Anaesthetists United (AU) welcomes the recent position statement from the Association of Anaesthetists (AoA). As key stakeholders it is important that the Anaesthetic workforce takes account of the direction that has now been set out by the AoA.

We emphasise that the provision of Anaesthesia must be led and overseen by physicians at all times. Anaesthesia Associates (AA) can only undertake work under the direction and care of an autonomously practising medical practitioner. 

The Royal College of Anaesthetists (RCoA) are working hard following the overwhelming mandate at the Extraordinary General Meeting (EGM) in October 2023. It is evident following the recent RCoA statement and the latest published Council Meeting minutes that the implementation of the EGM resolutions has taken a considerable amount of time and has taken resources away from the College. 

AU  recognises that  implementing the EGM resolutions is a significant undertaking and that due diligence is needed to ensure that its function as a Royal College and Charity is maintained, that legal liability is assessed and patient care is not compromised. We urge RCoA members to continue to support the College to ensure that it has a united and strong membership. 

There clearly remains significant concerns underlying the role of AAs within the workplace. We are encouraged that the College is undertaking further work including a far-reaching membership consultation, an independent academic literature review and a survey of clinical leaders. 

There is likely to be much more work to do to establish how best AAs can be integrated into the workplace given that the NHS Workforce plan proposes to increase AA capacity from 200 to 2000.  The Anaesthesia Associate Association (AAA) statement highlights the open letter from NHSE published on the day of the EGM claiming that such targets are “aspirational”. The letter itself does not use the term aspirational; rather stating that such targets shall be guided based on factors such as educational capacity, engagement with professionals and with Colleges. NHS England remains committed to expanding the numbers of Associates. 

Supervision of AAs

A study in the British Journal of Anaesthesia has recently demonstrated that the current model for AAs is not financially viable. To make economic sense either the level of supervision needs to be reduced, likely to compromise patient safety, or the AA programme itself should be terminated.

We note the AoA position that AAs should be supervised on a 1:1 basis. We are aware that the current published Scope of Practice (2016) for AAs advocates for 2:1 supervision. However, to add confusion to this matter, Therese Coffey has gone on the record to aspire towards 3:1 supervision. And more worryingly a previous AAA President spoke in terms of 4:1 supervision, without seeing this as a safety issue. 

It is crucial that the scope of practice and levels of supervision need to be clearly defined and agreed upon by all key stakeholders, including the College, AoA and the AAA. Levels of supervision should be at the forefront to ensure safe patient care. Any scope of practice or  document involving the integration of AAs into the workplace must have the full support of the AoA.

Locally governance regarding scope of practice should not be permitted – this position was overwhelmingly supported by College members at the EGM. Such clinical roles should only ever be reviewed and agreed upon at a national level by the key stakeholders, to ensure high standards are maintained uniformly across the country, and we urge all key stakeholders – including the GMC –  to support such a position. 

Expansion of the AA workforce 

The RCoA UK State of the Nation Report demonstrates a shortfall of 11,000 autonomously practising anaesthetists. AAs can not, in any way, contribute to this shortfall by virtue of the fact that they will always remain a supervised workforce. AAs however can complement and work alongside the Anaesthetic workforce in a limited manner. AU, like the AoA and RCoA maintains that the only possible solution to solve the Anaesthetic workforce crisis is to focus and direct resources into expanding the number of doctor training posts. Last year more than 2,500 doctors applied to Anaesthetic training with less than 600 offers being made. There is a doctor workforce ready, able and willing to be trained and it makes no sense to deny doctors the opportunity when it is evident that there is training capacity available.

AA Curriculum 2023

AU remains concerned regarding the implementation of the 2023 Anaesthesia Associate Curriculum. We particularly question the role of AAs in performing regional anaesthesia and neuraxial blocks, ASA 3+ cases (including emergency surgery and procedural sedation), resuscitation and transfer of unstable patients. We believe these should only take place under direct (Level 1) supervision, that the curriculum should be amended accordingly, and this should be supported by the wider Anaesthetic workforce after consultation. 

Faculty of Anaesthesia Associates

We are all aware of the problems the Royal College of Physicians has experienced hosting the Faculty of PA’s. We believe the RCoA members do not wish for a Faculty to be established, and that it would prefer to see a Committee or Board to oversee the education, training and standards for AAs. This would then be analogous to the SAS and AiT Committees. We believe it is crucial that standard-setting  for AAs remains within the College, in accordance with its Charitable objects. We urge the College to re-evaluate any  plans for a Faculty.

Social Media

AU remains concerned that some of the postings on social media remain a disquietude for Anaesthetists, AAs and, more importantly, our patients. Using such a public format to raise concerns portrays an image of discourse, anger, upset and distrust. It is an overarching necessity that the public must have confidence in the Anaesthetic community as a whole. 

This disquietude stems from the way two groups of professionals with radically different backgrounds have been placed alongside one another, with insufficient attention given to how they will integrate and work together. A more sensitive employer and regulator would give more attention to the practical issues around this. 

Conclusion

We urge that the RCoA delays publishing the “Planning the introduction and training for Anaesthesia Associates” draft document until the matters outlined above have been addressed. There remain significant concerns within the Anaesthetic workforce regarding important and fundamental principles including the scope of practice and curriculum. Only once these matters are resolved, and with the support of the membership who will supervise the AA workforce, should the document be published. 

We urge all parties to work together to resolve the crisis that is evolving in front of us.