After an incredible amount of work, led by the Royal College of Anaesthetists (RCoA) with input from the Association of Anaesthetists and the specialist societies, the Anaesthesia Associate (AA) Scope of Practice has been published for consultation. We strongly support this document, and advise anaesthetists at every level to take a look at it and respond to the consultation when it comes out. Engagement is absolutely crucial to provide the strength for our College to continue to advocate for members.
The full document is available here and there is also a summary.
It starts with the unambiguous reminder that AAs are
- Not doctors
- Not qualified to deliver anaesthesia or sedation without supervision
- Non-autonomous
- Must always be supervised by an autonomously-practising doctor (ie not a trainee or another AA).
Instead, the role of the AA is to work under supervision in preoperative assessment, provision of sedation, delivery of anaesthesia and a range of perioperative and non-perioperative support; all of which are defined with tremendous detail and care.
Standards relating to experience and performance
Experience and performance are inextricably linked. Our legal case against the GMC hinges on the fact that they have so far failed to set standards or issue meaningful guidance on these things, they will not say what can never be done by an AA, regardless of their experience, and are not planning to limit the role of AAs in any way.
The document defines three phases based on increasing experience – novice, years 2-4, years 5+. At each level the scope is defined, using a clear traffic-light system. Increasing experience is naturally linked to a wider practice.
But strict 1:1 supervision is still mandated in some areas, including ASA3+ cases, induction of anaesthesia (inc spinal anaesthesia), deep sedation and provision of sedation outside of theatres. At other specified times supervision must be no more than 2:1, with the supervisor remaining available within 2 minutes. With the exception of fascia-iliaca blocks, peripheral nerve blocks will remain within the remit of Anaesthesists.
In February, we published our own Position Statement on AAs, in which we raised our concerns over the safety of AAs working with higher risk patients. We are therefore pleased to see a clear statement ensuring that in these cases AAs can only work with 1:1 supervision.
Transition, support and consultant refusal
It has been known for some time that current AAs have been acting outside current RCoA guidance with local governance arrangements. Realistic ways of allowing this to continue in individual cases are proposed.
Outside of these transition arrangements, there is no support for AAs working outside the College scope.
Departments proposing to employ AAs must have appropriate support for their career development, and it gives guidance as to how this is achieved.
In addition, the document also acknowledges that not all clinicians would want their role to include supervision for AAs, and that it would be in everyone’s best interests to reach an agreement on this. We believe that this is an essential compromise. A reminder is provided that all clinicians must attend and support a colleague in the event of an urgent or emergency situation.
A model for other Colleges
Issuing meaningful guidance on experience and performance should be part of the bread-and-butter of every Medical Royal College and Faculty (just as much as standard setting and enforcement is the job of a regulator like the GMC).
So we are disappointed that the Academy of Medical Royal Colleges has been so unsupportive of our legal case. Our letter to the College Presidents has had only a few replies from individuals that wished us well but could not engage any further. Is that what Fellows of the various College expect from the Academy?
Our legal fight with the GMC is intended to ensure that well-researched documents such as this one from the College are properly enforced, and cannot be overridden at the whim of a hospital manager or clinical director. The current situation where College guidance can be overridden is unacceptable, and the CQC and the GMC should both be acting firmly to ensure patient safety.
This RCoA document is a significant step forward in the right direction. We ask all College members to take the time to read it and respond to the Consultation when it is released.