Disclaimer: This is independent research and commentary. It is not advice.
The Leng Review (July 2025) is more than an examination of two workforce roles. It is a case study in how modern healthcare responds to pressure: by adding new roles, expanding regulatory oversight, and creating additional governance mechanisms, while the underlying organisational logic remains centred on institutions, specialties and processes rather than on the lived reality of patients.
This analysis links the patient, clinical and governance perspectives set out in the accompanying articles and situates the Leng Review within the broader patterns documented across multiple public inquiries into NHS care.
The Recurring Pattern
The review’s own account of the rollout is telling. There was no clear national vision for integration. Medical leadership was inconsistent. Local change management was weak, especially for PAs. The result was role confusion, eroded trust, and a debate that became toxic in places, with reports of bullying and harassment.
Supervising doctors reported insufficient time and training; potential safety incidents were regularly identified and prevented by those supervisors. Patient and family accounts, including from those bereaved, highlighted that confusion about who was treating them affected how they responded to deterioration.
These findings echo the chronology set out in the Thirlwall Inquiry’s review of more than fifty years of inquiries: repeated identification of poor communication, failure to listen to patients and families, organisational defensiveness, fragmented accountability, and risk that is not recognised until harm has occurred.
The consistent response has been more guidance, more reporting systems, more oversight, more regulators, and more recommendations. Yet the underlying concerns persist.
The Leng Review itself represents another layer: renaming, credentialling, named supervisors, national protocols, separate GMC presentation of standards, staff-group data collection in safety systems, and a time-limited working group on MDT models.
These are sensible, pragmatic measures. They are also further evidence of the pattern – adding structure in the hope that process will deliver understanding.
Process Versus Understanding
The review is explicit that evidence on safety and effectiveness was limited, low quality, and often inconclusive. Interpretation required judgement and wider perspectives. In primary care – the setting of significant PA deployment – studies showed longer consultations and more advice-giving by PAs, with some association with fewer admissions.
These findings are neither clearly reassuring nor clearly concerning; they illustrate how narrow outcome metrics struggle to capture the complexity of real clinical encounters.
Crucially, the evidence base did not disaggregate by sex, age, or stage of life. It did not examine how role confusion, supervision models, or team fragmentation affect patients whose health needs are shaped by interconnected physiological transitions. This is a realisation gap with direct consequences for women.
Women’s Health and the Female Life Course
Women’s experience of health is not a series of discrete, specialty-owned episodes. It is a continuous biological and social narrative shaped by menstruation, fertility, pregnancy, miscarriage, breastfeeding, perimenopause, menopause, and ageing.
Hormonal fluctuations influence cardiovascular risk, mental health, autoimmune disease, medication response, bone health, and metabolic function.
Women frequently navigate between primary care, gynaecology, endocrinology, mental health, maternity, oncology and later-life services, carrying fragments of their story. Continuity is often lost precisely where it matters most.
Primary care is the setting where much of this navigation begins and continues. The Leng Review notes that PAs were deployed there partly to improve access in hard-to-recruit areas. Some patients reported positive experiences of being listened to; some studies suggested longer consultations.
Yet without sex-disaggregated data or a life-course lens, it is impossible to know whether these patterns benefit or disadvantage women with complex, multi-system presentations that do not fit neatly into single-specialty or single-episode models.
The review’s recommendation that physician assistants should not see undifferentiated patients except within national protocols is welcome.
Undifferentiated presentations are exactly where sex-based differences in symptom reporting, risk profiles, and disease trajectories can be most consequential – and where clinical curiosity about the individual woman is most needed.
Protocols alone cannot substitute for that curiosity, nor for team structures that support longitudinal understanding rather than episodic management.
The named-supervisor model and clearer identification measures address accountability. In a clinical negligence context, they clarify lines of responsibility and the information patients require for informed consent (Montgomery). They do not, however, redesign care around the woman’s life course. They add clarity within an existing institutional framework.
Linking the Three Perspectives
Patient: Role confusion and barriers to care (including prescriptions) undermine trust and can delay help-seeking. Bereaved families were explicit that knowing who was involved would have changed their actions. This is not merely a communication failure; it is a design failure.
Clinical: Doctors report supervision burdens, loss of mentorship in their own training, and the reality that they catch problems before they reach the patient. PAs and AAs bring commitment and stability; they also highlight the contrast with increasingly fragmented postgraduate medical training. The review’s call for protected time and training for supervisors is necessary but insufficient if the underlying team model remains reactive and episodic.
Governance: The rollout lacked vision, consistent leadership, and proper change management. The response is more roles, more credentialling, more audits, more working groups. Safety systems will now collect staff-group data — a positive step for monitoring, but still focused on counting within existing structures rather than redesigning those structures around patient need.
The common thread is fragmentation: of care pathways, of professional teams, of accountability, and of understanding. Women, whose health journeys are inherently cross-cutting, experience this fragmentation acutely.
Towards a Different Organising Principle
The Leng Review closes the immediate debate on PA and AA roles with pragmatic recommendations. It does not, and could not within its terms of reference, address the deeper design question: is healthcare organised around the convenience of institutions and specialties, or around the reality of people’s lives?
For women’s healthcare, the evidence from multiple inquiries suggests the former still dominates. The logical alternative is to organise care around the female life course itself – recognising the cumulative impact of biology, hormones, reproductive events, social circumstances, medication exposure and ageing.
Rather than asking which service or role “owns” a symptom, the question becomes: what is happening in this woman’s life at this moment, and how does it connect to her wider health trajectory?
Such a shift would require more than additional roles or governance layers. It would require integrated pathways, continuity mechanisms that follow the woman, sex-disaggregated data and research, and clinical and managerial curiosity that treats the patient as the constant rather than the organisation.
The Leng Review demonstrates that adding structure without addressing this underlying design tension risks perpetuating the very problems it seeks to solve: confusion, fragmented accountability, and a gap between process compliance and genuine understanding. For women’s health, and for the clinicians and systems that serve them, that gap remains the central challenge.
Mandatory disclaimer
This article is for general information and discussion only. It is not medical or legal advice, nor a substitute for professional advice. To contribute evidence, ideas, or corrections, please email womenshealthproject@outlook.com. Please do not share personal data when emailing. Individual cases cannot be reviewed.
This project does not offer any form of legal service and cannot assist with complaints, claims or individual advocacy. This platform is independent and not affiliated with any law firm, regulator, inquiry or clinical body.
© 2026 Women’s Health Inquiry Project (WHIP). This article includes original analysis of material from publicly available national sources. It may not be reproduced without permission.
References Leng, G. (2025) The Leng review: an independent review into the physician associate and anaesthesia associate professions. Published 16 July 2025. Available at: https://www.gov.uk/government/publications/independent-review-of-the-physician-associate-and-anaesthesia-associate-roles-final-report
Thirlwall Inquiry (ongoing at time of writing; chronology of prior inquiries referenced in public materials) – pattern of repeated findings on communication, listening and organisational response.
Montgomery v Lanarkshire Health Board [2015] UKSC 11.
NHS Long Term Workforce Plan (2023) and related workforce policy documents – context for role expansion and subsequent review.
Patient focus group and family testimony summarised in the Leng Review.
Clinical and staff survey findings (8,558 respondents) and CQC analyses reported in the Leng Review.