Physician associates and anaesthetic associates in UK: rapid systematic review of recent UK based research
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj-2025-084613 (Published 07 March 2025) Cite this as: BMJ 2025;388:e084613Linked Editorial
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Dear Editor-in-Chief,
In response to the article “Physician Associates and Anaesthetic Associates in the UK: Rapid Systematic Review of Recent UK-Based Research” published recently, we, as Physician Assistant (PA) scholars from the Netherlands, feel compelled to share our perspective on the PA profession, albeit from our Dutch viewpoint. Since skewed conclusions can lead to unintended effects, we want to emphasize the importance of obtaining best practices from countries with substantial evidence - especially when a professional group is under scrutiny.
Around the year 2000, the Netherlands addressed a medical workforce shortage through several initiatives, including the introduction of the PA model (1), being supported by the Ministry of Health through arranging legal and financial regulations (2). Although the professional profile of Dutch PAs closely mirrors that of PAs in the USA (3), the education and training system differs significantly from how PAs are trained in e.g. the USA and the UK. To enroll, students must already hold a bachelor’s degree in a health-related field and are selected by healthcare employers. During their training, Dutch PA students are employed by hospitals or GP practices. In addition to this "resident model," to acquire specialized clinical competencies, students also complete didactic coursework and do clinical rotations across major medical disciplines. The advantages of this system include alignment with the planning of the Dutch medical workforce, which currently consists of 23,000 medical specialists and 13,500 GPs, as well as the commitment of supervising medical doctors who precept their student PAs.
In the Netherlands around 2,400 Dutch PAs practice medicine autonomously, albeit in collaboration with medical doctors. This independent authority was obtained after proving that deploying PAs was effective, efficient and safe (4). In another Dutch multicenter study, it was shown that the length of stay, quality of care, and patient perceptions of received care of inpatients was comparable with the care provided by medical doctors or PAs (serving as substitutes for residents) and medical specialists available as backup (5). In 2018, the Ministry of Health granted structural independent authority to PAs. Studies continue to support the integration of PAs into the Netherlands’ healthcare system as a valuable addition to the medical team. They are enhancing healthcare delivery. However, this integration raises important questions regarding its impact, including cost control, patient satisfaction, and physician acceptance.
Two health economic studies explored whether PAs contribute to cost savings or, at the very least, do not lead to increased expenses. First, a cost-effectiveness analysis revealed no significant differences in inpatient care expenditures between wards managed solely by medical doctors and those where PAs provided daily inpatient care (6). The second study showed that PAs not only deliver cost-effective care in the hospital setting but also significantly alleviate the workload of general practitioners, resulting in a positive return on investment (7). From the patients' perspective, a survey demonstrated that patients appreciate the care they receive from their primary care PAs (8). Furthermore, the willingness of patients to receive care from a PA rather than a medical doctor, with time convenience as a trade-off, indicates that patients have confidence in the competence of PAs as their medical care provider (9). Finally, a study conducted among physicians to understand their motives for hiring PAs revealed that they experienced better continuity and quality of care, lighter workloads, and effective substitution for medical residents (10).
In conclusion, 22 years after their introduction, around 2,400 PAs are successfully integrated into the Dutch healthcare system, with a well-established professional profile and an adapted educational model. The key to this success was the strategic positioning of the workforce, supported by structured assessments and scientific research.
Luppo Kuilman, PhD, Principal Researcher (1,2)
1 Hanze University of Applied Sciences, Groningen, School of Healthcare Studies, Master Physician Assistant program. Groningen, The Netherlands.
2 University of Groningen, University Medical Centre Groningen, Wenckebach Institute, Lifelong Learning, Education and Assessment Research Network (LEARN). Groningen, The Netherlands.
Geert van den Brink, PhD, Program Director (3) and Strategic Advisor (4)
3 HAN-University of Applied Sciences, Institute for Master programs, Nijmegen, The Netherlands
4 Healthcare Professions, Radboud University Medical Centre, Nijmegen, The Netherlands.
References:
1) Spenkelink-Schut, G., ten Cate, O. T. J., & Kort, H. S. (2008). Training the physician assistant in the Netherlands. The Journal of Physician Assistant Education, 19(4), 46-53.
2) Dankers‐de Mari, E. J., Thijssen, M. C., Van Hees, S. G., Albertus, J., Batenburg, R., Jeurissen, P. P., & Van Vught, A. J. (2023). How does government policy influence the employment and training of nurse practitioners and physician assistants? A realist analysis using qualitative interviews. Journal of Advanced Nursing, 79(7), 2553-2567.
3) Hooker, R. S., & Cawley, J. F. (2021). Physician assistants/associates at 6 decades. American Journal of Managed Care, 27(11).
4) De Bruijn-Geraets, D. P., van Eijk-Hustings, Y. J., Bessems-Beks, M. C., Essers, B. A., Dirksen, C. D., & Vrijhoef, H. J. M. (2018). National mixed methods evaluation of the effects of removing legal barriers to full practice authority of Dutch nurse practitioners and physician assistants. BMJ open, 8(6), e019962.
5) Timmermans, M. J., van Vught, A. J., Peters, Y. A., Meermans, G., Peute, J. G., Postma, C. T., ... & Laurant, M. G. (2017). The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study. PloS one, 12(8), e0178212.
6) Timmermans, M. J., van den Brink, G. T., van Vught, A. J., Adang, E., van Berlo, C. L., van Boxtel, K., ... & Laurant, M. G. (2017). The involvement of physician assistants in inpatient care in hospitals in the Netherlands: a cost-effectiveness analysis. BMJ open, 7(7), e016405.
7) van den Brink, G. T., Kouwen, A. J., Hooker, R. S., Vermeulen, H., & Laurant, M. G. (2022). PA and NP general practice employment in the Netherlands. JAAPA, 10-1097.
8) Meijer, K., & Kuilman, L. (2017). Patient satisfaction with PAs in the Netherlands. JAAPA, 30(5), 1-6.
9) Kuilman, L., Nieweg, R. M., van der Schans, C. P., Strijbos, J. H., & Hooker, R. S. (2012). Are Dutch patients willing to be seen by a physician assistant instead of a medical doctor?. Human Resources for Health, 10, 1-6.
10) van Vught, A. J., van den Brink, G. T., & Wobbes, T. (2014). Implementation of the physician assistant in Dutch health care organizations: primary motives and outcomes. The health care manager, 33(2), 149-153.
Competing interests: No competing interests
Dear Editor
We welcome evidence to inform the ‘toxic debate’ relating to efficacy and safety of physician associates (PAs) and anaesthetic associates (AAs) in the NHS. Greenhalgh & McKee demonstrate the lack of robust evidence for their efficacy and safety since their relatively recent introduction into the NHS. However, we highlight areas for further consideration before conclusions are drawn.
Firstly, safety incidents in most healthcare contexts are unlikely to be attributable to a single cadre of supervised healthcare professional, and more likely to reflect wider system of care processes in which healthcare occurs (1,2). Our 2022 scoping review of Physician Associates and Advanced Nurse Practitioners in the UK NHS, similarly, demonstrated that evidence for the efficacy and cost effectiveness of PAs was limited (3). However, empirical studies revealed that consultations with PAs resulted in similar outcomes and processes for less complex tasks across primary and secondary care contexts (4,5,6). We acknowledge that ‘taskification’ is no match for the professionalism and knowledge that comes from a complex blend, drawn from training, experience, clinical reasoning and a myriad of sources (7). However, randomised controlled trial evidence to support the efficacy and safety of PAs & AAs is unlikely to be feasible given the complexity involved - for example the wide range of roles and integrated nature of their work. PAs work across a variety of patient groups, specialities, and in both acute, community and ward-based settings.
Secondly, while the introduction of PAs and AAs has been a natural experiment in the NHS, similar cadres of healthcare professional are effective and safe in certain low resource settings (8-10). The NHS has finite resources, and we have much to learn from these contexts, both about integration of new healthcare professionals into the health system, and in promoting interprofessional working. Whilst most healthcare professionals viewed PAs as effective members of a healthcare team (11-14), PAs have experienced significant hostility and ‘out-group disdain’ from doctors and nurses (12). This is not reflective of the inclusive values that drive the NHS and its constitution, nor does it reflect the views of the public. Our recent systematic review of public perception of PAs suggested the public are largely satisfied with the care received from PAs, although there was limited information about, and understanding of, the PA role (15). We identified a need for comprehensive public information regarding the roles and scope of practice of PAs, to provide clear expectations of their relative strengths and limitations for patients. Whilst we accept that there is currently an absence of evidence on efficacy and patient safety, this does not mean we should prematurely condemn PAs and AAs to history, and jump to the conclusion that they must, therefore, be a danger to patients.
Finally, it is worth remembering that behind each article about PAs and AAs are people who have, with good will, paid to study to be PAs and AAs, with the aim of contributing their skills to the NHS. It is our wish that the debate around PAs and AAs recognises the need for kindness for those impacted, and ensures that professional respect and dignity are considered alongside the need for further clarity, evidence and provision of high-quality care for our populations.
References
1. Longo DR, Hewett JE, Ge B, Schubert S. The Long Road to Patient Safety: A Status Report on Patient Safety Systems. JAMA. 2005;294(22):2858–2865. doi:10.1001/jama.294.22.2858.
2. Vincent C. Patient safety. John Wiley & Sons; 2011 Jul 20.
3. Wang H, English M, Chakma S, Namedre M, Hill E, Nagraj S. The roles of physician associates and advanced nurse practitioners in the National Health Service in the UK: a scoping review and narrative synthesis. Human resources for health. 2022 Sep 15;20(1):69.
4. Halter M, Drennan V, Wang C, Brearley S, Wheeler C, Gage H, et al. Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes. BMJ Open. 2020;10:037557.
5. Halter M, Drennan V, Chattopadhyay K, Carneiro W, Yiallouros J, de Lusignan S, et al. The contribution of physician assistants in primary care: a systematic review. BMC Health Serv Res. 2013;13:223.
6. Halter M, Drennan VM, Joly LM, Gabe J, Gage H, de Lusignan S. Patients' experiences of consultations with physician associates in primary care in England: a qualitative study. Health Expect. 2017;20:1011–1019. doi: 10.1111/hex.12542.
7. Wieringa, S., Greenhalgh, T. 10 years of mindlines: a systematic review and commentary.Implementation Sci 10, 45 (2015).
8. Hongoro C, McPake B. How to bridge the gap in human resources for health. The Lancet. 2004 Oct 16;364(9443):1451-6.
9. Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E, Bergström S. Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Human resources for health. 2007 Dec;5:1-6.
10. Oginga FO, Kulimankudya VD, Okila CS. Integrating Clinical Officers Into Primary Healthcare Delivery In Kenya: Challenges, Innovations, And Future Directions. International Journal Of Research And Scientific Innovation. 2024;11(15):15-29.
11. Brown MEL, Laughey W, Tiffin PA, Finn GM. Forging a new identity: a qualitative study exploring the experiences of UK-based physician associate students. BMJ Open. 2020;10:e033450. doi: 10.1136/bmjopen-2019-033450.
12. Brown M, Laughey W, Finn GM. Physician Associate students and primary care paradigmatic trajectories: perceptions, positioning and the process of pursuit. Educ Primary Care. 2020;31:231–239. doi: 10.1080/14739879.2020.1763210.
13. Williams LE, Ritsema TS. Satisfaction of doctors with the role of physician associates. Clin Med J R Coll Phys Lond. 2014;14:113–116. doi: 10.7861/clinmedicine.14-2-113.
14. White H, Round JE. Introducing physician assistants into an intensive care unit: process, problems, impact and recommendations. Clin Med (Lond) 2013;13:15–18. doi: 10.7861/clinmedicine.13-1-15.
15. Swainston R, Zhao Y, Harriss E, Leckcivilize A, English M, Nagraj S. Public perception of the physician associate profession in the UK: a systematic review. BMC Health Services Research. 2024 Nov 29;24(1):1509.
Authors:
Shobhana Nagraj, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK.
Geoff Wong, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK .
Tricia Tooman, Centre for Healthcare Education Research and Innovation, prior to University of Aberdeen, UK.
Kim Walker, Centre for Healthcare Education Research and Innovation, prior to University of Aberdeen, UK.
Gerry McGivern, Kings College London, UK
Yingxi Zhao, Nuffield Department of Medicine Centre for Global Health Research, University of Oxford, Oxford, UK
Rhys Swainston, Nuffield Department of Medicine Centre for Global Health Research, University of Oxford, Oxford, UK
Attakrit Leckcivilize, Nuffield Department of Medicine Centre for Global Health Research, University of Oxford, Oxford, UK
Mike English, Nuffield Department of Medicine Centre for Global Health Research, University of Oxford, Oxford, UK
Competing interests: Authors are part of an NIHR HSDR grant entitled: How might Physician Associates help (or not) address the workforce crisis in the NHS? https://fundingawards.nihr.ac.uk/award/NIHR153324
Dear Editor
Greenhalgh and McKee have produced a flawed analysis. Their paper is fundamentally derived from Greenhalgh’s rapid review submitted to the Leng review. In that review she stated her aim was to ‘… summarise the evidence base pertaining to PAs … in the UK’. However, she now states that the aim of this new paper is to ‘summarise research on the efficacy and safety of UK physician associates …’. Which is of course a rather different aim but has used the exact same method.
The first flaw is of course to exclude non-UK data; this is akin to ignoring FDA data on, say, Wegovy; or, since few PAs have been in post for a substantial period, to endeavouring to assess UK doctors’ safety while looking at only ST1s and below. It would have been far more scientifically sensible, in assessing the safety and efficacy of the PA role, to use 60+ years of USA experience; see for example (1).
The second flaw is recruiting another PA opponent (McKee) as co-author, who has, like Greenhalgh herself, a previous history of highly negative writing about PAs (both separately (2) and with Greenhalgh (3) ). One may as well ask Vance for an opinion on Trump! Much more honest would have been to recruit a completely neutral expert.
A third flaw is revealed by the language (and hence (presumably unconscious) cognitive bias) evident in this paper: I give one example of many: a PA has ‘a first degree that is usually (but not always) a science degree.’ An uninformed reader would interpret ‘usually’ as say 60%? Actually this is a half-truth; the proportion with a science OR health first degree (mostly nursing but can be pharmacy, physiotherapist, etc) is at least 90%. So, usually science’ may be true, but is misleading!
A fourth flaw is the amount of reference to concerns among clinicians, managers and patients who have not met or worked with PAs, about the fact PAs weren’t registered or couldn’t order ionising radiation. It is misleading to include these issues when the authors know full well they are, or soon will be, no longer relevant.
A fifth flaw is the decision to exclude single site reports; Greenhalgh herself has used such data (‘We might come to regret dismissing as anecdote the story of a choir practice with 60 people, of whom 45 are known to have developed covid-19 and two so far have died’ (4)). She has excluded a report from a level 1 ED with substantial long-term experience of PAs working in ED (which is not common so far in the UK) in which King (5) reports on substantially positive assessment of PAs’ contribution to the working of the department by 28 doctors and by 57 patients in the same ED. But these responses don’t fit with the authors’ bias.
Lastly, the limitations section: as noted both authors have published highly critical papers on the PA project in the UK. And been involved in reversing the RCP (London) previously strong support for the PA profession. To not make this clear, and to describe this involvement as ‘helped to organise an Extraordinary General Meeting’, is misleading.
1.van Den Brink, G. T. W. J., Hooker, R. S., Van Vught, A. J., Vermeulen, H., & Laurant, M. G. H. (2021). The cost-effectiveness of physician assistants/associates: a systematic review of international evidence. PLoS One, 16(11), e0259183
(2) McKee M. The Sovietisation of British medicine. JRSM 2024; https://doi.org/10.1177/01410768241257986
(3) McKee M, Greenhalgh T, Monk B, McKee H. Physician associates: New Zealand should learn from the United Kingdom's mistakes. N Z Med J. 2024 Sep 27;137(1603):152-154. doi: 10.26635/6965.6703. PMID: 39326028. https://doi.org/10.1177/01410768241257986
(4) Greenhalgh T, Schmid M B, Czypionka T, Bassler D, Gruer L. Face masks for the public during the covid-19 crisis BMJ 2020; 369 :m1435 doi:10.1136/bmj.m1435
(5) King N. Doctors', Patients' and Physician Associates' Perceptions of the Physician Associate Role in the Emergency Department; Health Expectations, 2024. https://onlinelibrary.wiley.com/doi/10.1111/hex.14135
Competing interests: I was the medical academic member of the DH committee jointly chaired by RCP(London) and RCGP and which set out the PA curriculum framework. I have chaired the PA National Examination. I was for over 10 years the Director of the PA PGDip at the University of Birmingham.
Dear Editor,
Greenhalgh and McKee (1) are to be congratulated for their rapid review which shows comprehensively how little empirical evidence to support such a major change in health policy, as noted in the accompanying editorial (2).
In our original call for an extraordinary general meeting, there were 9 motions, one of which specifically called for more research
"This EGM calls on the College to establish a pilot, similar to that established by the Royal College of Ophthalmology (3), to inform discussions on potential future roles, responsibilities and scope of practice for PAs within multidisciplinary teams. "
This motion was dropped after pressure from the executive for the 5 motions which were passed overwhelmingly (4).
Given that the RCOpth pilot study has now been completed, there is an urgency not just for the results to be published, but a wider consideration of both the patient safety and the economic basis of schemes such as the Additional Roles and Responsibilities Schemes (ARRS) in primary care (5) . It just seems incredible that anyone thought that physician associates could safely see patients with undifferentiated symptoms in primary care, without doing some research to establish whether this was safe first (6).
Although Greenhalgh (1) highlighted some of the risks of under-diagnosis in the coroners’ courts, there are also medico-legal costs - one law firm is managing a medico-legal case involving a physician associate which is anticipated to cost in excess of £1 million (7).
There are also risks of over-diagnosis and over-referral. As a neurologist in one of the most deprived area of England, I am seeing an increasing number of referrals from physician associates in primary care, where it is not clear if the patient has actually seen a doctor prior to referral, which in many cases would have avoided referral in the first place. This despite there being clear risks to the doctor supervising a physician associate if they fail to do so properly (8).
"No new medical intervention would enter mainstream clinical practice on the basis of the scanty, small scale, and underpowered studies we have on physician associates and anaesthetic associates in the UK" (2).
It does rather feel that the stable door is closing as the horse has bolted.
It seems likely that the medicolegal cases (7) and the fear of GMC referral (8) will kill this workforce experiment off, who at NHS England and NHS Workforce Training and Education will be held accountable?
References.
1. https://www.bmj.com/content/388/bmj-2025-084613
2. https://www.bmj.com/content/388/bmj.r437
3. https://www.rcophth.ac.uk/news-views/launch-of-physician-associate-pilot/
4. https://www.bmj.com/content/384/bmj.q670.full
5. https://www.nhsconfed.org/publications/assessing-impact-and-success-addi...
6. https://www.bmj.com/content/bmj/386/bmj.q1684.full.pdf
7. Physician Associates and Medical Negligence Claims. February 10, 2025.
8. https://www.pulsetoday.co.uk/analysis/gmc-case-in-focus/gmc-case-in-focu...
Competing interests: I was one of those called for an Extraordinary General Meeting at the Royal College of Physicians on the issues in relation to Physician Associates in March 2024. I have also submitted evidence to the Leng Review.
Re: Physician associates and anaesthetic associates in UK: rapid systematic review of recent UK based research
Dear Editor,
The Leng review: an independent review into physician associate and anaesthesia associate professions was established by the Secretary of State for Health and Social Care in November 2024. Professor Gillian Leng was appointed to lead this review.
Professor Greenhalgh’s systematic review, published 7 March 2025 has been formally submitted to the Leng review where it will be considered in full. We are grateful to Professor Greenhalgh for this contribution but note that this was not commissioned by the Leng Review.
To support the review, Prof Leng commissioned an independent review from the Policy Research Unit at King’s College London. We have ensured that the team at PRU is aware of Professor Greenhalgh’s review, and that it informs their own work where appropriate.
Alongside assessments of published research, we are also collating a range of other evidence and data, including a call for evidence, a dedicated survey and focus groups to gather views of patients. This will help ensure the review’s findings are based on the best available evidence.
We are grateful to the team at King’s College for conducting the independent review, as well as all those who have submitted evidence thus far.
Kind regards,
Professor Gillian Leng CBE
Competing interests: Independent review of physician associate and anaesthesia associate