We’ve published updated our advice. Please visit our new page here for the latest guidance.
We understand there is a lot of uncertainty for MAPs and employers on how to proceed following the release of the Leng Review, its recommendations and the subsequent letter from NHS England. We are currently seeking further advice on whether this guidance is mandatory, or whether adopting the guidance is at employers’ discretion. Despite repeatedly being asked for more clarity on this and requesting urgent meetings with NHSE, we are seemingly being stonewalled, as are employers and supervisors.
We want to make it explicitly clear, that we DO NOT accept the recommendations of the Leng Review. The review is unable to substantiate a legitimate patient safety concern and relies on conjecture to fill this void without referencing any of the real-world data submitted by UMAPs and CMAPs which demonstrated MAPs’ track record of safety.
NHS England’s letter, “Response to the recommendations of the Independent Review of Physician Associates and Anaesthesia Associates (the Leng Review)”, was sent directly to Physician Associates (PAs) and Anaesthesia Associates (AAs). It reads as a fait accomplis and seems to suggest that the changes outlined in the Leng Review are mandatory and will be rolled out by employers immediately. It is unclear what authority NHS England has to mandate or communicate contractual changes between employers and employees without following proper legal process. The letter also strips clinical judgement from PAs and AAs by removing their authority to assess undifferentiated patients and make a diagnosis – a fundamental skill in the MAP curriculum that has been routinely deployed to great effect over the last two decades.
In the letter from NHSE to employers, the language points towards a request to action rather than a directive that must be complied with. However, we are concerned that employers may act on the impression that this is a directive, which may then lead to a potential breach of employment law. The language difference in being a request over a directive, also raises questions as to whether or not an employer can contest the findings and await further clarity and information. This information should have been provided and made crystal clear to both employers and employees prior to NHSE rolling out such a monumental and catastrophic change. Had UMAPs been consulted we would have insisted on this clarity.
If the letter is indeed a request rather than a directive, then employers will be entitled to exercise their own discretion on implementing the Review’s recommendations. We strongly recommend that all employers seek legal advice on the correct interpretation and legality of NHSE’s letter.
For those Associates who have already been terminated from their Associate roles and had assistant contracts imposed, we have produced this preliminary guide to help you navigate the next steps.
Take Home Point
If you are asked to sign or accept a new contract/ job description/ framework or agreement – we advise you DO NOT sign, submit a letter of protest and request help from UMAPs.
Our Current Position
The recommendations of the Leng Review and response from NHS England and DHSC – in particular the instruction that Physician Associates must not see undifferentiated patients – completely contradicts the training, competency and job role of the profession. We have not seen any substantial evidence to justify this recommendation as a proportionate means to improving patient safety or satisfying NHS delivery target. This will preclude Physician Associates from being permitted to do the role that they have been trained to do, despite the Review citing no evidence that justifies such action.
Implementing job descriptions that remove Associates’ ability to exercise clinical judgement in favour of “national clinical protocols” that currently do not exist, recklessly squanders our profession’s proven knowledge and skillset. This fundamental change may itself be a patient safety issue, resulting in the loss of approximately 20 million primary care appointments per year.
Frustratingly, in the same guidance NHSE seems to insinuate that Associates may be able to utilise these skills if the employer can prove competence. This vague and inconsistent wording leaves UMAPs unable to take a definitive position on whether existing Associates can exercise clinical judgement. We strongly recommend that all employers seek legal advice on the correct interpretation and legality of NHSE’s letter. Rushed implementation may leave employers legally vulnerable to litigation as they are still subject to employment law.
Implementing the Leng Review recommendation and NHS guidance on not seeing undifferentiated patients is not just redeployment of the position. It is a fundamental reimagining of the job role that is unrecognisable from that of a Physician Associate.
Directing Physician Associates to follow the new guidance and not see undifferentiated patients could be considered a ‘Hogg dismissal’, whereby their previous job role no longer exists, and they have been rehired in a completely different role as a “Physician Assistant”. This can only be argued if the member disagrees with the change.
The sudden implementation of these unilateral changes without agreement or adequate consultation with Physician Associates, Anaesthesia Associates, or UMAPs as their representing trade union, and with no grace period to consider navigation, subjects the NHS and the Government to legal challenge. We now understand that the Royal Colleges were consulted on the creation of the suggested job descriptions, meaning that those directly opposed to our deployment played a decisive role in designing the highly restrictive position (Link here).
By guiding employers to carry out these changes immediately, without proper consultation or due process, NHSE may be placing trusts and surgeries at risk of breaching employment law. While we acknowledge this is a very difficult situation, UMAPs will bring forward all necessary legal challenges to protect our members’ rights.
We will continue to engage with all employers, who are struggling alongside our members, despite the combative position we have been forced to adopt.
We are also seriously concerned that the recommendations of the Review far exceed its original remit and will continue to engage with our legal teams to assess the options available to us.
In the meantime, we are recommending the following actions to members.
Next Steps
- UMAPs does not endorse the recommendations of the Leng review or the response from NHS England. However, if your employer has chosen to implement the new guidance, you are now working in a new role and we recommend the following.
- If you are asked to sign a new contract/ job description/ framework or agreement DO NOT SIGN IT and await further advice.
- You MUST provide a letter of protest to protect your position, stating that you will continue to fulfil your professional duties. This means that you do not agree to the changes and are “working under protest”. See end notes for further advice on how to do this.
- It is important that you “work to rule” – this means no deviation from the conditions of the new job role/description, as doing so may put you at risk of legal implications.
- This includes not seeing any undifferentiated patients. There is currently dispute around the nomenclature of undifferentiated patients. Until this resolves, it is our position that any new suspected diagnosis should be discussed with a supervisor for confirmation. Similarly, any ongoing cases that remain under your care but are undifferentiated (for example patients who have been referred to a speciality, but the referral has not yet been accepted, or tests have been ordered) need to be checked with your supervisor and referral made on their behalf.
- When “working to rule” your primary indemnity will still be covered through your employer. We are seeking further advice on whether you will still be covered by secondary providers in this new role and will update you as soon as we have a response on this. We believe the indemnity for this new role will be significantly less than that of the Associate role.
- We recommend that in the initial phase of any changes, PAs should be allowed to take time off to come to terms with the change, including any mental distress that has been inflicted on them through no fault of their own.
- Employers seeking to proactively contest this review should get in touch with us directly and join any further action as an interested party. It is currently unclear whether the NHS guidance is legally enforceable and we have requested additional information to aid employers on whether they must comply with changes prior to any official directives.
Further Information on Working Under Protest
Working under protest means continuing to carry out your job duties while clearly and formally stating that you object to the changes made to your employment contract. These changes may include alterations to your responsibilities, clinical autonomy, supervision model, or pay and grading.
It’s a protective legal step, often taken when an employer makes a unilateral change without consent. It allows you to register your disagreement and preserve your right to challenge the change later (e.g. through a grievance, tribunal, or legal action).
Write and Send a Protest Letter
You must put your objection in writing to your line manager and CC in HR. The letter should:
- Clearly state that you do not accept the change.
- Specify what has changed (duties, supervision, job title, etc).
- Declare that you are continuing to work under protest to protect your legal rights.
Sample Protest Letter
Subject: Working Under Protest – Contractual Changes
Dear [Manager/HR Representative],
I am writing to formally assert that I do not accept the recent changes made to my employment terms and conditions introduced as part of the implementation of the Leng Review. These changes include the revised job title of Physician Assistant, being prohibited from seeing undifferentiated patients, revised clinical supervision arrangements, modified duties, and a change in job role.
I consider these changes to be a repudiatory variation of my contract made without my express consent. While I will continue to carry out my responsibilities to patients and colleagues, I do so under protest and without prejudice to my legal rights. By doing so, I am expressly not affirming my contract. I reserve the right to challenge these changes and seek advice on further action.
Please acknowledge this letter and confirm that it will be placed on my personnel file.
Yours sincerely,
[Your Full Name]
[Job Title]
Repeat the Protest as Needed
Reaffirm your protest if:
- Changes are referenced in new rotas, appraisals, or pay documents.
- You are asked to sign new job descriptions or frameworks. Once again, DO NOT SIGN.
- Your employer treats you as having accepted the new terms.
Thank you from UMAPs
UMAPs are incredibly grateful for your amazing ongoing support and patience during this time. We recognise that this is a distressing period, and we fully support you if you need to take time off due to mental health. In the first 72 hours after the Leng Review was published, you helped raise a massive £10,000 in renewing donations, which is a huge increase in the legal funding available to us per month!
We continue to ask for additional financial support from members and non-members for us to take the action required to overturn this decision.
We are continuing to engage with our amazing legal teams and wider stakeholders regarding this matter and will continue to support and update you as further information becomes available. A lot of work is going on behind the scenes and we will not give up the fight to bring justice for our professions.
We cannot thank you enough for your outstanding ongoing commitment. A huge thank you to those of you who have already donated to our legal fund, this is going to be pivotal in the next steps going forward. If you wish to make a donation, please find the links here:
- Link to donate monthly: https://donate.stripe.com/7sY00igRJgci28VeJybII03
- One-off Donation here: https://donate.stripe.com/9B69AS44X7FM28V58YbII04
Please reach out to us if you need any further support.
