“Anaesthesia Associates are basically a solution without a problem. We need more anaesthetists who can do the work needed.”

The results of an independent survey, commissioned by the Royal College of Anaesthetists by ‘Research By Design’ and published today did not come as a surprise. But they make for difficult reading. 

They clearly indicate that support for AAs has been overestimated, and reinforce the mandate conveyed by members of the College at the EGM held last October on pausing expansion.

The sample size

This was a comprehensive and detailed survey with over 6000 respondents. Despite a slight over-representation of Anaesthetists-in-Training (AiTs) and an under-representation of SAS and Locally-employed (LED) doctors it represents 34% of College membership – a huge sample and significant result. 62% of the respondents had worked with AAs, and the results have been analysed and  presented in order to separate the views of those that have/have not had this personal experience. 

Overall impressions of AAs

Overall, the responses give a clearly negative opinion of AAs. In total 62% of respondents expressed a negative overall opinion of AAs, while only 15% were positive. Those that had worked with AAs directly held a more positive opinion but, even amongst those consultants that worked alongside AAs on a daily/weekly basis, only half of them gave a positive opinion.

The opinions amongst AiTs were more negative than amongst consultants and SAS/LED doctors with only minor differences between those who had worked with AAs and those who had not. That is to say, there is no evidence that the ill-will stems from having no previous exposure and that it would all be just fine “if only they could see”.

Specific areas of concern

This general picture and overall opinion towards AAs maps broadly onto more specific questions about the role and impact of AAs. There were concerns from all sides regarding safety, the impact on training and efficiency.

Impact on safety

Only 22% of the total respondents were confident in the ability of AAs to provide safe high-quality care. This proportion varied in the different subgroups, But even amongst those consultants working with them on a day-to-day basis there were still only 56% that felt confident in the AAs abilities

Both amongst SAS/LEDs and AiTs working directly with AAs there was a greater proportion who are not confident in the abilities of AAs than confident.

“AAs are not medically trained. They have dangerous gaps in their knowledge, including of how to manage emergency situations. I believe they pose a massive risk to patient safety, and serious incidents and harm will result from the expansion of their role.”

“When trained and managed well, AAs have a massively positive impact and are fantastic assets to the department. AAs allow consultants to be freed up to provide consultant level care for the more highly complex patients whilst still ensuring the less complex patients get excellent care with consultant oversight. We regularly review PACU data for our AAs which is consistently at or above the departmental average set by consultants. The AAs get regular excellent feedback from patients. 

Consultants who have worked directly with AAs

“They [AAs] are of variable skills and quality – some being better than others. I do not think AAs deliver as high-quality care compared with doctor anaesthetists as they have gaps in knowledge.”

SAS/LED who has worked directly with AAs

Training

The majority of AiTs felt that the presence of AAs in their hospital hindered training. 57% of AiTs who had worked with AAs believe that the presence of AAs has had a negative impact on their training – only 3% report a positive experience.

The consultants that had worked with AAs were more negative than positive about the impact of the presence of AAs on the training that they had delivered. Even amongst those that now worked with them regularly only 37% of them believing they were a help in training AiTs, with a similar number believing they were actually a hindrance.

“Trainee AAs require FAR more support than AiTs. This adds a significant amount of workload sometimes to very busy emergency lists. Even AAs who have completed training don’t add as much as an AiT does.”

“AAs have taken over regional anaesthesia block lists to run parts of the service in hospitals I have previously worked in. This reduced exposure of trainees to regional anaesthesia. Also, simple lists with ASA 1/2 cases which would be great for AITs were being done by AAs hence reducing clinical experience for AiTs”.

Consultants who have worked directly with AAs

Scope of Practice

The overall feeling of respondents is that the range of cases that AAs work on should not be widened, and nearly half of respondents felt that the range should be narrowed. Opinions again varied amongst subgroups but in each the call for narrowing, rather than widening, scope received more support.

Work on defining scope of practice is continuing, and as previously stated  we believe 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. We think the statements from the GMC and other Colleges, calling for scope of practice for Physician Assistants to be determined by local employers, is very mistaken and likely to lead to patient harm 

Effect on workload

A perceived advantage of associates is that they can somehow reduce consultant workload. This was not borne out by this study, with more consultants (who had worked with AAs) reporting that AAs actually increase, rather than decrease, their workload.

A greater proportion of SAS/LEDs cite AAs as being helpful (43%) compared to those who cite them as being a hindrance (30%), though  the median for this group indicating that AAs ‘neither help nor hinder’.

Value for money

10% of respondents believe AAs provide good value for money. 59% feel they offer poor value for money, with 31% indicating they provide ‘very poor’ value for money. A recent BJA article makes clear that the AA model is financially unviable. It is crucial that a costing analysis is undertaken to address this matter, particularly at a time when the NHS is under considerable financial constraint. 

Further expansion of AA numbers

There was considerable negativity to the expansion of AAs in the NHS by all subgroups. Less than 10% of respondents supported the expansion overall, and even in the most favourable subgroup (consultants that worked with AAs daily) the majority had a negative view of expanding the numbers. 

This reaffirms the motion passed at the EGM calling for a pause in the expansion, and the actions of the RCoA in implementing this. 

It is becoming evident that following the results of this survey, and the mandate set out by the EGM, the College should reconsider the need for the establishment of a Faculty for AAs. The needs of AAs might be best approached through a committee structure.

Conclusions

The College should be congratulated for carrying out this comprehensive survey and presenting the results so clearly and openly. But this independent consultation demonstrates that the workforce at large is deeply concerned with the expansion of the AA workforce. AiTs take a more negative view of this than consultant and SAS/LED doctors, but even those consultants working with AAs on a day-to-day basis are remarkably, and consistently, negative in their outlook.

In her comment on the survey, President Fiona Donald summarised that  “….the most significant concerns relate to aspects of patient safety and quality of care and to the negative impact on training opportunities for anaesthetists in training. We take these findings extremely seriously. Taken in context of the views expressed at the Extraordinary General Meeting last year, the survey findings reinforce the case for a pause in recruitment of new student AAs.“

Perhaps rather than a temporary pause in the expansion we should now be looking at making this pause permanent.