The British Medical Association has written to Professor Gillian Leng to condemn draft national clinical protocols that would allow physician assistants to see undifferentiated patients in some settings. In a letter dated 7 October, which was also addressed to the Secretary of State, Dr Tom Dolphin, chair of the BMA council, described the direction of the proposals as "unconscionable" and argued that they contradict the findings of her own independent review.

Professor Leng’s review appeared on 16 July 2025, after growing public argument over the safety of physician associates and anaesthesia associates. Both roles have since been renamed physician assistants. More than 3,500 physician associates were working in the NHS when it appeared. The review concluded that they should not see undifferentiated patients unless triaged into adult patients with minor ailments and working within clearly defined protocols agreed jointly by the Royal College of Emergency Medicine and the Royal College of GPs. 

The recommendation rested on a specific concern. If a physician assistant makes the wrong diagnosis, the patient may be put on the wrong course of treatment. Professor Leng cautioned, as she presented her findings, that such errors could cause serious harm.

The draft protocols were circulated to a select group of stakeholders and were not released for public comment. The Royal College of Physicians has since published a copy on its website. The BMA says it received the document as part of the consultation but took no part in drafting it.

The primary care section states that physician assistants should assess only limited groups of undifferentiated patients, because primary care is a setting in which immediate in-person review is difficult. A physician assistant would not hold sole responsibility for a final diagnosis, and the clinical supervisor would review and approve the list of patients with minor ailments allocated to them. If a patient returns a second time with worsening or unresolved symptoms, the case is to be discussed with the supervisor. A third presentation leads to an appointment with a fully qualified GP.

Dr Dolphin's first objection concerns process. The BMA says it opposed the decision to let the review team select individual doctors and assistants as core members of the drafting panel, whose members remain anonymous. Excluding the BMA and royal college representatives, he wrote, "dramatically reduced the usefulness and credibility of the group". He said the result was proposals that were unsafe and highly flawed.

His second objection concerns content. Dr Dolphin argues that the document replaces the safety issues that prompted the review with an account of the role's successful implementation across many NHS settings. He cites a statement that physician assistants have provided consistency and continuity for the health system, which he says is a finding absent from Professor Leng's report. A protocol built on a partial understanding of how the role is used in practice, he wrote, is "doomed to repeat the same mistakes". He added that the document portrays safe working that most doctors would not recognise and would allow the NHS to use physician assistants in a manner little different from before the review.

The BMA's position, restated in the letter, is that physician assistants must not assess, diagnose or manage undifferentiated patients in any healthcare setting. It also holds that resident doctors, at any level, must not be responsible for supervising them.

The matter remains unresolved. No response from Professor Leng, the Department of Health and Social Care or NHS England had been made public at the time of writing. Consultation on the draft has been limited to stakeholder organisations, and the BMA has told doctors to submit their views through the relevant royal college or faculty.