Extraordinary General Meeting (EGM) 17 October 2023 resolutions

Proposed expansion of Anaesthesia Associates

The Council is advised to ask the Clinical Directors network to pause recruitment of AAs until the proposed RCoA Survey and Consultation is complete and the impact on doctors in training has been assessed and reviewed.

The Council is advised to ask the College Tutors (CTs) and Regional Advisors (RAs) to ensure that doctors-in-training are given priority over AAs in their exposure to training opportunities. If CT/RAs find that is not the case then they should feed this information back to the Training Department, in order that the training capacity of that hospital be reviewed.

Supporting statement from the proposer

We recognise the dedication and personal contributions made by individual Anaesthesia Associates (AAs) across the NHS.

We note with concern the proposed 10-fold expansion of the AA workforce, as outlined in the NHS Long Term Workforce Plan published in June. We believe this expansion is misplaced and that further expansion of AAs would not be in the best interests of trainees or patients. 

We further note the College’s recent workforce report, stating that  “…unless urgent action is taken, the UK will be 11,000 anaesthetists short by 2040”. In overtly supporting the proposed expansion of AAs, in a financially constrained NHS, the College is actively hindering the urgent action required. 

Consultant anaesthetists have key roles in all areas of perioperative practice, and have undergone a more rigorous, broad and prolonged training. An expansion of AAs would implicitly lead overall to a less-skilled workforce, something that is completely at odds with the College’s charitable aims. In contrast, the protection and benefit of the public, a cornerstone of its objectives, are best met by a replete and well-trained workforce.

Proposed by Dr Danny Wong

College Council and Board of Trustees response

Anaesthesia Associates (AAs) are practitioners working under the supervision of an autonomously practising anaesthetist.

We recognise the strength of feeling among our members regarding NHS England’s proposed expansion of the number of AAs, to an estimated 2,000 by 2036/2037. Indeed, we have advised NHS England against rapid overexpansion given the current lack of evidence about the potential impact on anaesthetic training and other factors.

Furthermore, NHS England has confirmed that the AA expansion plan set out in the NHS Long Term Workforce Plan is aspirational and that they are keen to work with the College to grow and assess the evidence base around AAs. NHS England also acknowledge that modelling over 10–15 years is inherently difficult and will need to be continually refreshed to assess progress and assumptions.

We agree that training opportunities for anaesthetists in training must be prioritised and have asked that College Tutors inform the College of any concerns about their department’s ongoing capacity to train anaesthetists in training. We will shortly finalise and publish our updated guidance for departments who employ or are considering introducing AAs, which includes a requirement to undertake a training capacity assessment and principles for how that assessment should be undertaken.

Since the introduction of AAs, the College’s role has been to provide leadership and guidance on their education, training and professional standards. This is consistent with our responsibility to safeguard standards in anaesthesia, including through the education of medical and other appropriately qualified healthcare workers (as set out in our Charter).

Delivering this role does not prevent us from taking an evidence-informed approach to AAs or advocating for a change of policy on AAs if supported by evidence. We have recently conducted a member survey about AAs and are in the process of commissioning an independent review of the international evidence about AAs and their overseas equivalents. The findings from both will form the basis for further consultation with members and patient groups.

If we find evidence of negative impacts on issues such as anaesthetic training, patient safety, or service efficiency we will put these points to NHS England and national governments in robust terms. We will also bring a discussion and vote to our AGM in 2024, once our evidence gathering stage is complete and regulation has been implemented. We will do this whether this resolution is passed or not.

We encourage members to consider the potential risk of this resolution:

• requesting a pause in recruitment of AAs may be viewed by NHS England as incompatible with the College fulfilling the long-standing leadership role outlined above. If this responsibility is ceded to another body with much less expertise in anaesthesia and related training, education, safety and quality issues, the College (and its members) will have little influence.

We do not oppose this resolution and will seek to act on it if passed by a simple majority.

Supervision of Anaesthesia Associates

The Council is advised to amend the Guidelines for Provision of Anaesthetic Services (GPAS) the Anaesthesia Clinical Services Accreditation (ACSA) and other relevant College documents to make it clear that local opt-outs from the College’s position on the supervision of AAs are not approved by the College. 

Supporting statement from the proposer

We note and reaffirm the current stated College position that AAs should always be supervised by a named and readily-available Consultant Anaesthetist, and consider that this requirement is inviolable. We believe that individual hospitals should not unilaterally waive this requirement. We also believe that if it is necessary for AAs to work outside their initial scope of practice (as currently defined in Appendix E: AAGBI and RCoA Executive Summary: Scope of Practice for a PA(A) on qualification), then they should be directly supervised by a Consultant, physically present in theatre throughout (Level 1), and that this requirement should be inviolable.

We believe that this is essential to maintain the highest possible standards of professional competence in the practice of anaesthesia.

Proposed by Dr Danny Wong

College Council and Board of Trustees response

We agree that adequate supervision of anaesthesia associates (AAs) is crucially important. The scope of practice for AAs upon qualification – including supervision arrangements – is set out in our draft 2023 guidance for introducing AAs.

Any area of practice that differs from the scope of practice upon qualification is known as an enhanced role. We do not currently support enhanced roles for AAs until statutory regulation is in place.

However, enhanced roles for AAs do exist within some trusts. These roles are supported by local governance arrangements – a provision that is acknowledged in the Guidelines for Provision of Anaesthetic Services (GPAS). Services supported by enhanced roles may often have been in place for many years and in some cases are understood to function well for the benefit of patients. The need to maintain these services will have to be taken into consideration alongside the need for adequate supervision, and evaluation of patient care.

Through this EGM process and our own member engagement, we understand that members have legitimate concerns about supervision of AAs and about the lack of a scope of practice beyond qualification. We will continue to take steps to address those concerns. Our current work in this area includes:

• establishing a working group to develop a scope of practice for enhanced roles outlining safe supervision levels, to take effect when regulation is in place. We will ensure the working group has representation from all relevant stakeholders, including anaesthetists in training
• conducting a series of surveys of AAs, clinical leaders and the membership to gain further information about how AAs are working and the views of the membership.

In addition we will:

• engage with NHSE and university AA course providers to try and ensure a consistent understanding of supervision levels
• request that clinical leaders pause in the development of enhanced roles for AAs.

We do not oppose this resolution. If passed by a simple majority the Council and Board of Trustees will seek to act on it whilst taking into consideration their duty to ensure the College carries out its purposes for the public benefit.

Information for patients

The Council is advised to ratify as a professional standard the need to inform patients, when applicable, that an AA could be involved in their care, that an AA is not a registered medical practitioner, and who their responsible Consultant Anaesthetist is.

Supporting statement from the proposer

We believe that patients should be informed preoperatively when an AA could be involved in their care, be made aware that an AA is not a registered medical practitioner, and be told who their responsible Consultant Anaesthetist will be. This is a key plank of the College’s charitable aim of educating the public in all matters relating to anaesthesia. NICE guidelines, as we were recently reminded in Parliament, make it clear that the onus is on the individual professionals to properly explain their role to patients, especially if there is a likelihood of this not being automatically understood.

Proposed by Dr Jan Hansel

College Council and Board of Trustees Response

The principle that anaesthesia associates (AAs), like all healthcare workers, should be open and honest about their experience, qualifications and role when talking to patients is incorporated into the GMC’s Good Medical Practice (GMP 66), the 2024 edition of which will apply to AAs once they are regulated by the GMC.

This principle is also included in both the current and forthcoming editions of our guidance for introducing AAs to departments. Our patient representative group, PatientsVoices@RCoA has previously been consulted on this issue and supports the College’s position that patients must be appropriately informed of who will be managing and overseeing their care. 

Additionally, to avoid any unintended confusion for patients, we will work with our ethics committee and others to produce supplementary guidance about how members of the anaesthetic team should introduce themselves and the titles they should and should not use.

We support statutory regulation of anaesthesia associates, which is due to be implemented in 2024. This is now even more pressing and we will continue to push for regulation to be implemented at the earliest possible opportunity.

This resolution reflects current College policy and we do not oppose it. We will seek to act on it if passed by a simple majority.

Rotational training

The Council, together with the Education, Training and Examinations Board, is advised to fully consider the personal impact of rotational training, to work with the relevant stakeholders to reduce the need for any short-term placements of under 1 year except in situations where experience cannot be gained without rotating (e.g. cardiothoracic anaesthesia), and to present a report on their progress at the College Tutors Meeting in June 2024.

Supporting statement from the proposer

We acknowledge that the impact and effects of short-term rotational training for doctors in training posts has changed over the last 20 years. 

Such placements may create a sense of isolation and transience, affecting morale and workplace cohesion. Unfamiliarity with local processes and protocols is a hindrance to doctors in maintaining the highest possible standards of professional competence, which is one of the College’s charitable objectives. Furthermore, unfamiliarity with the educational needs of individual doctors on short-term placements has, anecdotally, resulted in preferential allocation of valuable educational opportunities to permanent staff. Rotational training

Short-term placements may have significant and detrimental consequences on the family life of doctors, especially those with caring responsibilities and health issues.

We consider that more could be done to ensure that the importance of stability and the educational and personal benefits offered by longer placements are taken into account when considering the need for breadth of experience.

Proposed by Dr Ramey Assaf

College Council and Board of Trustees response

We share the concerns raised regarding the impact of short rotations on the health and wellbeing of anaesthetists in training.

We have been considering this issue for some time and believe there is a unique opportunity now that the 2021 Anaesthetics Curriculum has been established, to work with heads of schools, training programme directors and regional advisors to review rotations and the way in which training is delivered within different regions.

We will continue this work, informed by our members’ views. We will establish a working group to look first at the rationale for rotational training, including its value as an educational tool. The working group will also consider the current structure of rotations and the reasons for it, whether service reconfiguration could be delivered to support better training and the potential risks and benefits of that.

We will also work with regional advisors, training programme directors and heads of school to better understand the regional differences in the impact of rotational training on anaesthetists in training. We will report on this work at the College Tutors meeting in 2024.

We note that decisions on rotational training are not solely in the gift of the College.

This resolution aligns with ongoing work by the College and we do not oppose it. We will seek to act on it if passed by a simple majority. 

National Recruitment for Doctors-in-training

The Council is advised to:

• make necessary enquiries in order to acquaint itself with the reasons for the delay in publishing the SIR report, and discuss its findings
• consider whether there is any evidence, on the basis of the report, that HR records were not kept clearly and accurately, whether or not adequate auditing and benchmarking systems were in place, and whether or not staff had the necessary knowledge, skills and training to carry out their roles
• consider whether or not it still has confidence in the leadership and senior management of the Anaesthetic National Recruitment Office (ANRO).

Supporting statement from the proposer

We note with great concern the findings of the multiple systematic failures, as described in the Significant Incident Report (SIR) of December 2021, and the considerable delay and reluctance in releasing this report. Ensuring that the best candidates are appointed into training posts, and that HR processes are as good as possible, are prerequisites for ensuring the highest possible professional competence. The College also has a public duty, in the light of the privileged and confidential information that it holds, to ensure that any breaches of the GMC’s  Good Medical Practice and Leadership and Management for all Doctors are acted upon.

Proposed by Dr Richard Marks

College Council and Board of Trustees response

The recruitment process run by the Anaesthetic National Recruitment Office (ANRO) has significant impact on doctors’ careers and personal lives and we share the great concern expressed by members regarding its systemic failures.

The Significant Incident Report into errors that occurred in recruitment in autumn 2021 (published in July 2023) was discussed at Council in September 2023, alongside the report into errors that affected CT1 recruitment in February 2023. These reports will be the subject of further discussion at Council’s November meeting. The discussion will include consideration of a report of progress against the recommendations and will cover the points raised in the resolution. Minutes of both meetings will be published on the College website in due course.

ANRO is an administrative team based within the West Midlands Deanery. Recruitment is overseen by Regional Deans and the NHSE national recruitment team and ultimately the Medical and Dental Recruitment and Selection Committee (MDRS) on behalf of the four Statutory Education Bodies (SEBs).

We believe that ANRO is itself the recipient of poor support from MDRS/NHS England, and that its performance is a result of inadequate resourcing and support. This is evident in the recommendations of the incident reports, and the fact that MDRS/NHSE have only recently agreed to provide additional resource following sustained pressure from the College.

This resolution aligns with ongoing work by the College and we do not oppose it. We will seek to act on it if passed by a simple majority. In addition, we will continue to make representations to NHS England and MDRS regarding their inadequate support and resourcing for ANRO.

Regional recruitment

The Council is advised to set up a group, together with any other stakeholders it sees fit, which may include the Academy of Medical Royal Colleges, to investigate whether a centralised national recruitment centre is in the best interests of our specialty, to explore the legal and practical possibilities of recruitment at a regional level, and to present a report on their findings in due course.

Supporting statement from the proposer

We believe a strong case can be made for recruitment at a regional or local, rather than national level, using the present metrics for assessment. Benefits may include local consultant buy-in and better information and choice for applicants.

Proposed by Dr Richard Marks

College Council and Board of Trustees response

We have listened to the concerns of members about national recruitment. Equally, we have heard from members who oppose a return to a regional system. We therefore welcome this resolution as an opportunity to gauge the views of the wider membership.

We have taken early steps to ascertain the interest of other stakeholders in working with us to consider the relative benefits of regional recruitment. While the appetite so far has been limited, we will formally approach stakeholders, including the Academy of Medical Royal Colleges, to join a working group to consider this issue.

We note that it would be difficult for the College to explore the possibilities of a return to regional recruitment without the involvement of other parties.

We do not oppose this resolution and will seek to act upon it if passed by a simple majority.