Have anaesthetists' concerns about anaesthesia associates finally been justified?

We congratulate Cook et al. on the publication of their important article [1] produced with data from the 7th National Audit Project (NAP7) from the Royal College of Anaesthetists [2]. The topic of anaesthesia associates remains highly controversial in UK anaesthesia and has suffered from a relative lack of objective data to inform discussion. We feel this documented window into the clinical activity of anaesthesia associates reinforces our concerns on patient safety and parallels with training of anaesthetists.

It is now clear that anaesthesia associates are working outside the original 2016 scope of practice [3]. This includes the provision of anaesthetic care of patients undergoing paediatric, obstetric, neurosurgical and vascular surgeries [1]. Carrying this out under the auspices of ‘local governance’ is mentioned in the 2016 scope document [3]; however, a restriction to these extended roles is now reflected in position statements from the Royal College of Anaesthetists and the Association of Anaesthetists. Updated guidance is awaited but it seems that, if this practice is already embedded within some departments, it may be difficult to reverse.

Scope of practice supervision levels were also not consistently followed. Supervising consultants were not always immediately available and, in 63 cases, the anaesthesia associate was identified as the most senior anaesthetic provider [1]. This concern has been raised in a recent publication by Evans et al. [4]. If the standard of practice for anaesthetists in training and non-autonomous Specialty doctor and Associate Specialist was applied to this (via the use of the Cappuccini test [5]), the supervision of anaesthesia associates would frequently be inadequate.

The proposed expansion of anaesthesia associates risks negatively impacting the training of anaesthetists. The well-used argument against this has traditionally been that they only take part in the care of healthy patients in limited scenarios. The clinical activity data in this publication disproves this by showing activity across all acuity and comorbidity levels. The potential for the reduction of clinical experience in anaesthetic training is, therefore, significant.

Anaesthesia is a field of medicine still fraught with risk and remaining aware of one's unknowns guards against complacency. It is, therefore, concerning to read that anaesthesia associates felt they did not need more training in the management of peri-operative cardiac arrest and were confident in existing guidelines [1]. Peri-operative cardiac arrest must be viewed as a distinct entity, the management of which is not adequately covered as part of current Advanced Life Support courses.

Drawing firm conclusions from this article about the role anaesthesia associates play in UK anaesthesia is difficult, given that the authors have explicitly warned against this. However, this evidence reinforces the idea that regulation is a pressing necessity, and serious questions must be asked regarding the utility of anaesthesia associates in a profession that prioritises patient safety and quality of care in an increasingly older and comorbid patient population [6].