Association of Anaesthetists submission to Leng Review
The Association of Anaesthetists is the largest membership society for anaesthetists in the UK. Our members include consultant, resident, SAS and locally employed doctors in anaesthesia, with just over 10,000 members. This submission is also supported by the Association of Paediatric Anaesthetists of Great Britain and Ireland, Regional Anaesthesia UK (RA-UK) and the Society for Obesity and Bariatric Anaesthesia (SOBA UK).
Patient safety is one of our key areas of involvement and one of our core charitable aims.
Our comments relate to anaesthesia associates (AAs). For clarity, AAs are medical associate professionals (MAPs) who anaesthetise patients under direct or indirect supervision of an anaesthetist (a doctor specialising in anaesthesia). They are not the same as physicians’ associates (PAs), who often work in a support role. Their qualification and training are distinct from that of PAs.
The Association has been involved with the development of the AA role for many years. We were joint authors of the 2016 scope of practice document with the Royal College of Anaesthetists (RCoA) and were represented on the Clinical Reference Group and the Core Writing Group for the 2024 Royal College of Anaesthetists interim scope of practice. We have also been party to many of the discussions that have taken place along the way. Our members have been vocal in expressing their diverse range of opinions covering the full spectrum, from support for widening scope to complete objection to the role. Consequently, we feel able to add value to your review.
We would like to make the following points to the review:
General
- It is of profound regret that a review of the AA role is taking place only now, after the role has been created, implemented and made subject to regulation. One conclusion of the review should be to recommend this order of events never be repeated. Consultation on any new role should always come before implementation.
- The following two points have already been made to the review under separate cover:
- Given our central role in patient safety and our key involvement in the AA role for many years, we were disappointed and somewhat bewildered that we were not included as stakeholders in the review, nor invited to the recent round table launch discussion. This is despite making contact with the review team at the outset and making our availability clear. Of all the stakeholder organisations, only one (RCoA) represents anaesthetists. We believe our 10,000-strong membership will share our bewilderment. We understand that the review will include “thematic workshops on a range of relevant topics such as scope of practice” and we formally request to be involved in these. Time cannot be turned back, but we remain ready and willing to engage.
- We note that the review will include “a bespoke survey to PAs and AAs and to the teams that work with them”. We believe that this is a vital input to the review which must happen. However, we have seen no such survey launched yet and time is short if the evidence-gathering phase is to be complete by the end of February, as stated. We urge the review team to address this matter and launch the survey.
Scope of practice
- We believe that the scope of practice at qualification and in extended roles should be set nationally and not by local governance. This is to guard against local opt-outs of key safety
provisions and to protect against degradation
of standards that could be sanctioned locally and lead to patient harm.
- We request that the review accepts the 2024 RCoA interim scope and does not recommend any changes. It should be allowed to go forward and be implemented and data should be gathered prospectively about the implementation and safety of the AA role with the RCoA scope of practice as the governing document.
Gathering and interpretation of evidence
- The inputs to the review will generate many submissions. However, there is still precious little genuine evidence available.
- Greenhalgh and McKee and colleagues have published thorough and up-to-date evaluations of how we got to where we are, and these papers should form part of the evidence included in this review.
- In the interest of clarity and transparency, we request that the review’s final report grades the quality of all evidence used, employing a recognised scheme for doing so, such as the GRADE system promoted by Cochrane.
- The review team should remain particularly conscious that examples describing AAs working in extended roles beyond the scope specified in the interim document or working under lesser supervision levels than those laid out in the new scope are largely the province of those with an interest in championing the role. This naturally involves very driven, enthusiastic individuals providing a very high level of overall scrutiny. This cannot be taken to be generalisable to all situations.
- Likewise, even excluding those AAs working in extended roles, there are still fewer than 200 currently practising in the UK and this cannot necessarily be used as evidence of scalability as was proposed in the NHS Long Term Workforce Plan.
- Any evidence about the implementation and safety of the AA role should be gathered prospectively, starting now. Historic data, gathered from selected sites, when the AA role was unregulated and when there was no published scope for extended roles, should be scrutinised and considered, but should be viewed through a narrow lens with patient safety at the heart. It is also imperative that a lack of data on harm is not equated to non-inferiority.
- Similarly, models used elsewhere in other health care settings that may be submitted to the review cannot be taken automatically to be applicable to the UK health care setting. They should be viewed critically and assessed for equivalence before any conclusions are made.
- The Royal College of Anaesthetists carried out a detailed member consultation, relating to its interim scope document with over 3000 respondents, comprising resident, consultant and SAS anaesthetists. We contributed responses to that consultation and we agree with its findings.
- The RCoA consultation is important, as it provides the largest survey of the group of doctors who train and supervise AAs. It is also important because the AA role is a dependent role and its safe implementation depends upon the ‘buy-in’ of the doctors supervising it.
- The RCoA consultation showed that a wide range of views exist, some supportive of the AA role, some not. The majority view was that the interim scope of practice was one which could be implemented, but the results contained caveats. For instance, only 22% of respondents were confident that AAs could provide safe high quality patient care, which is the cornerstone of anaesthesia practice.
- We believe that the RCoA’s consultation is credible, as evidenced by the range of views its report contains. Contrary to some commentary, it is not wholly negative and contains positive views.
- We expect the review team will closely scrutinise, critically assess and comment upon the equipoise and origin of the RCoA consultation report and any other surveys submitted as evidence.
Other members of the workforce
- Resident anaesthetists will be the supervisors of the future. In a time of a workforce crisis (with an anticipated shortfall of 11,000 anaesthetists by 2040) a larger proportion report a negative impact than positive on their training when working with AAs. A majority of residents in the RCoA consultation raised concerns about the impact of AAs on the training of residents and regarding patient safety.
- The Association believes that more should be done to invest in the SAS and LED workforce, which already contributes substantially to anaesthetic service delivery and is often overlooked in the allocation of training and other resources. Developing SAS and LED careers would offer a more sustainable, useful and potentially more cost-effective option. The review may consider this particular point outside its remit, but we suggest it is worthy of highlighting.
- Consultants and some SAS doctors are autonomous providers of anaesthesia and require no supervision. The review should not lose sight of the value of training resident, SAS and LED doctors to become autonomous providers of high-quality anaesthesia.
Indemnity
- Despite assurances, doubts and uncertainty remain about issues of indemnity, both for supervising doctors and AAs themselves. There remains a need to address this uncertainty.
Patient autonomy
- Patients have an absolute right to know who is treating them, the training that individual has undergone and the alternatives available. Informed consent requires access to at least all of the above. The RCoA has written clear guidance on how health professionals in anaesthesia should introduce themselves and the review might consider them worthy of extrapolation outside anaesthesia.
Financial impact
- The introduction of MAPs was premised on the idea that this would provide a cost-effective solution to workforce shortages by operating under a supervision model that maximized efficiency. However, current salary levels undermine this economic rationale. For a 2:1 supervision model to be economically viable, AAs would need to earn less than half the salary of their supervisor. With current Agenda for Change bandings this is not the case.
- The review should recommend that any plan to expand AA numbers should not be at the expense of the finite financial resources and training opportunities for the training of resident, SAS and LED doctors.
International registration
- We note that the GMC has opened registration for MAPs with overseas qualification. They have specific guidance for those seeking registration as AAs (and likewise for PAs). The review should satisfy itself that these provisions are appropriate.
We thank the review team for taking our submission into account.
Signatories
Dr Tim Meek, President, Association of Anaesthetists
Dr Emma Wain, Chair, Association of Anaesthetists SAS Committee
Dr Sarah Marsden, Chair, Association of Anaesthetists Resident Doctors Committee
Ms Nicky de Beer, Chief Executive, Association of Anaesthetists
Dr Simon Courtman, President, Association of Paediatric Anaesthetists of Great Britain and Ireland
Dr Nat Haslam, President, Regional Anaesthesia UK (RA-UK)
Dr Andrew McKechnie, President, Society for Obesity and Bariatric Anaesthesia (SOBA UK)