UMAPs has spent months gathering evidence of what has actually happened on the ground since the Leng Review was published in July 2025. Through Freedom of Information (FOI) requests submitted to NHS trusts that employed PAs in emergency departments at the time of the Review, a deeply concerning picture emerges – about the chaos, inconsistency, and patient harm caused by the rushed implementation of recommendations, many of which were pushed through without any impact assessment whatsoever.
As of 29 April 2026, we have received responses from 32 trusts. They tell a story that ministers, the Royal College of Emergency Medicine (RCEM), and the BMA should be required to answer.
Most trusts made changes without assessing the impact on patient harm
22 of the 32 trusts that have returned FOIs made changes to the PA role in their emergency departments following the Leng Review. Of those 22, only three conducted a formal impact assessment before doing so. That means the overwhelming majority of trusts that restricted PA roles did so without any analysis of what that would mean for their patients, their rotas, or their departments.
The few trusts that did carry out impact assessments produced findings that proved there were substantial operational and patient safety risks associated with implementing the recommended restrictions to PA scope of work.
Mersey and West Lancashire Teaching Hospitals, one of the three that assessed the impact before acting, found that its PAs saw approximately 44% more patients over a comparable period than its resident doctors. Its internal assessment was unambiguous: full compliance with RCEM guidance “would decimate the rota, directly impact patient care and safety and attract a significant financial cost.” It calculated that replacing its 10 whole-time equivalent PAs would require 15 WTE clinical fellows simply to maintain existing patient volumes.
Some trusts that implemented PA restrictions found they had to reverse them
Perhaps the most telling evidence in our FOI findings is not what trusts did in the immediate aftermath of the Leng Review – it is what happened next.
Multiple trusts including, Guy’s and St Thomas’, James Paget University Hospitals, Mersey and West Lancashire, restrictions that had been introduced in response to RCEM guidance and NHS England’s call for “immediate action” were partially or fully rolled back after operational problems became apparent.
At Guy’s and St Thomas’, one of the country’s leading emergency departments, an internal review found that requiring mandatory prior senior assessment before every PA encounter had caused “an underutilisation of an experienced part of our workforce, a negative effect on the timely assessment and treatment of patients within the department and subsequent impacts on ED crowding.” The trust’s consultant body agreed that strict RCEM implementation “was not in the best interests of patients or departmental flow” and reverted to pre-Leng working arrangements.
Guy’s and St Thomas’ – a flagship NHS trust – implemented the recommended restrictions, watched them cause measurable harm to patient care, and reversed course.
James Paget similarly reversed its restrictions in September 2025, telling PAs it was keen to revert to their previous way of working once NHS England had softened its stance on the “immediate action” requirement.
More trusts diverged from RCEM guidance than complied with it
Of the 31 trusts, 12 followed RCEM guidance, 15 did not, and four gave ambiguous or uncommitted responses. That means the majority of trusts, when given the opportunity to make their own clinical judgements, chose not to follow the guidance of the Royal College of Emergency Medicine.
Several non-compliant trusts argued that their existing supervision arrangements already met the spirit of what was required. But others went further and directly challenged the guidance itself. Mersey and West Lancashire described its position as “not in full agreement with RCEM guidance”, arguing that its approach represented a safer outcome than full compliance: removing experienced PAs and replacing them with unfamiliar bank staff, it said, most likely jeopardised rather than improved safety.
Guy’s and St Thomas’ concluded after its internal review that strict implementation of RCEM guidance “was not in the best interests of patients or departmental flow and was not reflective of the level of experience provided within this group of clinical practitioners.”
These are considered, documented clinical judgements from senior emergency medicine consultants at major NHS hospitals. And they raise an uncomfortable question about the guidance itself and about who shaped it. As UMAPs has previously revealed, published minutes of Royal Colleges appear to show that the Leng Review team gave advance access to its potential recommendations to organisations that had already publicly declared their opposition to the PA role and consulted them on their acceptance of the findings. The RCEM guidance that so many trusts ultimately rejected may therefore reflect not independent clinical judgement, but the interests of organisations that were given a preferential opportunity to shape the Review’s findings from the outset. From pre-action correspondence seeking clarification from RCEM, they had confirmed that no patient impact assessment had been carried out and that the guidance was based simply on a member survey.
The outlier: Leeds Teaching Hospitals
Leeds Teaching Hospitals stands apart in the dataset as the most extreme example of post-Leng PA restrictions. All 8.1 WTE PAs in its emergency department were temporarily redeployed to alternative roles following the publication of RCEM guidance, making it the only trust in our dataset to remove its PAs from the ED entirely. There is as yet no indication that their roles have been reinstated. Leeds conducted no impact assessment before making this decision.
What this tells us
UMAPs has been arguing since the day the Leng Review was published that its recommendations were not grounded in patient safety evidence, that they are being implemented without proper consultation, and that the consequences would be felt by patients across the NHS in injury or death. These FOI findings bear that out in black and white.
The majority of trusts that made changes did so without impact assessments. Those that did assess the impact found it that implementing the recommendations was detrimental to the operations of the emergency departments. Several trusts reversed their own restrictions once they encountered the reality of implementing them. More trusts rejected RCEM guidance than followed it. And at every stage, it was experienced, supervised, competent PAs, with no evidence of increased safety incidents, who were caught in the middle.
Stephen Nash, UMAPs Secretary General, said: “These findings paint a deeply troubling picture of how NHS trusts have responded to the Leng Review and its recommendations, with many trusts proceeding to make drastic changes to PA scope of work without prior assessments or evidence. It is striking how many trusts have stepped back from their initial restrictions once they encountered the reality of implementing them. Guy’s and St Thomas’ – one of the country’s leading emergency departments – found that the recommendations caused seemingly measurable harm to patient flow and crowding and reversed the policy on that basis.”
If the campaign to restrict and marginalise the PA profession continues to be driven not by patient safety evidence – which does not support these restrictions – but by anxiety about professional competition, it is only a matter of time before the consequences will be measured in patient mortality. As some emergency departments have reported, restricting the work of PAs has caused depleted rotas, longer waits, and experienced clinicians replaced by unfamiliar bank staff. These are the conditions in which patients come to harm.”
