A trainee perspective on anaesthesia associates and their scope of practice – caution and clarity are needed

I read with interest the article regarding the clinical activity of anaesthesia associates, as reported to the 7th National Audit Project [1], which raises many questions about their current and future roles.

Anaesthesia associates have a nationally defined scope of practice on qualification, published by the Royal College of Anaesthetists (RCoA) in 2016 [2]. This limits their supervision ratios to a maximum of 1:2, with the proviso that the patients must be American Society of Anesthesiologists physical status 1–2 undergoing minor to intermediate surgery in adjacent operating theatres. This scope of practice excludes anaesthesia associates from performing regional anaesthesia (both central neuraxial and peripheral techniques). The RCoA does not currently support local opt-outs of this scope of practice, sometimes termed as ‘enhanced’ roles. The work by Cook et al. shows that many anaesthesia associates are working outside of this scope of practice, as 24% of cases were major or complex surgery with an anaesthesia associate as the senior provider [1]. In 21% and 25% of spinal and regional anaesthesia cases, respectively, an anaesthesia associate was the senior provider.

There is concern that these enhanced roles may lead to loss of training opportunities. Evans et al. reported that 35.5% of anaesthetists in training who had worked with anaesthesia associates felt they had a negative impact on their training [3]. Their thematic analysis showed that ‘loss of regional anaesthesia experience’ and ‘trainees covering emergency work so that anaesthesia associates can do elective work’ were among trainees' chief concerns. Elective surgery lists with healthy patients undergoing low-complexity surgery are ideal for anaesthetic trainees to gain vital experience in independent practice conducted under consultant supervision. These lists, likely decreasing in number as the patient population becomes more complex, may not be available for anaesthetic trainees if there is an expansion in anaesthesia associate numbers.

Financial modelling by Hanmer et al. suggests that expansion of the anaesthesia associate workforce, as outlined in the NHS Long Term Workforce Plan, is not financially viable without a relaxation in supervision ratios beyond the 1:2 currently accepted by the RCoA, or other less plausible alternatives [4]. This has led to concerns that supervision ratios may relax, and anaesthesia may begin to move from being physician-delivered to physician-supervised. These concerns, among others, resulted in an emergency general meeting of the RCoA in October 2023, where a motion to pause the expansion of anaesthesia associate numbers passed with 88.9% of a vote that totalled more than 5000 respondents overall [5]. A subsequent survey by the RCoA showed that 78% of over 6000 anaesthetists, of all grades, held negative views about the expansion of the anaesthesia associate workforce [6].

The National Audit Projects have shown that patients are becoming more complex, with higher rates of frailty, obesity, and comorbidity [7]. In the face of this, and concerns raised about anaesthesia specialist training, the expansion of an alternative, lesser trained workforce, with a paucity of evidence to support it, must be challenged. Anaesthetists in training are, rightly, asking why rotational training, countless out-of-hours shifts and rigorous examinations are required if anaesthesia associates are given carte blanche to deliver any anaesthetic they please, to any patient group, via local opt-outs.

If the expansion of anaesthesia associates is to go ahead, despite well-founded concerns, a national scope of practice, without local opt-outs, is essential for their safe utilisation. I eagerly await the publication of the revised scope of anaesthesia associate practice from the RCoA and hope the concerns of the anaesthetic community are reflected within it.