Anaesthetists United response to the current GMC Consultation on Associates highlights the failure of the GMC to consult on scope of practice – arguably one of the most contentious issues in the entire debate. We consider that Section 3 of the Anaesthesia Associates and Physicians Associates Order makes it a requirement to consult on this, and that the failure to include this topic renders the consultation invalid and incomplete.

We also consider that the consultation does not go far enough in addressing issues around consent for treatment. Patients should be made aware if and when an Associate is to be involved in their care – this is alluded to in current GMC guidance on consent – yet this requirement can be overlooked.

In general, there is a lot in the GMC’s proposals that we approve of, but in our response to their consultation we have highlighted these issues. Our full response is quoted below.

Response to the GMC Consultation on Associates

An immense amount of work has gone into the GMC development of the rules, standards and guidance for AAs and PAs, and we approve much of it. We would like to comment on a small number of specific issues.

Curriculum Standards

What is expected of an Associate?

We strongly approve CR1.2 which states that curricula must Describe the knowledge, skills and capabilities expected of a graduate. Given that associates make up a new profession where the capabilities of practitioners are largely unknown or ambiguous we think this requirement is essential. Similarly, we approve CR1.5 which states curricula must  Demonstrate how the key interdependencies between the curriculum and the training and practice of other healthcare professionals have been identified and addressed. 

Where a Scope of Practice already exists, for example in the case of Anaesthesia Associates, the curriculum should work within that Scope.

Other groups involved in curriculum development

CR2.5 requires input from professional bodies involved in research and policy. However it does not explicitly mention seeking involvement from those doctors who will be supervising associates. Given that associates are always to be working under the supervision of doctors, and that the levels and details of supervision need to be manageable and practical, we think that representatives of doctors should be explicitly mentioned in this section. 

CR2.5b – we think input from  patients, relevant patient groups, carers and lay people is too demanding especially in the case of anaesthesia where the state of being a patient is very transient – the and in this clause would be better as an *or*.

Linking the curriculum to ‘Good Medical Practice’

CR3.3 We have written to you separately to explain how ‘Good Medical Practice’ cannot apply to associates since they are not medical practitioners, and that it must be replaced with ‘Good Associate Practice’ aimed at those who are in associate practice. 

With that caveat, we agree with the underlying principle that this guidance should be tied to the curriculum. This comment applies to all other references to GMP in the consultation.

Redundant form-filling

CS4.2 As well as removing redundant elements of the curriculum we would like to see the burden of unnecessary form-filling removed. 

Course Standards

Supervisors should be named

R1.8 Organisations must make sure that learners on placement are supervised, with an appropriate level of clinical supervision at all times by an experienced and competent supervisor, who can advise or attend as needed. 

We suggest that this is reworded as “…. supervision at all times by a named experienced and competent supervisor

The timing of supervision

R1.9  Learners’ responsibilities for patient care must be appropriate for their stage of education. All patient care must be reviewed by a supervising healthcare professional 

We suggest that this is amended to clarify that patient care must be reviewed by the supervising doctor (rather than the ambiguous use of healthcare professional), and that the review should take place before the patient is discharged.

Procedures that require consent

R1.11 states that  Learners can only carry out consent tasks under the direct supervision of the medical professional who is responsible for the consent being taken 

The wording on this is ambiguous and unclear, and it needs to be reworded. However there is a much bigger issue around consent that has been glossed over. In their guidance on consent the GMC states that ‘the names and roles of key people who will be involved in their care’ should be shared with patients. This statement necessarily requires that if an Associate (or learner-Associate) holds a key role in treatment then that information should be part of the consent process.

This would tie in to the motion passed at the Royal College of Anaesthetists EGM last year that ratified as a professional standard the need to inform patients, when applicable, that an AA could be involved in their care, that an AA is not a registered medical practitioner, and who their responsible Consultant Anaesthetist is.

We therefore propose that R1.11 is reworded as:-

Learners can only carry out tasks that require informed consent under the direct supervision of the person who obtained consent from the patient; and patients must be made aware when they give consent, when appropriate, that associates will be involved in their care.

Failure to consult on Scope of Practice

We note with dismay the preamble to the consultation which states:-

What this consultation is not about  … we’re not consulting on …. the scope of an AA and PA’s practice – it isn’t the role of the regulator to determine what tasks individual professionals can safely carry out once they are registered with us, because that depends on their individual skills and competence, which develop over time. We won’t determine scope of practice for AAs and PAs beyond initial qualification competencies, just as we don’t determine it for doctors. We know that NHS leadership, employer bodies and royal colleges have begun looking at how AA and PA scope of practice may develop over time. We welcome those developments and encourage involvement of the AA and PA professions in them also.

We consider this statement to be misleading, and that the issue should have been part of the consultation. We do not agree that setting scope of practice should be relegated to market forces. And, while it is possible that the results of the consultation would agree with the GMC’s chosen position, that cannot be taken for granted.

The Anaesthesia Associates and Physician Associate Order (AAPAO) was introduced to Parliament under Schedule 3 of Section 60 of the 1999 Health Act. Such an order may make provision for establishing the “privileges of members admitted to practise” in a new profession. Section 3 of the AAPAO gives the regulator power to determine standards applicable to associates … [relating to] … knowledge and skills, experience and performance (and such other matters as the Regulator may prescribe) and places on it the requirement to consult before determining this standard. Article 8 also allows for the Regulator to impose conditions on practice.

In short, Parliament has given the GMC the power to set scope of practice had the regulator wished to, and has placed on it the requirement that it consult. We therefore consider that the current consultation, with respect to this issue, is inadequate and incomplete.