Responses to your Let's Talk questions

In addition to the work we are already engaged in, including our campaigning for more training places, and in response to the concerns expressed by some members, we will commit to programmes of activity to support anaesthetists in training, including:

• Working with Schools of Anaesthesia, statutory education bodies and the GMC to look again at patterns of training rotations, which we know can be detrimental to the work-life balance and life choices of anaesthetists in training.
• Where rotations remain necessary for training, we will work with Schools of Anaesthesia to try and avoid short, frequent rotations and reduce the negative impact on the lives of anaesthetists in training.
• Renewing our drive for improvements to rest facilities and working conditions for all doctors including anaesthetists in training through our ACSA standards.
• Continuing to push for a system of a ‘lead employer’ within regions to mitigate against incorrect or absent payment of salary when moving from one department to another and to reduce the administrative burden on anaesthetists in training.
• Provide additional support to recognise experience gained outside of a training programme when a doctor re-enters training.
• Work with Schools of Anaesthesia to better align CT1 and ST4 numbers to both reduce the current bottleneck and help streamline the programme.

Building on these foundations, we will map out and promote the lifelong career opportunities for all grades of anaesthetist, including consultants, SAS doctors and locally employed doctors, in order to develop our existing activities, support and advocacy at each stage.

More research is needed into the effect of AAs on training opportunities for anaesthetic doctors, the costs and benefits for departments, and the quality and safety of patient care. The College will play its role in furthering that research by conducting a detailed survey of members’ opinions and their experiences of working with AAs. We have accelerated our plans for the survey and hope to issue it in the early autumn.

We will also commission an independent academic review of UK and international evidence about AAs and their overseas equivalents, taking into account safety, quality of care, outcomes for patients and impact on the existing workforce. We will publish the output of that research and use it to help guide our future activity.

We have been inviting members to share their feedback at our Let’s Talk and other events. We will continue to invite and respond to this input. We will also continue to consult with our Anaesthetists in Training Committee and Representative Group and the Founding Board, which includes anaesthetist in training representation.

We have benefited from consultation with members – including anaesthetists in training – in the development of the forthcoming updated guidance for introducing AAs into departments. The guidance includes a requirement for departments to conduct a training capacity assessment before introducing AAs. We are currently developing guidance and methodology to facilitate this assessment and will incorporate the resultant standards into the GPAS Good Department guidelines and ACSA.

We hear the disappointment that we have not yet consulted the whole membership about AAs and we will address that through a survey of all members in early autumn, to obtain a larger and representative sample of the views and experiences relating to AAs. The findings from the survey will inform how we represent our members’ voices in our ongoing discussions with regulators and government.

We are setting up a representative group to develop a comprehensive and clearly defined scope of practice beyond qualification (the current version describes what AAs can do ‘upon qualification’). This will be subject to consultation with stakeholders including Clinical Directors, anaesthetists in training and other members, representatives from the Association of Anaesthetists, anaesthesia associates and patient representatives.

AAs have been a part of the NHS workforce for 20 years, albeit in small numbers. However, the proposed expansion in the number of AAs makes the need to increase the relatively limited evidence base more pressing. Member views are, and will continue to be, a very important part of that evidence.

We have accelerated our plans to conduct a survey of all members in early autumn. This will provide a large and representative sample of views and experiences relating to anaesthesia associates. The survey will allow ample space for members to give free-text responses on all themes related to AAs, including effects on training, patient safety, service efficiency, and any other issue that members wish to raise.

The findings from the survey will help shape further engagement with members and inform how we represent their voices in our ongoing discussions with regulators and government.

AAs have been part of the anaesthetic workforce for 20 years, albeit in small numbers. The recent decision to expand numbers came from NHS England and is not driven by the College. We have advised NHS England against over-expansion given the limited evidence of the effect of introducing AAs into departments on the ability to maintain the current quality of anaesthetic training, patient safety and service efficiency.

We have always advocated for regulation of AAs as we believe it is an essential patient safety requirement. Royal Colleges are not in control of the decisions or timetable in relation to regulation, which requires legislation. The need for regulation is now even greater given NHS England’s proposed increase in the number of AAs and we support its implementation next year. 

We have also maintained that the College is best placed to provide leadership and guidance on education, training and professional standards for AAs. For example, we stipulated that AAs must always be supervised by a consultant anaesthetist.

The drive to expand AA numbers has come from the Government and NHS England. It is not something for which the College has advocated and NHS England has confirmed that the planned expansion is not contingent on the College’s involvement. 

We do think it’s vital we understand more about our members’ views and experiences so that we can represent them in our ongoing discussions with regulators, NHS England and the Government. As the next step we will gather evidence and survey all members in the early autumn. This will provide a large and representative sample of the views and experiences relating to AAs.

If there is evidence of negative impacts on issues such as anaesthetic training, patient safety, or service efficiency we will put these points to senior NHS figures and national Governments in robust terms. We will also use the survey results to guide further targeted engagement with members.

In the meantime, we do not think it would be a good idea to disengage from the programme given NHS England’s plans to expand AA numbers. AAs have been working as part of the anaesthetic team for 20 years and we believe the College is best placed to lead on education, training and professional standards for AAs. We think that doing so is in the interests of our members and of patients. We think the risks of not doing that, and losing control over working practices, including supervision, are too high. 

If it becomes clear that the training of anaesthetic doctors has been adversely impacted by the introduction of AAs to a department the College will work with local clinical leads and trainers to explore the situation and support them in finding a solution. We are committed to supporting our training networks and working alongside Schools of Anaesthesia to protect and develop the training of anaesthetists.

We have continued our work to update the guidance for introducing AAs into departments, including incorporating feedback from stakeholders following further consultation. We are also developing guidance and methodology to support departments in undertaking the recommended training capacity assessment. And we have written to our training networks to provide additional detail on any issues that arise relating to training capacity and supervision of anaesthetists in training.

The guidance for introducing AAs into departments signposts to the scope of practice ‘upon qualification’ in the curriculum. The scope of practice for experienced AAs is currently defined by local governance arrangements and the position of the College has always been that once AAs are regulated we will develop a comprehensive and clearly defined scope of practice beyond qualification.

We are setting up a representative group to develop this scope of practice, which will be subject to consultation with stakeholders, including Clinical Directors, anaesthetists in training and other members, representatives from the Association of Anaesthetists, anaesthesia associates and patient representatives.  

Our position is that anaesthesia is, and will remain, a doctor-led specialty. Anaesthesia Associates are not a substitute for doctors and must not be viewed as such. Anaesthesia Associates will remain a supervised workforce and the College would not support a move to an independently practising AA role.

...the AAs there should be money for trainees; why does the College not refuse to validate AAs and stand up for our members? I appreciate everyone is trying hard but there must be more levers to use.

The expansion of medical associate professions (including AAs) is being driven by the NHS and the Government, not the College. We hear and we share members’ frustration that more money has not been made available to train the medically qualified anaesthetists that we need.

We have made it very clear to NHS England that we want to see an immediate expansion of specialist training, especially at ST4 level and that this should be a higher priority than increasing the number of AAs. 

We will continue to campaign for more training places for doctors. AAs are not a substitute for anaesthetic doctors and we have argued the case strongly to Government and NHS England that any expansion in the number of AAs must be in addition to, not instead of, funding additional training places for anaesthetists and posts for SAS doctors and consultants.

Ultimately though, decisions on what to fund are made by the Government and NHS.

Decisions to train and employ AAs will continue to be made in individual Trusts and health boards. While we cannot influence those decisions we can and will lead on the development, training and supervision requirements for AAs. For example, by ensuring that Trusts undertake an assessment of training capacity before introducing AAs to protect and prioritise the training of anaesthetists in training.

The Government determines the amount of money for specialty training and HEE (now NHS England) determines how that funding is allocated across the medical specialties in national training numbers. Bypassing that process would need to be a decision made by individual Trusts and there is no guarantee that money would be provided for such posts. 

The Certificate of Eligibility for Specialist Registration (CESR) is an alternative route and we are currently undertaking work to help provide quality assurance and a registration process for CESR programmes. This is so we have oversight and potentially a route for the specialty to have more influence over the number of doctors being trained than we do in relation to national training numbers allocated by NHS England.

We have also published guidance on counting experience prior to recruitment to a core or higher training post.  

The current scope of practice for AAs describes what they can do ‘upon qualification’ and the scope of practice for experienced AAs is currently defined by local governance arrangements. The position of the College has always been that once AAs are regulated we will develop a comprehensive and clearly defined scope of practice beyond qualification.

We are setting up a representative group to develop this scope of practice, which will be subject to consultation with stakeholders, including Clinical Directors, anaesthetists in training and other members, representatives from the Association of Anaesthetists, anaesthesia associates and patient representatives.

In relation to how the scope of practice for AAs will differ to that of anaesthetic doctors, the College’s position is that the role of anaesthesia associate must not be an independently practising role and should always be supervised.

The scope of practice for anaesthetists in training up to and including the point they gain their CCT is defined by the curriculum and approved by the GMC. For autonomously practising doctors, there will always be developments that mean the scope of practice extends. Within that, individual departments are responsible for reviewing the responsibilities of anaesthetic doctors as part of job planning. That includes the scope of an individual’s practice as well as any additional roles and responsibilities.

No, we do not support progression to ‘consultant AAs’.

The College’s position is that anaesthesia will remain a doctor-led specialty. Anaesthesia Associates are not a substitute for doctors and must not be viewed as such. Anaesthesia Associates will remain a supervised workforce and the College would not support a move to an independently practising AA role.   

...the pathway and standards are clear as we have all been there. I suspect some of the unease around the AA role is fueled by a lack of transparency.

We agree this needs to be clearer. The current (2016) guidance for introducing AAs into departments is 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.

We will shortly publish updated guidance, which includes signposting to the expected competencies of AAs upon qualification. The scope of practice for experienced AAs is defined by local governance. The position of the College has always been that once AAs are regulated we will develop a comprehensive and clearly defined scope of practice beyond qualification.

We are setting up a representative group to develop this scope of practice, which will be subject to consultation with stakeholders, including Clinical Directors, anaesthetists in training and other members, representatives from the Association of Anaesthetists, anaesthesia associates and patient representatives.  

We published the draft curriculum for AAs in 2022 and it contains the competencies and learning outcomes student AAs must achieve to qualify. Further information about AA’s training and education is available on our website.

This is a recommendation in the forthcoming guidance on introducing AAs within departments. We have not yet stipulated a methodology, but we are developing guidance for the assessment of training capacity and will incorporate the final standards into the GPAS Good Department guidelines and ACSA. 

This will include the recommendation that if anaesthetists in training perceive that their training has been negatively impacted by the training of AAs they should make their College Tutor aware of their concerns. If this cannot be resolved internally the College Tutor should contact their Head of School and/or Regional Adviser Anaesthesia for support. This will ensure that the School of Anaesthesia is aware of any difficulties and can share details of these with the College if further support is needed.

We will be looking very carefully at supervision ratios in role descriptions when planning the integration of AAs within a consultant-led team and this will not be modelled on the American system.

AAs will remain a supervised workforce and the College would not support a move to an independently practising AA role or the development of any role equivalent to that of certified registered nurse anaesthetists (CRNAs) in the US.

We hear the comparisons that are drawn between the UK and the US in terms of AAs. In the US, there are both CRNAs, who can practise independently and certified anesthesiologist assistants (CAAs) who work under the supervision of an anesthesiologist and are more comparable to AAs.

While comparisons with the US system are not always meaningful given the very different healthcare contexts, it is worth saying we would not support development of any UK role equivalent to CRNAs.

We understand that members have concerns about scope of practice. The current scope of practice for AAs describes what they can do ‘upon qualification’. The scope of practice for experienced AAs is defined by local governance.

The position of the College has always been that once AAs are regulated we will develop a comprehensive and clearly defined scope of practice beyond qualification. We are setting up a representative group to develop this scope of practice, which will be subject to consultation with stakeholders, including Clinical Directors, anaesthetists in training and other members, representatives from the Association of Anaesthetists, anaesthesia associates and patient representatives.  

Training opportunities for anaesthetists in training must always take priority. 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.

Our forthcoming updated guidance on introducing AAs into anaesthetic departments includes a requirement for a training capacity assessment to be undertaken prior to taking on AAs. The purpose of this is to ensure that employers have capacity to introduce and train AAs without compromising the training of anaesthetists in training. We are developing guidance and methodology for the assessment of training capacity and will incorporate the final standards into the GPAS Good Department guidelines and ACSA. 

The College’s position is that the role of anaesthesia associate should not be an independently practising role and should always be supervised. AAs are not a substitute for doctors but can be an addition to the workforce.

The scope of practice for experienced AAs is currently defined by local governance. The position of the College has always been that once AAs are regulated we will develop a comprehensive and clearly defined scope of practice beyond qualification.

We are setting up a representative group to develop this scope of practice, which will be subject to consultation with stakeholders, including Clinical Directors, anaesthetists in training and other members, representatives from the Association of Anaesthetists, anaesthesia associates and patient representatives.  

We believe that the anaesthetic training programme does align with contemporary ways of working.

The anaesthetics curriculum provides a framework for training anaesthetic doctors, articulating the standard required to work at consultant level and at critical progression points within the programme.

The College revised the curriculum in 2021 and it is designed to provide a flexible, attractive programme for doctors training in anaesthetics; ensuring they have the opportunity to develop the full range of knowledge, skills, behaviours, and attributes needed to practice as a consultant anaesthetist in the NHS. The content of the curriculum reflects the wide range of clinical and professional skills required to meet the needs of clinical services across the whole of the UK.

We understand that members have concerns about scope of practice. We do have a scope of practice document for AAs at the point of qualification, as agreed with the Association of Anaesthetists, and this has been used to date to introduce AAs into anaesthetic departments.

The scope of practice for experienced AAs is currently defined by local governance. The position of the College has always been that once AAs are regulated we will develop a comprehensive and clearly defined scope of practice beyond qualification. We agree this needs to be done as soon as possible.

We are setting up a representative group to develop this scope of practice, which will be subject to consultation with stakeholders, including Clinical Directors, anaesthetists in training and other members, representatives from the Association of Anaesthetists, anaesthesia associates and patient representatives.  

...restricted. This leaves very experienced and qualified colleagues stuck at bottlenecks.

During discussions with NHS England we made it clear we wanted to see an expansion of training places for anaesthetic doctors and we advised against over-expansion of AAs. NHS England has taken the decision to fund additional student AA posts. We have not advocated for this.

In terms of further resistance, we do not have the means to stop departments from introducing AAs. We also know there are differing views within our membership on the subject and that the evidence is not there in either direction to justify rapid expansion, nor provide a case for an immediate halt.

We think there is a continuing role for AAs within the workforce but only if there is an expansion in the medically trained anaesthetic workforce to produce the clinicians needed to supervise them and address the workforce crisis. Expanding training places for anaesthetists and increased posts for SAS doctors and consultants should take priority over the expansion in numbers of AAs.

Our position is that anaesthesia will remain a doctor-led specialty. Anaesthesia associates are not a substitute for doctors and must not be viewed as such. Anaesthesia associates will remain a supervised workforce and the College would not support a move to an independently practising AA role.

NHS organisations are vicariously liable for the acts, omissions and negligence of their employees and those working under their direction. Therefore, the Trust would be liable and responsible for the actions of the AA, providing team members have responded and undertaken duties that are required of them.

For example, the AA has called for assistance when needed and not unreasoningly deviated from an agreed plan or undertaken any duties for which they are not trained or competent in without communication to their supervising anaesthetist. The supervising anaesthetist should be available and responsive should the AA require assistance.

The College cannot independently fund additional training places. Our income is largely derived from membership fees and it would not be fair to expect members to fund training beyond the level they already contribute to membership and examination fees.

More fundamentally, the NHS Constitution for England states that the NHS is a national service funded through national taxation. It is beyond the remit and charitable objectives of Royal Colleges to propose a different funding model.  

We have heard from many anaesthetists in training about the difficulties caused by frequent rotations and the impact it has on their personal and professional lives. In response, we will:

• Work with Schools of Anaesthesia, statutory education bodies and the GMC to look again at patterns of training rotations which we know can be detrimental to the work-life balance and life choices of anaesthetists in training.
• Where rotations remain necessary for training, we will work with Schools of Anaesthesia to try and avoid short, frequent rotations and reduce the negative impact on the lives of anaesthetists in training.

The College has responsibility for setting curricula, delivery of postgraduate examinations in anaesthesia and supporting the delivery of high-quality anaesthetic training. We hear the concerns raised by some members following the announcement of NHS England’s planned expansion of the AA programme and can confirm that the resources of the College’s training department have not been diverted to support this pathway.

We also recognise the disruption associated with the transition to the 2021 Curriculum and want to assure our members that the College’s training and examination departments remain focused on providing ongoing support to deliver and develop the curriculum, support training, develop the LLP and deliver the FRCA examination.

We have forcefully lobbied on this issue. We have raised the matter with Government Ministers, the Health and Social Care Select Committee, opposition and backbench MPs, members of the House of Lords, and policy makers in NHS England and the devolved nation equivalents. While these efforts have resulted in an additional 210 anaesthetic posts in England over a 3-year period, and progress in Scotland and Wales, there is much more to do.

We argued strongly for more ST4 posts when we were consulted about the NHS Long Term Workforce Plan and were disappointed to see a lack of specifics. As such we will redouble our efforts to persuade the aforementioned stakeholders. The Government has committed to review the NHS Long Term Workforce Plan every two years so consultation is likely to start again soon.

In the interim we will work with Schools of Anaesthesia to:

• better align CT1 and ST4 numbers to both reduce the current bottleneck and help streamline the programmes
• support regions to maximise less than full time slot sharing in line with the guidance released by NHSE
• continue to support the recognition of experience gained outside the training programme to enable faster progression once back within it.

High quality training in individual departments requires the ongoing support of clinical and educational supervisors and College Tutors. We recognise that the capacity of these individuals to deliver training is finite. It is this capacity that has governed the number of training places awarded within Schools of Anaesthesia over the years and needs to be protected.

It is vital that any decision by a department to begin training AAs includes confirmation from the College Tutor that the department has the capacity to do so whilst continuing to provide the necessary high-quality training for anaesthetists in training. We have also made this case strongly to NHS England.

The College Tutor should also confirm that the training of AAs will not impact on the ability of anaesthetists in training to access all aspects of the curriculum available in their department.

If College Tutors have any concerns about their department’s ongoing capacity to train anaesthetists in training we request that they contact their Head of School and/or Regional Adviser Anaesthesia for support. This will ensure that the School of Anaesthesia is aware of any difficulties and can share details of these with the College if further support is needed. As part of this process of assurance, we will publish guidance on the process of assessment of training capacity within a department.

The MSRA has been used since 2013 as a medical specialty assessment tool for use in recruitment and shortlisting in multiple specialties. The test is run by the Work Psychology group. The MSRA Steering group has representatives across all medical specialties that use the test including in question writing.

Prior to undertaking the use of the MSRA, we looked closely at the performance data of doctors who had taken the test and were subsequently successful in gaining an anaesthetic CT1 job. This data showed that anaesthesia candidates were high scoring candidates and those that scored highly also scored highly at interview. A more recent look at this data shows that this cohort were more likely to have a successful outcome at ARCP and also pass the Primary FRCA at first sitting.

As with any selection method we will continue to work with MDRS and WPG and look closely at performance data and outcome of candidates. 

Recruitment is under a huge amount of pressure to allow as many candidates who wish to apply to anaesthesia as possible. The MSRA is key to allowing open competition to those who wish to apply and to shortlist them effectively. We will continue to review this as we have access to more data.