Position statement on Anaesthesia Practioners (February 2006)

We are aware that in recent weeks the support of both the Royal College of Anaesthetists (RCOA) and the Association of Anaesthetists (AAGBI) for the Anaesthesia Practitioner (AP) project has been called into question on several occasions. We acknowledge that some of our colleagues are fundamentally opposed to any form of non-medically qualified assistance with the direct delivery of anaesthesia and we respect this view. Indeed we have done so in situations where we have supported such opposition in the face of Trust management keen to introduce anaesthesia practitioner training. We believe that a clear explanation of the current situation and our future plans is necessary to allay some of the fears which appear to be prevalent at the present time.

Where are we at present?
The New Ways of Working in Anaesthesia (NWWA) project has been running for three years and has reached a stage where the initial five pilot site projects are nearing completion. A great deal of progress has been made to date in the development of a national curriculum and establishment of a second round of pilot sites; still more work is needed both in these and also over the issues of registration and regulation. In order to encourage individual departments interested in development of the AP role to join the national programme, the Stakeholder Board has recently invited bids from NHS Trusts to enrol in September 2006.

Assessment of the pilot sites and evaluation of the roles that Anaesthesia Practitioners (APs) might play within the anaesthesia team have always been integral parts of the project. To date there have been no formal assessments of the pilots, nor will this be practical for at least another year. Even then, there will be a need to explore the roles of APs in the future. The RCOA and AAGBI agree on the importance of continuing to support the AP project until the information from the pilot sites has been fully evaluated. At the same time, it is important to accept that moderate expansion may take place within the pilot project.

It is appropriate at this stage of the project to reflect on the progress to date and to check that the assertions under which the project was developed still hold.

Background to the project
The original premise under which the AP project was developed was of a predicted and unavoidable workforce shortage of anaesthetists in the next decade. As a result, the development of a new role, the Anaesthesia Practitioner, was considered a possible addition to the anaesthesia team that could help to alleviate the predicted shortage in a similar way to that which exists in other countries. The development of the role also linked with an expansion of support roles for other groups of medical staff including surgery and medicine.

Workforce predictions
Workforce predictions made in 2000 suggested that the UK would have too few medical anaesthetists to meet the expansion proposals of the then NHS plan and the anticipated impacts of the 2004 and 2009 implementation of elements of the European Working Time Directive (EWTD). The NWWA programme started in 2002 as a joint project between the Royal College of Anaesthetists and the NHS Modernisation Agency within the English Department of Health (DH) to investigate a potential role for non-medical practitioners in the UK. In order to undertake a feasibility evaluation, a Stakeholder Board was established to include all with a direct or indirect interest in the project.

The Pilot Scheme 2003-2007
In 2003, five Trusts started as pilot sites for the programme, and in 2005, an additional 21 Trusts joined, with 34 trainees organised in seven training clusters. The NHS University commissioned an AP training curriculum from the University of Birmingham, and arrangements were proposed by which the RCOA would undertake a final assessment of APs before their registration. At present, three universities are delivering the programme, Birmingham, Hull and Hertfordshire. Currently, arrangements to establish a voluntary register of APs are under discussion, as are equivalence arrangements to allow assessment of the training of overseas applicants. At present, there are no qualified APs in UK. Five students should qualify in October 2006, and 34 more should complete their training in 2007.

Recent Changes
Since 2002, the NHS has changed, and will continue to change substantially. The NHS tariff, the increasing policy of outsourcing elective work to the independent sector, financial problems in acute Trusts, increased but varying numbers of overseas doctors in the NHS, increasing numbers of medical graduates in the UK, the impact of Modernising Medical Careers and concerns over medical unemployment have radically altered the way that healthcare is likely to be delivered in the future. It is important to ensure that the continuing development of Anaesthesia Practitioners is appropriate for the future NHS. With the impending dissolution of the current Stakeholder Board and transfer of overall responsibility for the future of the project to the RCOA, it is essential that action is taken now to ensure the effectiveness of the role.

We believe that the pilot project must continue to be clearly and unambiguously supported, to ensure that all the questions about the suitability and practicability of APs working in the UK are properly answered, whatever the ultimate outcome. A significant number of individuals and departments have devoted enormous energy and effort to the development and delivery of the project to train APs for the potential benefit of us all and they deserve our support. Those opposed to the project believe that if the College and the Association simply withdrew their support, the project and APs would cease to exist, but this is simply not the case and certainly should not be allowed to happen. We would like to remind everyone that our initial involvement in the Anaesthesia Practitioner project came about because we learnt that the Modernisation Agency was looking seriously at developing the role itself in a variety of settings and we believed that it was far better for us to become involved at the outset rather than watch others do it outside the influence and control of the National Anaesthesia Bodies. However, rather than simply join as observers, the RCOA realised that full engagement with the project was all important and that any development should be based on sound experience and clearly directed for the benefit of patients and our anaesthetic services.

As a result, a number of us undertook a detailed evaluation of the variety of ways in which non-medical staff contributed to the delivery of anaesthetic services in Holland, Sweden and the USA, to ascertain the most appropriate way forward for our pilot project (The Role of Non-Medical Staff in the Delivery of Anaesthesia Services 2002 www.rcoa.ac.uk). If we withdraw our support now, the project will still continue, but the national bodies representing anaesthesia will have lost control altogether. The project will fragment, but then rebuild outside our current structures and processes. In order to prevent this, the RCOA is seeking to take the administration, accreditation and registration of the project into the College to ensure that we retain control.

Workforce Concerns
Nevertheless we acknowledge a serious concern over the future workforce need for APs, which centres around doubts over the accuracy of the College’s workforce predictions for the future. How do we know we will really need APs? There are two areas to consider. Firstly trainee numbers and one concern expressed is over what happens if the assumed evolution towards a consultant delivered service stops? Is this fundamental shift in service provision crucial to future workforce predictions in terms of trainee numbers? Irrespective of the actual numbers involved the current situation of trainees delivering service is unsustainable in the long term for two reasons:

  • If we continue to use the same number of trainees to deliver service work, but don’t create consultant posts for them to take up, based on our current numbers we will overproduce by about 240 CCT holders each year.
  • If on the other hand, service work which trainees undertake is transferred to career grade posts, once we have a full complement of career grade staff delivering the service, trainee numbers will inevitably fall to a number sufficient to replace retirements.

In addition to this fall in trainee numbers, the second area of concern is over career grade posts. There is already competition for consultant posts in some parts of the UK and with the increased intake into medical school, such competition will only increase. In short, the fear is that APs will take away jobs from fully-trained medical anaesthetists by being a cheap option. We must, of course, address the whole of the UK and the availability of anaesthetists varies markedly across the country. Furthermore will consultants really want to take over all the duties and service commitments currently undertaken by trainees, when, as they inevitably will be, trainee numbers are reduced in the future?

In order to address these issues, the College is undertaking a review of its workforce predictions in the next few months, using two separate methods to test different predictive models. Workforce planning is never an exact science, with major variables such as service demands, changing workforce demography and aspirations to name but three. We will make every effort to make realistic and sensible predictions for the future and this should help us estimate the need for all grades of anaesthetists as well as APs.

The key issue is what role APs will play as part of the anaesthesia team of the future? We must stress yet again that they are not a cheap substitute for anaesthetists and they are not there simply to address a shortfall in medical anaesthetic recruitment; please read the article by David Greaves in the January College Bulletin entitled “Anaesthesia Practitioners – 12 questions answered”. The plain truth is that whatever our study of workforce numbers shows, the way in which anaesthetic departments deliver their service responsibilities will change and APs will provide an additional option for departments to consider in developing an anaesthetic team and department which will work in the 21st century. There is no doubt that with consultant expansion and the increasing move towards a consultant-delivered anaesthetic service, trainees numbers will decrease and our ability to depend on their service contribution will diminish. Once the speciality is saturated with consultants, we will only need to train sufficient anaesthetists to replace consultant vacancies. Based on current predictions, this will require about half the current number of trainees and it is this workforce gap which we must worry about. How will a department function with half the number of trainees or maybe none at all if they are concentrated in fewer training departments as happens in many other countries? While few consultants undertake all their lists without any medical help at all, many of us undertake much of our work in this way and the occasional presence of a trainee has many advantages. How will we manage the difficult case which might need two anaesthetists, who will go and see the patient who is added to the list or who only appears in hospital after the start? Who will look after the patient in theatre, while the anaesthetist goes to see patients in the recovery room? How will patient safety be assured if the anaesthetist needs to take even a short break during a long case? It is this support role for which we rely heavily on trainees at present and which will need replacing by another member of the anaesthetic team in the future.

Proposed action

  1. Any significant change in practice from the 2000 workforce projections is likely to challenge the premise upon which the AP project was established. In order to verify the continuing validity of the predicted workforce data, an urgent review needs to be conducted. This review should pay particular attention to the effects of the current changes in the NHS and should attempt to project likely workforce needs over the next 10-15 years. This review of course must extend beyond the needs of individual professional groups and must look at the future requirements of the whole anaesthetic team and service. The results of this review may or may not confirm that there is an impending significant shortage of medical anaesthetists. In order to ensure that local issues are considered in this review, each hospital will be contacted to provide appropriate information including the influence of the changing NHS, and the altering demography of future anaesthesia providers. This may demonstrate an improving, or a worsening capacity to deliver anaesthetic services.
  2. While the RCOA and AAGBI will continue to support existing pilot sites, they have maintained the consistent position that the existing pilot programme needs robust assessment to evaluate its true potential for UK anaesthesia before the project can be fully ‘rolled out’. This assessment cannot be carried out at present but will need to be undertaken after the Phase Two students qualify, and then again two years after APs have been working in the NHS, i.e. in 2007 and 2009. Any attempt to judge the scheme now would be premature.
  3. Only when these reviews of workforce and the AP pilot sites are available will the Department of Health and the profession be able to assess the need, practicability, safety, cost effectiveness and desirability of APs. At that stage, changes to AP roles, relations, training and curriculum may become necessary to tailor their input to the needs of the NHS. It will also be the time to evaluate the success of the direct entrance of science graduates into the trainee AP programme.
  4. The importance of proper assessment and evaluation of the existing sites, and the need to allow time for such, must not lead to the development of ‘alternative’ AP projects. While both the RCOA and AAGBI continue to support existing pilot sites to ensure that the interests of patients, trainers and trainees are fully represented, we do not support any other AP training programmes outside these official ones.
  5. The RCOA’s formal review should include consideration of the extra anaesthesia capacity created by APs, a review of their impact on the training of anaesthetists, anaesthesia safety and how the role actually evolves in the workplace, which may be different from those anticipated. This may result in the curriculum being re-designed to ensure that the AP programme is fit for purpose. Additional data on recruitment and retention, and the introduction of science graduates will be also be important. The RCOA and AAGBI do not support significant expansion in the numbers of trainee APs until results from the planned workforce review and from an evaluation of the existing pilots have been properly assessed.

The College and Association are both committed to supporting the project in the expectation that it will be properly evaluated to ensure its applicability for the future and the quality and safety of patient care. It is entirely possible that APs will find an important and successful role in some NHS Trusts, but it is also possible that they may not. This is why the initial project has always been considered and conducted as a pilot and this is how it must continue to be viewed. Different hospitals, in different situations and with different needs will require a variety of options to deliver service and APs can certainly help in some models of service provision. To those colleagues who are not interested or even opposed to the project, we would ask you to allow those who are working to continue to pilot this potential option for the future development of the anaesthetic team to continue to do so; they are working on everyone’s behalf and deserve the support of the profession. Meanwhile, the College will work to review our predictions of future workforce requirements of medically-trained anaesthetists. Anaesthesia practitioners are new members of the anaesthesia team, who will work with us and support us in the future, but are not substitute anaesthetists. In short, we believe that we may be able to recruit and train sufficient anaesthetists, but it is the need to replace the inevitable reduction in trainee numbers, which will provide the biggest challenge.

Dr David Greaves, Project Lead
Professor Mike Harmer, President, AAGBI
Sir Peter Simpson, President, RCoA

 

01 February 2006