The Medical Independent has obtained submissions made during the HSE physician assistant review. Catherine Reilly takes a closer look
The Irish Nurses and Midwives Organisation (INMO) “opposes” the introduction of physician assistants (PAs) in Ireland, stated its submission to a HSE review process.
The submission, dated October 2025, reveals a position more entrenched than may have been clear from the published review.
“The INMO opposes the introduction of physician associates in Ireland on the grounds that international evidence does not demonstrate safety, efficacy, or added value, and such a move would undermine patient safety and public confidence in the health service,” stated the submission.
“Resources should not be diverted into an untested role that has raised serious concerns elsewhere.”
Investment must instead focus on expanding capacity to train nurses and midwives and increase advanced and specialist nurse/midwife posts. These are regulated professionals “whose contribution to complex care is central to Sláintecare, proven to improve outcomes, and vital to the sustainability of the Irish health system”.
While the INMO submission acknowledged the PA role was long established in the United States (US), it argued that the US healthcare model was “fundamentally different”.
The recent UK experience and the Leng Review (2025) were also noted. The submission cited a rapid review (Cooper et al, 2025) which, according to the INMO, “found insufficient evidence to justify” expanding the PA role in the UK due to “ongoing concerns about patient safety and health service efficiency”.
This rapid review sought to determine the impact of PAs, compared with physicians, on quality of care in the context of the UK policy review. “The evidence found in this [rapid] review is limited and does not support the safety or effectiveness of indirect supervision of physician assistants in undifferentiated (pre-diagnosis) settings,” stated the paper. Rather, the available evidence indicated that PAs “perform safely and effectively under direct supervision, working in post-diagnostic care, or doing procedures for which they are highly trained, working as part of a medical team”. National guidance on supervision and scope of practice “can ensure that they practise safely and effectively”, according to the authors.
Governance
The Leng Review, commissioned by the UK government, came on foot of serious patient safety incidents and concerns about how PAs were being deployed. It recommended that PAs should not see undifferentiated patients except within clearly defined national clinical protocols. It also advocated measures to support PA career development and endorsed the concept of an ‘advanced PA’.
The HSE review was not prompted by patient safety incidents. It arose from concerns (particularly among medical bodies) about a lack of clarity relating to PA purpose, scope, and governance.
The Independent Review of the role of Physician Assistant in the Irish Public Health System was published in May. The review, led by former Medical Council CEO Mr Leo Kearns, reflected a range of views among healthcare stakeholders.
“Consistent themes emerged, including the agreement on the need for a clearly defined and nationally governed scope of practice, strong emphasis on patient safety and clinical accountability, concerns about role overlap and potential substitution of NCHD training opportunities, and the importance of a robust governance and supervision framework, including regulatory clarity,” stated the review.
Some 38 PAs are working in HSE-funded services. The feedback from clinical teams which have a PA was positive.
According to the review, PAs were “consistently” described as providing valuable continuity and organisational support within consultant-led teams, particularly in environments characterised by high NCHD rotation, fragmented pathways, and operational complexity.
“Their permanent presence contributes to safer care through consistent documentation, reliable follow-up processes, and support for multidisciplinary communication, while freeing NCHDs to focus on training and clinical decision-making.”
However, the role had evolved without a “clear, nationally agreed” definition of its purpose, scope of practice, or governance framework. This had resulted in “considerable variability” across sites, uncertainty for clinicians and PAs, and avoidable risk.
The review made recommendations to support a governance framework locally and nationally. It outlined a core and extended scope of practice, and a ‘principle-based exclusions list’ (ie, activities that must not be delegated to PAs due to legal restrictions, required medical expertise, or patient safety considerations. Examples include prescribing medications and diagnosis). The issue of PA regulation was outside the terms of reference.
The review made recommendations to support a governance framework locally and nationally
The HSE has said it will work with stakeholders to implement the recommendations.
‘Invaluable’
Stakeholders could contribute to the review process through submissions or by participating in virtual consultation meetings. The HSE has released the submissions to the Medical Independent following a Freedom of Information (FoI) request.
Several submissions were made by consultants at Beaumont Hospital, Dublin, and provided an insight into positive experiences of integrating PAs.
A submission signed by five Beaumont consultants said the team’s PA has made a “measurable difference” to the service. The PA is “innovative in developing new pathways, efficient in managing patient care, and plays a vital role in both supporting our trainees and ensuring continuity for our patients”.
Their duties include attendance at consultants’ outpatient clinics weekly; booking patients for scopes, surgical procedures, and referrals as per consultant instruction; and ordering “appropriate” non-ionising imaging investigations; among other clinical work.
The PA actively participates in ward rounds, particularly during NCHD changeovers. They also provide support to NCHDs with documentation and practical clinical skills (catheterisation, cannulation, NG tube placement, etc).
They assist in theatre when required – particularly during post-take days and when NCHDs are absent due to leave or training.
The PA reviews and manages the surgical waiting list on a quarterly basis, reducing waiting times from 36 to 15 months (through patient chart reviews, contacting patients for outstanding investigations, and outsourcing suitable long-waiting patients after discussion with consultants). The PA has also established a ‘see and treat’ pathway for NCHDs and developed educational opportunities, including wet labs, audits, structured teaching, and journal clubs, among other contributions.
They work “in close collaboration” with the consultants and registrars, with “clear pathways” for supervision and escalation. “We strongly support the further integration of PAs across the Irish health service. With clear governance, regulation, and defined career pathways, their role can provide continuity, service development, and essential support for both patients and clinical teams.”
Another consultant at Beaumont described “several areas” in their surgical and cancer service where the PA was “invaluable”.
The PA undertakes the recording of clinical outcomes at the cancer MDT on a weekly basis. They help to coordinate this meeting and assist in coordinating patient care along with the team’s cancer nurse specialists.
“[The PA] is a constant presence to ensure that patients’ outcomes are recorded accurately, in a manner which junior doctors who are passing through our service in a transient manner find difficult.”
The PA has been “instrumental” in providing surgical assistance for the development of the robotic surgical programme. They are the first assistant at the bedside and robotic assistant during resectional robotic operations. The PA has developed “exceptional skills” in this regard.
“Indeed as our senior registrars passed through the unit it is [the PA] who at the bedside is able to instruct them on the safe exchange of instruments during robotic surgery.”
The work of the PA also allowed some of the basic administrative duties to be taken away from surgical trainees.
“The addition of a physician associate has only enhanced patient care, safety, and consistency with which we look after our patients. I have no doubt that if this role was to be rescinded or taken away, it would leave a large deficit which would be difficult to fill.”
Another submission from a consultant at Beaumont reflected similar sentiments.
I have no doubt that if this role was to be rescinded or taken away, it would leave a large deficit which would be difficult to fill
The addition of a PA within their team had improved efficiency by providing additional support in clinics and day theatre, and co-ordination of waiting lists resulting in a reduction in waiting times. The PA provided continuity of care and service for team members and patients, particularly during challenging times of the year, such as NCHD changeover. Their continued involvement in research and team activities “strengthens the service that we deliver” and enhances patient outcomes. The role was “well established and defined within the team”.
A submission from Cavan General Hospital outlined: “Their scope [at the hospital] is well defined, governance arrangements provide clarity and accountability, and their contribution to continuity of patient care and engagement is notable. Challenges remain around role clarity and limitations in acute care, but with safe deployment and appropriate clinical oversight, they represent a strong asset to the Irish healthcare system.”
The PAs at the hospital report to a named consultant “ensuring accountability and clarity of supervision”. Their work is “always consultant-led and delegated by same or [the] SpR, which helps define professional boundaries.”
Their scope of practice includes completing ward rounds on “stable patients” by taking histories, doing physical exams, making progress notes, and devising a treatment plan, which is only implemented after agreement with the team. The PAs prepare “detailed medical clinical summaries often with greater attention to detail”, and conduct clinics “with consultant supervision on differentiated patients”, among other duties.
RCPI
The FoI documents included submissions from three postgraduate medical training bodies. A synopsis of their views was presented in the review. It also noted their feedback amounted to “cautious or negative support for introducing PAs into specialty training environments at this time, pending definitive national decisions on role definition, scope of practice, governance, supervision, regulation, and patient-facing transparency”.
The RCPI submission sought to capture “cross-College emerging views” and address “collective views on opportunities and risks”. It highlighted areas that “would require clarification prior to seeking consensus” on a common position. “There are several reported benefits arising from the PA role,” the RCPI submission stated. “However, when examined none of these withstand scrutiny as unique to the PA role and indeed with proper reflection and consideration existing roles are better positioned to provide these same benefits.”
Continuity of care, for example, was “not something inherent” to the PA role. “Continuity arises from offering contracts of longer duration and this could very readily be applied to ANPs [advanced nurse practitioners], NCHDs, and staff grade doctors. The aim of a consultant delivered service is the ultimate solution to the continuity challenge.”
The fact that a PA can transfer their skills between specialties/departments “is often misrepresented as flexibility, suggesting they are working at a higher level, providing specialist care”.
“The flexibility simply arises from the fact they are providing low complexity, protocolised care. In a similar fashion a medical intern or SHO is highly flexible. Indeed, they offer greater flexibility as they have a clear expectation to extend their skill and competence over time.”
Alluding to the medical model of PA training, the submission said “much is made of training along the medical model”
“This is an overly simplistic presentation of clinical training. Medical training is a constant evolution and not a fixed model. It takes the best of teaching and learning theory available. Current training emphasises the value of interprofessional training. ANPs are just as capable at carrying out procedures and patient assessment having come through a ‘nursing model’.
“In a modern educational framework of outcomes-based education, arbitrary semantics about a fixed model are less relevant than clarity regarding the training outcomes required.”
It further sought to deconstruct any economic argument in favour of PAs. It referenced costs including supervision, onboarding, and the development of regulatory functions, governance, and industrial relations management.
“The intrinsic risk of cost related to clinical risk and medicolegal actions further erodes the argument. Further the opportunity cost of not investing [in] medical training pathways, the infinite flexibility that comes with a medical graduate and the path towards the ultimate goal of a consultant delivered service is high.”
It argued that the “diversion of limited consultant time” to supervise and mentor a new role “comes at significant cost to NCHD training”.
The RCPI submission said the effectiveness of current clinical grades should be supported and maximised. Only when such steps have been “exhausted” should there be any consideration of new roles in healthcare delivery. “RCPI is not planning to participate in physician assistant training or deployment.”
CAI
As noted in the review, the College of Anaesthesiologists of Ireland (CAI) does not support introducing anaesthesia associates (AAs) in Ireland. The CAI cited incompatibility with a consultant-delivered model of anaesthesia, unresolved regulatory and indemnity questions, potential diversion of training capacity, and heightened patient safety risks in time-critical, high-acuity environments.
The CAI recognised the urgency of addressing workforce challenges across the health system. However, the introduction of PAs – and specifically AAs – was “not the appropriate solution” for the specialty.
The CAI “will not participate in their training or deployment”. It said delegating core anaesthetic tasks to less-trained personnel – even with supervision – may place patients at risk, especially in smaller hospitals where consultant presence is not constant.
According to the CAI submission, it remained open to further dialogue. However, it “cannot support or participate in” the development or deployment of the AA role as currently proposed. National priorities should focus on expanding anaesthesiology training capacity, improving working conditions, and enabling multidisciplinary team models within a clearly regulated framework.
The Irish College of GPs made a short submission, which highlighted benefits and risks of the PA role. The College strongly emphasised the risks and drew from the UK experience.
‘PAs bring significant value – when used appropriately’ – ISPA
There is a risk of “overreliance” on physician assistants (PAs) – in place of doctors – “if governance is not maintained”, according to the Irish Society of Physician Associates (ISPA).
In its submission to the HSE review, the ISPA outlined benefits and risks associated with the role. The risks also included “role confusion among staff or patients if regulation and scope are unclear”.
The Society said the lack of statutory regulation may create risks in accountability and public confidence. In addition, PAs could be ‘misused’ through the allocation of “menial tasks” and excessive administrative duties.
The benefits included continuity of care (PAs “provide stability” within rotating medical teams.); workforce capacity; flexibility; improved patient experience (“accessible, consistent point of contact for patients”) and support for training (“PAs can reduce service pressures, allowing doctors more time for education and specialist training”).
Commenting on areas outside the PA scope of practice, the ISPA listed independent, unsupervised practice; prescribing (currently not legislatively enabled in Ireland); signing fit notes or legal certificates requiring a doctor’s authority; and undertaking tasks outside their competence or without appropriate supervision.
The Society said PAs “bring significant value to healthcare systems – when used appropriately”.
“Their role is designed to enhance, not replace, existing medical teams, and their integration can lead to improved patient care, better workflow, and reduced pressure an overburdened service.”
The ISPA’s submission explained its preference for the title ‘physician associate’ over ‘physician assistant’.
“The term ‘associate’ reflects partnership with doctors and the MDT, indicating a professional role with defined training and responsibilities. The term ‘assistant’ implies a subordinate or auxiliary function, which does not accurately represent the PA’s level of training, autonomy (within supervision), or clinical contribution.”
The ISPA said it encouraged members to be “transparent in their role when introducing themselves to patients, families, and colleagues”. It suggested a public information campaign to heighten awareness of the role when the grade is formally recognised.
Following publication of the HSE review, the ISPA welcomed “many” of its recommendations. The Society said it would like to discuss “some aspects” with the HSE and obtain clarification on the HSE employment embargo.
Ms Helen Farrell, outgoing ISPA President, told the Medical Independent it welcomed recommendations supporting the role’s safe implementation.
However, she said there is concern some aspects of the recommendations could lead to underutilisation of PAs, impacting on efficiency and recruitment.
Many established PAs believe the proposed scope of practice does not fully reflect the reality of clinical practice – and the qualifications and level of training of PAs in Ireland.
For example, the preparation of discharge summaries for consultant sign-off is part of the extended scope of practice. Ms Farrell said a PA, deemed competent by the consultant and who is involved in the patient’s care, can safely complete the discharge summary. In practice, she said, a discharge summary is based on a plan agreed with the consultant. Therefore, a blanket requirement for consultant sign-off would be inefficient.
Ms Farrell, who previously worked as an advanced paramedic, is a graduate of the RCSI MSc PA programme – the only such programme in the Republic of Ireland. From 2016 to 2025, about half of students in the RCSI programme had prior professional experience in a clinical setting, with nursing representing about half of all clinical entrants in 2025.
The RCSI has consistently emphasised the stringent entry criteria. Applicants to the 24-month programme must hold at least a level 8 science/health science degree (minimum 2.1), provide official transcripts, references, a personal statement, and attend an on-campus interview.
According to the review, the success rate of all applications (percentage of applicants who successfully enrolled) has gradually increased from 20 per cent in the initial years of the programme to 30 per cent.
When on placement during the RCSI programme, PA students are required to complete the RCSI competency booklet of clinical skills (the same booklet used by RCSI medical students). The competencies must be observed, performed and signed off by the teaching NCHD/consultant.
Post-review
Ms Farrell said that, to her knowledge, there had been no changes to PAs’ day-to-day working since the review’s publication.
The review said implementation of governance frameworks “may have variations” necessary to reflect local circumstance. It also recommended a national process to facilitate hospitals to apply to expand the local scope of practice for a PA.
Ms Farrell expressed optimism that medical bodies that do not currently support the role may change their position – particularly through greater direct exposure to PAs.
Meanwhile, she said the HSE recruitment embargo has “negatively affected morale and mental wellbeing across the profession”.
Ms Farrell said the HSE invested €750,000 in the training of over 30 PA students at the RCSI (in return for a service commitment). She said the students had an understanding they would progress into HSE employment upon completion of the programme and the national PA exam.
This investment was viewed as a “progressive step” for the future of Irish healthcare.
However, months after this agreement was established, the HSE instigated a hiring embargo and a national review. Ms Farrell said it was incomprehensible these now qualified PAs are being overlooked with new public healthcare facilities coming on stream.
Approximately 80 PAs are registered with the ISPA. There are 38 PAs working in the public system and 20–25 working in private healthcare.
A HSE spokesperson said it is engaging with the Department of Health to secure a PA grade code and salary scale, relevant to the scope of practice outlined in the review. This will also require approval from the Department of Public Expenditure.
“Every effort will be made to expedite this process.” The recruitment of new PAs “remains on hold” until this matter is concluded.
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