August 2025 - Leng Review Response

In the last 2 years, following the publication of the NHS Long Term Workforce Plan in July 2023 and the planned expansion of PAs (Physician Associates, now Physician Assistants), the BOTA Committee has been working collaboratively with multiple national stakeholders on the role of PAs in the evolving healthcare system. As BOTA President and BOTA Sustainability & Workforce Representative, we were both heavily involved in the working groups of the Royal College of Surgeons of England (RCSE), the Academy of Medical Royal Colleges (AoMRC) and the British Orthopaedic Association (BOA), to define a safe scope of practice of PAs within both surgery generally and Trauma & Orthopaedics specifically. Through all our engagements and collaboration, BOTA highlighted the key priorities of orthopaedic trainees: ensuring patient safety and the protection of training opportunities for trainees. 

From the outset, BOTA were keen to ensure that the views of the members we represent were heard by the Leng Review.  We wrote to Professor Leng shortly after the end of the 2024 BOTA Conference, and it soon became clear that there would be opportunities to submit to the ‘call for evidence’, which we did in March 2025.  We consulted with members from all four nations to ensure fair representation of a breadth of views in the creation of this submission. Our priorities throughout this process was always to safeguard patient safety and protect the training of surgeons for the future. Our view has been that PAs are best utilised to support the ward based care of surgical patients and support surgeons with administrative tasks during on-call shifts, with limited benefit from their deployment to theatre, where SCPs and SFAs are already working. In a primarily ward-based capacity, they provide excellent continuity of care whilst supporting rotating doctors, and allow resident surgical trainees to spend more time in theatre and clinic to gain the core skills of our craft.

It is clear that Professor Leng went to significant length to analyse and consider all the available research on PAs, as well as the experiences and feedback of the public and the medical profession. Recommendations were made regarding PAs, with a further four recommendations pertaining to both PAs and Anaesthesia Associates. 

The first recommendation is the renaming of PAs to Physician Assistants, in order to reposition the role as an adjunctive role to doctors. Whilst the name change may seem minor, it is important in reducing patient confusion as to who they are seeing and what they can expect, as well as defining how they should be deployed. It was also recommended that PAs should have potential to gain qualifications in prescribing medication and ordering non-ionising radiation, which will allow them to undertake many ward tasks to support doctors. Career progression will come through the potential for progression to advanced PAs, although it was left undefined what this would entail, and the Leng Review was clear from the outset that it was not aiming to define a detailed scope of practice for PAs (as this remains the responsibility of the regulator and the Colleges). That said, a recommendation of the review was that PAs should not be seeing undifferentiated patients except within clearly defined national protocols. We welcome Professor Leng’s emphasis on improving doctors’ training and that future changes should not limit opportunities for resident doctors. 

Overall, we welcome the recommendations from the Leng review, which have been accepted by the government in full. The renaming and repositioning of the roles as assistants is important for protecting patient safety and training of doctors. It is crucial now that clearly defined scopes of practice are developed by the Royal Colleges, and we hope to see this lead to PAs deployment in a primarily ward-based capacity to support doctors practice and training. The BOA have already since published the specialty-specific recommended scope of practice for PAs in Trauma & Orthopaedics, which had been formulated prior to the Leng Review with significant input from BOTA and endorsement from our committee. We feel that this document (which can be accessed here) represents a strong and sensible position for our profession, which will protect both patients and the training of resident surgeons.

Mx Karen Chui - BOTA Past President

Mr Ollie Townsend - BOTA President