RCoA position statement on anaesthesia associates

Published: 26/06/2023

The subject of anaesthesia associates (AAs) arises frequently in conversations that I and others at the College have with members, particularly in relation to the forthcoming regulation by the GMC, and NHS England’s recent plans to fund additional AA posts.

I am grateful for the insight and feedback these conversations provide. I appreciate there is a need for the College to clarify its current position with regard to AAs and to provide answers to the most common questions we receive. It is vital that we continue to represent the voices of our members in ongoing discussions with regulators and government.

In doing so, I recognise that there are differing views among our members, which include both opposition to, and support for NHS England’s plans, and some frustration that the College’s role in those plans has not been made clear.

I have heard from some of our members a deeply held and entirely understandable concern that the College is advocating for AAs at the expense of a much-needed increase in higher anaesthetic training places. I would like to reassure you this is not the case – we argue strongly for more anaesthetic training places at every opportunity, underpinned by the evidence we have collected from our members. This has long been our top campaigning priority and will remain so.

Beyond that core principle, the College’s role in relation to anaesthesia associates is, and always has been, to ensure patient safety by facilitating their safe integration into the workforce. In practice, this means:

1.  We support GMC regulation of anaesthesia associates, which is due to be implemented in 2024.

AAs have been working within the UK for almost 20 years and the role has been unregulated. We have been supportive of their training and integration into the workforce since the inception of the role, but we have always seen regulation and the establishment of consistent standards as essential patient safety requirements. This is now even more pressing as numbers of AAs are expected to increase.

2.  We believe the College is best placed to provide leadership and guidance on the education, training, and professional standards for anaesthesia associates.

We have a responsibility to ensure the quality and safety of patient care through the safeguarding of standards in anaesthesia and we believe this is best done by representing the anaesthetic team as a whole.

We have received funding from NHS England to undertake work to develop AA numbers safely, which includes producing the curriculum for AAs and updating the guidance for introducing them into departments. Our advice to NHS England includes a recommendation that Trusts must undertake a review of both training needs and training capacity. This is to ensure they can meet their obligations to train their anaesthetists in training before looking to introduce student AAs. It would not be fair or helpful to either group to go beyond training capacity.

As part of this programme of work, we also expect to establish a Faculty of Anaesthesia Associates, accountable to the College Council and aligned to our charitable objectives.

These projects are not funded by membership fees.

3.  We understand the need to take an evidence-informed approach to this issue, but we are mindful that the evidence base relating to anaesthesia associates is relatively limited.

We will keep emerging evidence under close review and will contribute to the evidence base by conducting a comprehensive survey of all our members later this year. We want to better understand the relationship between the role of AAs and a range of other factors, including anaesthetic training, service efficiency, and patient safety. Member views are, and will continue to be, an essential part of the way in which we will develop our approach over time.

We welcome the recent survey of anaesthetists in training by Evans et al. The authors found that amongst respondents who had worked with AAs, the most commonly reported impact on training was neutral or no comment, but of the remaining respondents in that group a greater number reported a negative impact than a positive one. We want to understand more about these concerns, and the other issues raised by anaesthetists in training. The views of AAs are also important, and we welcome their involvement. 

4.  We have advised against over-expansion of anaesthesia associate numbers.

A number of departments have found AAs to be valuable members of the anaesthetic team. However, we recognise that different departments have different needs and AAs are not the answer in all cases. NHS England has funded a recent increase in student AA posts and this will add to the approximately 160 AAs currently practising in the UK.

We have advised NHSE to proceed cautiously in relation to expansion as there is not yet sufficient data about the potential impact on anaesthetic training and other factors relating to integration within departments. We have strongly emphasised the need for regular reviews to ensure any future decisions regarding AA numbers are grounded in the best available evidence. We also believe decisions to employ AAs need to be made locally based on the needs of each department and not imposed centrally.

5.  We will continue our campaign to address workforce shortages including through the expansion of training places for anaesthetists, through an increased number of posts for SAS doctors and consultants, and through workforce retention. This is, and will remain, our absolute priority.

We have had some success in securing an additional 70 places for anaesthetists in training and 30 for intensivists in training in England each year for at least a three-year period. In Scotland, following sustained pressure from the College, 15 new posts were approved for August 2022. In Wales, 5 additional core/ACCS posts were created in 2022 and 9 additional higher training posts in Anaesthesia were created between 2020-22.

We have also strongly represented the views of anaesthetists in training to ANRO, the national recruitment office for anaesthesia, with calls for urgent action to address errors that have caused immense distress and uncertainty to doctors who have committed so much of their time and personal finances to a career in anaesthesia.

Alongside this, we have sought to address retention issues in the workforce and have been instrumental in securing changes to pension taxation that will help retain senior doctors in the NHS at a time when they are most needed. We also want to see greater support for career progression and development for SAS doctors.

We will continue to make the case to government and healthcare leaders that the expansion in the number of AAs must not be at the expense of funding additional training places for anaesthetists, and posts for SAS doctors and consultants.

Our next steps

We are updating the existing guidance for introducing AAs into departments. The current version, produced in 2016, is now out of date and does not fully reflect the requirements of the AA role, patients’ needs, or the factors departments should consider before introducing the AA role to the team. 

The guidance has been informed by feedback from stakeholders, including anaesthetists in training and AAs. As mentioned above, it includes a requirement for a training needs analysis to be undertaken prior to taking on AAs to ensure employers can meet the training needs of anaesthetists in training as well as those of AAs. We plan to publish the guidance next month.

We will continue to work towards establishing a Faculty of Anaesthesia Associates. We are acutely aware we need to do this in a way that balances the needs of this emerging profession with our existing focus on the needs of anaesthetists and anaesthetists in training. We believe the best way to achieve this balance is by incorporating AAs within a faculty of the College.

Fundamental to our work to facilitate the continued safe integration of AAs into the workforce is our commitment to ensure that training opportunities for anaesthetists in training are not compromised.

We continue to listen and respond. I encourage members to share their views at our next Let’s Talk event on 28 June, or at next month’s event on Tuesday 25 July. I also hope that you will complete our survey later in the year, so that we can capture the views and experiences of as many members as possible in relation to AAs and their role within the anaesthetic team.  

Dr Fiona Donald, President

Frequently asked questions (FAQs)

We see regulation as essential to the safe expansion of AA numbers, but our sights remain firmly on the anaesthetic workforce as a whole and on continuing to make our voice heard at the highest levels. The anaesthesia associate role was introduced in 2004 and there are currently approximately 160 qualified AAs in the workforce playing an important role as part of the anaesthetic team. 

We do not think that increasing the number of AAs alone will solve the current anaesthetic workforce shortage – that can only be done through training more anaesthetic doctors. We will not stop our campaigning for additional training places, training opportunities for anaesthetists in training in their current roles, or the need for additional SAS and consultant anaesthetists to tackle the surgical backlog and meet the future needs of patients.

NHS England has taken the decision to fund additional student anaesthesia associate posts. If the number of AAs increases, we would like to see associated increases and support provided to the existing workforce at all levels. We see regulation of AAs as an essential patient safety requirement, and the College is ideally placed to provide leadership, guidance and influence for the specialty and stakeholders on education, training and professional standards for AAs.

We understand there have been concerns since the introduction of the anaesthesia associate role in 2004 that the training and presence of AAs may impact on the training of anaesthetic doctors. The evidence base remains relatively limited, but studies into the impact of working with AAs have reported both positive and negative experiences.

A qualitative investigation into the demographics and scope of practice of AAs in the UK in 2017 concluded the overall experience of working with AAs was positive (Sellers et al. 2022). More recently, a survey of anaesthetists in training found that of those who had worked with AAs, a higher proportion reported a negative impact on their training than a positive one although the largest group either did not comment or were neutral (Evans et al. 2023).

We will conduct our own survey of members later this year to further enhance the existing evidence base, and that will inform our work. It is important that we represent our members’ voices in our ongoing discussions with regulators and government – both in respect of AAs and in relation to wider workforce issues.

We are strongly of the view that when introducing AAs into departments, there should be strategic planning and local governance in place to ensure there is sufficient training capacity to continue to meet the required levels of supervision and access to appropriate clinical cases to meet curricular training requirements for anaesthetists in training. For example, our forthcoming updated guidance on introducing AAs into anaesthetic departments includes a requirement for a training needs analysis to be undertaken prior to taking on AAs – to ensure that employers have capacity to introduce and train AAs without compromising the training of anaesthetists in training. 

We believe the College should provide leadership and guidance on the education, training and professional standards for AAs. We have a responsibility to ensure the quality of patient care and safety by safeguarding standards in anaesthesia, and we believe that is best done through representing the anaesthetic team as a whole.

AAs are currently eligible to be affiliate members of the College and we welcome those who have chosen to join. As statutory regulation is implemented, we see the College as the professional home for AAs as well as anaesthetists. The College has received funding from NHS England to cover the work we are doing to support regulation and curriculum development for AAs. This work includes establishing a Faculty of AAs, to provide a professional and supportive home for these members of the anaesthetic team. We are in the early stages of development of the faculty, and we expect to establish it in 2025. This work is being led by a Founding Board, which includes representatives from across the specialty.

We have also been working closely with the GMC to facilitate regulation. This includes the development of a new anaesthesia associate curriculum aligned to GMC learning outcomes and standards, of which the draft was published in September 2022. We are also working with the GMC on the development of a registration assessment for AAs to take upon qualification, in order to practice and be placed on the AA register. This is being developed and run by the GMC initially, with strong input from the College on the standard settings and assessment model.

No. The work we are doing to support regulation and curriculum development for AAs, including developing a faculty, is funded by NHS England. We are developing a long-term sustainable financial model for the future of this work, which will be considered by College Council and trustees.

We have been inviting members to share their feedback at our Let’s Talk events, as well as in Q&A sessions at relevant presentations at our events. We will continue to seek this input. We will also survey all our members later this year, to obtain a larger and representative sample of the views and experiences relating to AAs.

This will allow ample space for members to give free-text responses on all themes related to AAs, including impact on training, patient safety, service efficiency, and any other issue that members wish to raise.

The findings from that will inform how we represent our members’ voices in our ongoing discussions with regulators and government.