Abstract Background The NHS has introduced a range of new and extended roles in recent decades. Physician associates / assistants (PAs) have become one of the most politically scrutinised of these roles. In 2024, the UK government-commissioned Leng Review highlighted national concerns around the clarity, governance, supervision, and career development of PAs, but offered limited guidance for NHS organisations to operationalise them. This study, initiated prior to and independent of the Leng Review, examined how NHS hospitals and clinical teams in England and Scotland develop, integrate, retain, and support PAs in practice. Methods We conducted a multiple-case qualitative study across five NHS organisations in England and Scotland. Semi-structured interviews (n = 126) and one focus group (n = 8) were undertaken with PAs, consultants, resident doctors, other team members, senior organisational leaders, and stakeholders involved in workforce planning, supervision, and governance. Data were analysed thematically using a framework informed by prior scoping review and organised across macro (system), meso (organisational), and micro (individual/team) levels, with within- and cross-case comparisons. Results We identified 12 themes across macro, meso, and micro levels of the health system. At the macro-system level, labour market dynamics, fluctuating policy and regulatory signals, and wider public and professional debates, influenced organisational confidence in the PA role. At the meso-organisational level, PA role implementation was sometimes driven by well-intentioned local leaders responding to service needs but with short-term business case logics and pragmatic pressures, rather than long-term workforce planning. Governance arrangements were often developed retrospectively and inconsistently communicated. At the micro-team level, PAs’ interpersonal skills and contribution to continuity of care were widely valued, though progression remained highly variable and reliant on local supervision and individual negotiation. Conclusions The development, integration, retention, and career progression of PAs in hospitals are shaped by interacting system, organisational, team and individual influences. Many of these challenges reflected wider NHS workforce implementation dynamics, rather than features unique to PAs. To continue to support safe, effective, and sustainable use of PAs, and other new and extended roles, organisations and clinical teams need strong workforce planning, local change management processes, and fair career pathways.
Zhao et al. (2026) studied this question.