctors who have a minimum of six years of education and six years, six to 12 years to become a specialist. How can this be considered safe?

Gillian Leng (17:41)
Right, I'm also trying to read the long question while you were speaking. I haven't been asked specifically to look at that question around PA substituting for doctors. If you remember, the question was about safety and efficacy of the roles within the wider team. So I'm going to look at that data and answer based on that in terms of how do PAs and AAs fit

into the wider team. ⁓ I absolutely get the question that you're asking and there are issues around who is in which role and what training they've had and are they safe. So I will look at that in terms of the broader context and I am intending to make some comments about the wider context even where I'm not. ⁓

not been specifically asked to look at it. So the specific question, safety and efficacy, but it's all about the wider context and the wider environment, particularly about medical teams.

Chair AoMRC (18:49)
Okay, the next one is how have you touched on it a bit, but how has the review ensured that individuals do not submit multiple responses to the survey as there was no requirement to provide an identifier?

Gillian Leng (19:01)
Yeah, that's a really good question. We did discuss in quite a lot of detail whether we should have some sort of identifier to the survey. The downside of doing that was that we thought some people would be put off, that they'd be worried about not being anonymous. They'd be worried about being identified. We looked at whether there was a way of

forwarding the survey perhaps through trusts, perhaps directly to people so that we could do as I described, which was get a response about individual PAs and AAs and the people working with them so that we'd look at that locus. That also wasn't practical. It was a bit of a shame that it wasn't. So we have very carefully asked in the survey about, you know, who are you? What's your relationship to a PA and an AA?

And we will do our best to use technical solutions, to use AI if that can help, to help us look for people that might have given us ⁓ duplicate responses. I mentioned gaming that I know has been going on. And if people are responding and saying, actually, we don't work with an AA or a PA, then for this particular survey, those responses will not be included because I did want the group.

we're working together.

Chair AoMRC (20:32)
Okay, we've got a couple of questions from an ETH-Citizt and I'll leave you whether you, as they're here, you know, you've got one coming up that says, there's one about, I regularly work with AA's and I always pick up errors. How can we make sure that we guarantee patient safety? The other one is, will you wait my AA experience more than the PA? So you've probably answered that one, but I think it's a bit about the patient safety.

Gillian Leng (21:03)
I'm keen to hear more from anesthetists. There is very little in the literature, there's very little data about the role of AAs and how safe and effective they are. I said at the beginning that there's not a huge amount of literature around PAs, but there's an awful lot more than there is around AAs. And of course we've...

got a small number working at the moment in the NHS. I think it's only about 200, so perhaps that's why there isn't much data.

takes me back to the fact that I want to have a separate webinar with an e-satist because I'm keen to try and explore this issue a little more because some people will give me very positive responses about AA's that they work very effectively, they've never picked up any errors and that's not the same as what you've written here. So I'd like to delve into it a bit more, see what...

actually there might be in terms of solutions, in terms of opportunities to monitor and supervise more closely moving forwards, assuming that we think that the role should continue. So I'm going to leave it there and encourage you and colleagues to come to that final webinar.

Chair AoMRC (22:21)
Thanks Jill. The next question I think is quite, ⁓ covers a sort of broad brush of, it's how will you approach the work that's already been completed by the stakeholders if a Royal College has developed a scope of practice and consulted on it, will the review support this?

Gillian Leng (22:40)
first thing to say is I think the colleges have done a whole load of really useful work over the past few years and I'm absolutely drawing on all of that. I'm looking at all the things that the colleges have done. I've set up a stakeholder group where there wasn't enough space around the table to invite all the Royal Colleges, but ⁓ engaging with all of them and we'll be looking at that work. I can't give you, this is a bit about me being

I can't say definitively at this point whether I'm going to support all the scopes of practice that have been developed by the Royal Colleges. There are quite a few. I've got a lovely slide which I didn't show you today with all the various scopes of practice. There are quite a lot. Some cover primary care, some cover secondary care, some cover both. For the PA role, it's a bit more straightforward for AAs because there's the College of Anecdotes and the work that they've done. But I'll need to take...

⁓ take a view on that and conclude in the final review.

Chair AoMRC (23:43)
Okay, the next question I've got is a bit ⁓ about how PAs identify themselves and how do we make that much more obvious to the public and to other members of the healthcare team who don't understand what the roles are.

Gillian Leng (24:02)
And that's something that has come across quite clearly from the relatives of people that have been involved in deaths ⁓ related to the role of PA, the identification of the role. And it was very clearly in the scope of this review at the start because it...

It is something that we don't want to cause confusion. So I have said that we will look both at the name and at the identification that might be wider than just a name. It's the clothes that you wear, it's the way that you present yourself and the words that you say. If anybody listening to this has any suggestions, please add them to the Q &A and we'll be interested to get any votes.

Now, of course, the name of physician associate is set in legislation. It's not going to be straightforward to change it, but people do seem to feel quite strongly about it. So as I say, if you have any thoughts, then let me know. I know some countries use terms like medical assistance, clinical assistance, doctor's assistance. And of course, we used the phrase, didn't we? Physician assistance prior to the most recent change.

However, the physician can be confusing in the UK because perhaps in medical circles we use the word, but patients don't in the UK. They don't talk about going to see their physician by and large. So I think there is something about a name. So suggestions welcome.

Chair AoMRC (25:55)
Okay, the next one I've kind of lumped a few together that are very themed closely. The next one is can you extend the survey deadline as a number of doctors working with PAs were not aware of the deadline and are very keen to contribute. ⁓ Somebody said the news about NHS England was what distracted them.

Gillian Leng (26:16)
I can't give a definitive answer because I can't see the faces of the team to know if they're going to say it's possible or not. It will depend on the timing of how much we have to do in relation to getting this done by June, but it's fair point. And I understand why you're asking. And we will if we can. A cagey answer, isn't it?

Chair AoMRC (26:39)
It's an answer. mean, I think there's a bit about. Again, there's a bit about misinterpreting, especially for women, because women traditionally get mistaken for other groups, but there's also a bit about from Scarlet. There's a bit about administrative tasks and you know. How do you to reduce the overload of work onto doctors? Will your review identify which tasks could be under undertaken? Well, they are now registered practitioners, but it's.

Scarlett's talked about other non-registered practitioners such as doctors assistants or scribes.

Gillian Leng (27:19)
We're going to look at some of the roles undertaken ⁓ as appropriate as part of looking at scope of practice because ⁓ it's obviously the area that people are most exercised by the scope of practice. I heard that loud and clear at the start. And within that, I think it's concern from some doctors that this is

That the role is fine, but their scope creep and. Probably what I hear most about a concerns that there's no sense of a ceiling of practice and that it might. You know these roles might extend and become effectively a doctor and some some people feel feel that that the roles can and should. If you look at what's happening in the US, then they have recently extended. They have a program that is.

PA to MD, but it's a specific programme, specific direction of travel and ⁓ looking at what future training and development might be for PAs is within the scope as is looking at the types of work that they carry out.

Chair AoMRC (28:33)
There's a quick one which says what body of knowledge or practice do PAs bring that is not already provided by an existing staff group.

Gillian Leng (28:48)
Yeah, and I get why that question is being asked. These people are trained in the medical model. They are trained to take histories, to create management plans, to carry out tasks and procedures with additional training. Part of doing that, of course, is to provide a flexible workforce to support doctors.

That's the intention of the role. What we're doing in the review is looking at whether that is how they are being used in practice, whether it's appropriate or not. So any views that people want to add to the Q &A about how they feel these roles are working, whether they find them useful if you're a consultant, be helpful to get your views as well as questions in this Q &A.

Chair AoMRC (29:42)
There's quite a lot of comments, which is good news, Jill. You're getting a lot of comments I'm seeing as I'm going through. There's a class, there's one which you could talk about the methodology. Everyone makes mistakes. How do you ensure you judge AAs or PAs by a similar standard to other healthcare workers with respect to making errors?

Gillian Leng (30:05)
Yes, that's a very good question. That's a very good question. And I feel that I am doing quite a deep dive into all the data and all the evidence that there is around AAs and PAs. Lots of people, organisations have been trawling through stuff to show me the data. I haven't been doing a comparative trawl of all the other professions and all the other rates of errors.

didn't have time to do that. Where I can, where we've got published research that has drawn that comparison, I'm particularly keen to look at comparisons of teams, because that was what the question was about, workforce teams with and without PAs and AAs in them. But you're absolutely right, everyone makes mistakes, and I'm sure everyone on this webinar has made a mistake, and sometimes they're serious and sometimes they're not.

The untangling bit is interesting, which is the bit about PAs and AAs working under supervision and where the fault lies, where things do go wrong, because that is often not collected. In terms of safety, I have Henrietta Hughes, who you will probably know is the lead role around patient safety. I've talked to her about the data that we might collect. And in many instances, data is collected

anonymously, it's not attached to a particular individual. Rightly so, because we're keen to ⁓ not blame on people, but to encourage reporting of safety incidents, which are often systemic failures, aren't they? They're not individuals. I fear I'm rambling, but I'm sure you do all understand better than anyone else that these things are often systematic and everyone does make mistakes and I shall do my best to trawl out what I can.

Chair AoMRC (32:04)
The next one is the question that the research on PAs is generally about not about safety or other aspects of patient mortality. It's about those who are positive about the role and how are you going to look at that bias within what you do?

Gillian Leng (32:23)
Sorry, Jeanette, could you just repeat that?

Chair AoMRC (32:25)
Sure, it says there's a lot of money being put into research for PAs, mostly funded by the NIHR. The studies don't look at mortality, they don't look at other patient outcomes because the research has been conducted by those who advocate in a positive way for workforce substitution. That's a research bias. Are you taking that into consideration? Apologies for

Gillian Leng (32:48)
Yeah, yeah, yeah, no, it's a good question. And the short answer is yes, I'm taking into account bias. There's always bias in research and there are some technical ways that help you try and determine whether there is likely bias in what you found. However, there is also bias in the other direction because there are quite active opponents of the PA role.

who might be the ones who have influenced the survey, who might be people sending me data. So whether positive studies or negative, there is a lot of bias that I'm trying to manage and I'm trying to stay on that tightrope, being cautious about what I'm being told, trying to distill the quality from the bias. And it's tricky. make no excuses for that.

wisdom of somebody I shall need to draw upon to get some careful considerations. You know, I'm in no doubt, as in many nice guidelines, as you might or might not know, the evidence is never black and white. In most circumstances, the evidence is not black and white. You have shades of grey and you have to then draw careful

around all the considerations that you have to draw, be they patient perspectives, be your healthcare system, be they workforce, you put all those considerations around the data and come to a conclusion that is defensible, but it isn't straightforward.

Chair AoMRC (34:25)
I think there's another difficult question about, you know, are thousands of fellows of the Royal College of Physicians who voted overwhelmingly to limit the expansions of PAs of vocal minority. Will you take a firm stand against the slandering of those raising concerns about patient safety as toxic?

Gillian Leng (34:51)
I'm going to take the stand that is the right one based on the evidence and data and all those considerations I've just described. There is a toxic culture, particularly on social media, as I'm sure everyone's aware, and I will, as appropriate, call that out. I think we absolutely need to apply our brains to the future of healthcare. All of us around this virtual table need to apply our brains to the future of healthcare.

You know, I had 20 years at NICE. I saw lots of change. I saw the impact of all the new technologies, all the new drugs transforming the way we manage things. We now have a really complex healthcare team to support all of that change. Perhaps some of those incremental changes haven't been the right ones. We need to step back and we need to look with the government who is committed to improving. I'm not doing a party political broadcast here, but we're committed to

get they are rightly committed to improving for the future and we need to look at what we need. And we haven't mentioned it in this conversation, but almost every conversation I have about the future of healthcare talks about artificial intelligence. That is going to have the biggest change on what we do. And we as leaders, as members of teams, we need to look at what we need, coolly, calmly and intelligently, because it's not going to be straightforward.

I can't remember your initial question, Jeanette. Did I get any right?

Chair AoMRC (36:23)
I think that kind of covers it. think, you know, some of these are more statements than questions and I'm trying to pull the question out, especially ones that are very popular where people have up voted. I've now got one where, you know, it says that the prior degree that PAs must have doesn't have to be science based. Their course is unregulated and variable, not any more from the GMC. Obviously, they are regulating every course.

And a two year course is not sufficient. I mean, think would you want, is that something you view, the review will be discussing?

Gillian Leng (37:05)
I there is now the role of the regulator, which I don't want to do what the regulator will be doing. But it's an important question in relation to the direction of travel because PAs were set up as they were to do what people thought they should be doing at the time.

You could have a PA role where you decide that they have more training or you decide that you want people, as they do in some countries, already have had training in another healthcare profession. So you might be taking ⁓ trained nurses or paramedics and giving them added qualifications to become a PA. That's one role that you boost those qualifications.

I'd be interested in whether people think that's the right direction of travel because in some ways that's making these roles bigger and more like a doctor. Or you decide that you want to keep it ⁓ with less training, less experience, less skill development.

than the medical training because that's right, you don't want to confuse the roles but then you have to be clear about how those roles work in practice, what supervision they have because they have had less training. So it comes down to less training, more supervision, able to do less versus a bigger role, able to do more possibly, views welcome more confusion with the role of a doctor.

Chair AoMRC (38:51)
I think that thanks Jill. think there's a comment here which I think it's worthwhile saying about the concerns about in one of your recent visits, for example, that there was not necessarily a belief that the groups of staff were invited, including the resident doctors. So are you going to be scheduling additional visits is number one.

Gillian Leng (39:17)
Am I going to be scheduling additional visits? Possibly. It depends on time. There's a lot to be done. But just to say that the concerns that were raised, think were genuine, but they weren't from lack of my trying. I was very clear before going to those visits that I wanted time with the resident doctors and I wanted time with the consultants. And yet when you do these visits,

you have to rely on the folk at the trusts to manage it, to make those invitations, to set it up. And I'm grateful to those that did. I couldn't have had the visits without them. And I do understand that there were some groups of medics who were given 24 hours notice. And in another visit, I don't think that the resident doctors were invited at all. And a couple managed to find their way to me. So that was nice.

I get those concerns. It wasn't from lack of me trying. At the moment, I'm hoping that by and large I'll get enough engagement through these webinars. But if I can squeeze in some more visits, I will do. They're very valuable. Was there a part two? You said the first question, Jeanette.

Chair AoMRC (40:34)
I'm trying to get the questions up. I think there's a bit about, there was a question, would you do more visits, would you do virtual visits? But again, you've got the residents webinar coming up and the anesthetist webinar. There's a question basically around safety again. Why was recruitment to the roles not halted as part of the review process?

Gillian Leng (41:00)
That wasn't my decision. So I can't give you a definite answer. However, I do know that the other side of the coin is that it's quite a challenge for people that are in training, that are coming out of training, that can't find roles. So although recruitment hasn't been halted, there aren't really many jobs for people to go into. So employment has been halted.

So although there wasn't a formal decision, in practice people are struggling to work and that is very difficult for some people. mean, if we're being human for a moment, you've got people coming out of training and no roles to go to.

Chair AoMRC (41:45)
Okay, and I'm just trying to get the most up voted ones. I'm just checking the ones that we've not done. There is a bit about the banding that the PA posts attract and a number of those roles can be done by others who perhaps are on a lower banding. Is the review giving, you're given consideration to cost effectiveness, but does it look at the opportunity and cost of employing ⁓ more staff members?

not necessarily in the AAPA roles, but on the lower banding.

Gillian Leng (42:21)
Short answer to that is no. I didn't think it was practical in the time that I've got to do the review to look at pay banding as well. It isn't in the question I was given, which is safety and effectiveness of the role. I wasn't asked to look at pay. However, it will of course be considered by others.

Chair AoMRC (42:50)
There's another question from Luella. I'm just trying to find it again because I'm losing bits of it. you know, we have looked at, there's a number of folk in the chat who are talking, or in the Q &A talking about taskification and the breaking down of medical work into tasks, especially procedures. And

There is some research apparently suggested, which presumably has been submitted to you, which suggests that the system is less efficient and care is worse for patients. Will that evidence be taken into consideration in the analysis?

Gillian Leng (43:29)
Jeanette, is that question about medical work and the medical team in general, including doctors, or is that specifically about?

Chair AoMRC (43:37)
looks

to me about medical work. Medical work, it says the fundamental issue with the devaluing of medical work, especially procedures, the research suggests that taskification makes systems less efficient and care for patients worse.

Gillian Leng (43:56)
Probably not, it probably won't be included because it sounds like it's beyond the specific review question. However, what became clear very early on to me looking at the role of PAs and AAs is that it's difficult to separate it out from the wider context of what's going on in training of doctors and the unhappiness that there is around the training of doctors and that the concerns being raised by

Some of the residents are genuine, they're concerned about being treated like widgets in a production, you know, on a production line. And I'm noting all of the things that have been raised to me. I was very pleased that Chris Witte and Steve Powis announced the fact there would be a review of medical training because I think that is needed and I will feed in.

to that. Indeed, I'm going to talk to the four CMOs later this week to feed in what I've heard to date because I can look at the PA and AA role, but that is absolutely within a wider context.

Chair AoMRC (45:08)
Yeah, there's a number of folk who are expressing dissatisfaction with the term medical model, but don't really have questions around that. There's a bit about, again, bringing in more people who have patient care backgrounds, which is partly what you touched on in nurses, paramedics and physios.

Gillian Leng (45:31)
Can I just stop you there, Jeanette? Of course you can. People who don't like the term, is it the term medical model that they don't like? Right, okay. Because I used it, didn't I? Yeah. Did I use it? You did. it to describe that, because I've seen this written down. I didn't make it up. I've seen it written down in the early descriptions of physician associate and what they would do.

It was written down at the time that they would be trained in the medical model, which meant that they would be there as a resource that had some training in the way that doctors work rather than perhaps being more different if you're a nurse or a pharmacist. That is, think, well, it must have been what the intention was. I haven't made that up, if that helps. that's why it was a quote.

put it in inverted commas. But if you don't like it, that because people think it's wrong that physician associates should be trained in the medical model or do they just think that there's no such thing as a medical model?

Chair AoMRC (46:45)
think it's reading the because they're not actually questions, which is why I've not read them out. It's the phrase that they dislike the thing. So there is a question here. It says, any other health care roles have a national limiting scope of practice? A scope of practice is usually applied to an individual based on qualifications, experience, CPD and is fluid.

⁓ which is perhaps not for you, but it is there because you will presumably be looking at comparisons with other rules.

Gillian Leng (47:20)
We're looking at comparisons of the roles, comparisons of what regulators are doing, and we'll be looking internationally to draw a conclusion around that. And I think, I presume, am I right, Jeanette, that that question was being asked with the suggestion that there shouldn't be a national limiting scope of practice for this group of people.

Chair AoMRC (47:41)
read it out virtually verbatim actually that time Jill. reading it, you could read it either way, but I would say it's more on the pro than the con side. But again, I don't want to put words into anybody's mouth here. am purely a mouthpiece of what I'm reading in the chat. Now it says as part of your evidence, are you including information from FOI requests about PAs and AAs prescribing medications?

and requesting radiological investigations, is illegal. ⁓ This was a huge issue in my local trust and seems largely to have been without consequence for those involved.

Gillian Leng (48:21)
If we've been sent information from those FOI requests, then I will look at it and I think I think there is some of that information that's come through the call for evidence. OK, short answer.

Chair AoMRC (48:42)
Again.

Sorry, I'm just trying to work out which are questions and which are comments.

Gillian Leng (48:51)
Yeah, I'm glad you've got the reading out job, Jeanette,

Chair AoMRC (48:56)
Blame me if you don't get your question read out, it's fine.

Are you going to assess theatre efficiency and productivity with the addition of A's to theatre team? This is very important in the current situation looking at the backlogs.

Gillian Leng (49:14)
Yes, if we've got that data, definitely, definitely. So I see productivity outcomes as important in looking at the addition of these roles, because I think that makes a difference. And somebody commented that in the webinar that I did around with the AA group, not to forget that they have a role outside the operating theatres and they are doing work on the wards as well. So you mustn't

underplay what they're doing by assuming it's only working in operating theatres.

Chair AoMRC (49:47)
There's a bit about the view that those coming out of a very short training course would benefit from a mandatory foundation stroke preceptorship stroke year of that before they get into independent practice. Just do I don't know if you want to comment on that.

Gillian Leng (50:13)
Yeah, I'm happy to comment from my tightrope, which is not giving a final answer, but a number of people have raised that, including some of the physician associates, particularly themselves, that they think that that might be a helpful model.

How are we doing? got 10 minutes left Jeanette, do you want to?

Chair AoMRC (50:45)
I'm

trying to find the ones that are slightly different from what you're doing. I think there's a view, please could you make clear what the review will not be covering so that there's not a raised expectation? That would be quite useful I think. will the government accept your recommendations? Does the government have to accept your recommendations?

Gillian Leng (51:00)
Mm-hmm.

So the bit about what we're not covering, that is on the gov.uk website. So there's some information about the scope of the review there. So if I can direct anyone towards that, and if you're still not clear, then email leng.review at dhsc blah, blah, and we'll get back to you. And then does the government have to accept the recommendations? I don't think there's any formal mandate that says they have to.

but I am assured that they want to, I'm assured that they don't have any preconceived notions or ideas about what I am going to say or indeed what I should say. And I think everybody is hoping that we can come to some agreement around the future. There has been somebody used the toxic words, there is a toxic debate online.

There's a lot of unhappiness both in the resident doctor community and in amongst the PAs and the AAs themselves, they're finding it all very difficult and we have to find a solution. We have to reset what's happened, whatever the review concludes. And I am now actively with the team looking at how we land the review well. I don't know if that's a good analogy, but it's got to land well, crash landing.

isn't going to help, it's got to be carefully positioned, whatever it says, so that we can move forwards. Because there's such a lot that we need to get right in the NHS right now. It's not in the best place ever. There is willingness to improve it. There will be a lot more change to come. And I'd really like us all to be able to move on ⁓ and to focus on what's going to be right for patients in the future.

Chair AoMRC (53:04)
As a question, will the review identify key components of clinical and professional governance from board to floor that contribute to safety and effectiveness of PA and AA roles?

Gillian Leng (53:17)
Well, I haven't been asked to do that, but that is clearly an important question. And if I find some evidence that shows that in that chain of safety, that there are some things that are not being addressed properly and that might improve things in relation to PAs and AAs, then I will either make a recommendation or flag it up as context, but it's not the focus of the review.

Chair AoMRC (53:45)
And there's a comment about the bit about the task. We can train anyone to do a task. We can train anyone to do even quite a complex task quite well. in medicine, it's not just about the task. It's about the decision. Do you do the task? Don't do the task? When should you do that? is there a bit about, it says, the training of PAs and AAs does not cover the decision making. They are being asked to deliver.

And how are you going to square the task from the decision making?

Gillian Leng (54:22)
Can you just repeat that final sentence?

Chair AoMRC (54:27)
It says, would you, it says, so the training of PAs and AAs does not cover the decision making they are being asked to deliver. And how are you going to square the task from the decision making?

Gillian Leng (54:42)
Okay, so the bit about doesn't cover that decision-making they're being asked to deliver is is interesting because I'm not sure where the gap is because if you The these roles are all about working with and for Trained doctors that's about them being a supervised member of staff. So who is asking them?

to deliver this decision making that they're not trained to do. Where is the error falling? That is something we should reflect on because if it works well, they should be being supervised and they shouldn't be taking decisions outside of their competence. They absolutely shouldn't. So it may well be about the way things are being operationalized. I don't like that word, but operationalized on the ground.

We've got five minutes left, Jeanette, so we don't have time for one or two more.

Chair AoMRC (55:46)
We've got one or two more. think one which you might want to see a very brief thing on, but you probably will be addressing when you talk to the residents is the fact that there is a perception that PAs and AAs have significantly impact detrimentally on the training of residents. And in a few years, these residents will be the consultants who will be, you will be asking, we will be asking to supervise the AAs and PAs. They will be asked to supervise roles that they.

don't feel have been implemented well. So again, it's that.

Gillian Leng (56:17)
Yeah, those are really good points.

bit about residents being the consultants of the future. I mean, at the moment, most consultants that I've spoken to are enthusiastic about any PAs that they work with. They're enthusiastic because there they have a member of their team that they are able to get to know because they're consistent and consistency, providing the glue on award, words that I've heard used. And so they like them. They can train them. They can

be confident that they know what they're doing. So the consultants at the moment are enthusiastic, but of course, of course the residents will become those consultants. So they need ⁓ to be happy with the role. And there seems to be mixed evidence and mixed impressions about the impact on their training. Part of it seems to be that

areas that residents might once have taken responsibility for in terms of doing procedures are now being covered by trained PAs. But some people will argue against that and say it's not a problem because those trained PAs are quite happy to train the residents so they get the experience that they need. So it's it's not easy to disentangle that. I suspect that there's there's much more about

the unhappiness of resident doctors and how they fit into the team and the fact that they don't often have the opportunity to have that more permanent relationship with the consultants that they see that the PAs are able to develop. And I think that's probably is genuinely quite hard. It takes me back to what about the context that all of this is happening in and how do we make that better?

Chair AoMRC (58:15)
Yeah, I think I think we've asked most of the questions or in a theme of the quest that most of the questions there are positive and negative discussions about AAs and PAs and what some folk are saying they don't work well, some folk are saying they do work well, some folk that were saying they're not trained enough, some folks are saying if they're supervised well, they're trained well. So I think there's a lot of good data for you here in the chat. And there's a lot of people

offering you sympathy that is a difficult difficult journey.

Gillian Leng (58:50)
Right.

Chair AoMRC (58:51)
I think the one thing I would say that when the legal precedent is that the supervising doctor is held to account when a mistake is made, what is the point in a role that helps doctors if I have to duplicate everything they do?

Gillian Leng (59:09)
So I'll look forward to reading all the comments because I've been focusing on what Jeanette's been asking me. But thank you to everyone who has put in some information into the Q &A. And it feels as though I'm going to need to carry on walking along the tightrope and that there are a range of different views. The legal precedent and the bit about

supervision I think needs to be untangled in relation to what does supervision mean. I don't think it means duplicating what's done. It needs appropriate supervision, confidence, what can be delegated and perhaps the bit about taking the decisions where there was a previous comment wasn't there about, you know, decisions being taken at the wrong level. there's a lot to untangle there and I'm not going to try and give a detailed answer now, but I think I

⁓ I can conclude and thanks to you all again and thanks so much, Jeanette, for going through those questions. It sounds like it was quite complicated, I'm glad I didn't have to do that. And we will read ⁓ what is there and hasn't been vocalised today. Thanks also to the team in the background for making this work and thanks for all your time ⁓ today, those that I can't see out in the webinar. Thank you very much.