1. Executive Summary 

The final draft of the Anaesthesia Associate (AA) Scope of Practice 2024 is now being presented to the membership for formal consultation. The document has been created following a request from the wider anaesthetic community to provide:

• clarity around the role of AAs post-qualification
• assurance around the levels of supervision required to support the AA role
• guidance on potential progression post-qualification.

If implemented by departments in all four nations, this document would provide the first nationally accepted scope of practice for all AAs. It outlines clearly defined supervision levels and effectively removes the widespread requirement for reliance on local governance alone to cover the work of AAs post-qualification.

The Anaesthesia Associate Scope of Practice 2024:

• confirms the AA curriculum and AA registration assessment (AARA) as the starting points for an AA’s post-qualification clinical practice
• outlines phases of AA practice post-qualification and the requirements and opportunities at each stage
• clearly defines supervision levels and provides detail on the role and responsibilities of the supervisor
• provides a RAG rating describing the aspects of anaesthetic practice that are included in the scope of practice and those that are excluded
• outlines the aspects of practice that require more direct supervision
• describes the importance of a stable transition onto the new scope of practice to ensure patients are not impacted through loss of services
• gives detail on how AAs who have established practice should be supervised to continue to deliver high quality care
• emphasises the importance of appropriate clinical supervision and the need for adequate numbers of medically qualified clinical supervisors to be in place prior to any further expansion of the AA workforce.

Throughout the process of developing the new scope of practice, we worked alongside representatives from the Association of Anaesthetists and with a wider clinical reference group of stakeholders who have provided challenge and support in equal measure. We have also taken into consideration the views of the membership as expressed through both the extraordinary general meeting and the membership survey conducted in 2023.

We believe the 2024 Scope of Practice represents a workable solution to enable ongoing safe clinical practice and clarity around the role of AAs within the anaesthetic team. We also believe that it ensures the College meets its charitable aims, particularly the requirement to maintain the highest possible standards of professional competence in the practice of anaesthesia for the protection and benefit of the public. Our aim throughout has been to provide a framework that will allow AAs to continue to deliver patient care but at the same time addresses the concerns we have heard about ensuring patient safety.

The briefing below outlines the process involved in the writing of the 2024 AA Scope of Practice and the approaches taken to address areas of concern. We encourage all members to read this briefing, alongside the scope of practice, to provide the background and detail to best support them during the consultation process.

2. Background 

AAs, formerly known as physician assistants (anaesthesia), were introduced in 2004 and the role is now established within many NHS hospitals.

Qualified AAs have successfully completed an anaesthesia associate training programme (Birmingham, UCL and Lancaster) and are members of the anaesthetic team, working alongside others such as consultant anaesthetists, SAS doctors and anaesthetists in training. AAs are additional members of the team, and the intention is for them to assist with the overall service requirements of a department.

Whilst AAs are not doctors, they are trained practitioners who work under the supervision of a consultant or autonomously practising SAS anaesthetist. 

In 2019, the General Medical Council (GMC) was selected by the UK Government to be the regulatory body for AAs and physician associates (PAs). Regulation is due to begin in December 2024 and all qualified AAs will be required to register with the GMC. In preparation for regulation, the GMC published a process for revalidation and the Good Medical Practice: interim standards for PAs and AAs  and the PA and AA generic and shared learning outcomes, which newly qualified AAs must meet to be register with the GMC. The GMC, alongside partners including the RCoA, has also developed an AA registration assessment which will be implemented after regulation begins and all qualified AAs will be required to successfully pass to register with the GMC and practice.  The RCoA welcomes regulation of this profession and sees the centralised regulation and oversight of AAs as an essential patient safety requirement. It is also important that the distinction between AAs and doctors remains clear for all, including patients.  

The RCoA Council remains committed to supporting AAs currently working in the NHS or in training. We have a duty of care to them as individuals and a responsibility to maintain service provision for patients.

3. Why do we need a scope of practice for AAs?

The last national scope of practice for AAs was written jointly by the RCoA and the Association of Anaesthetists in 2016 and only described the AA role at qualification. This guidance is now eight years old, and it is recognised that many experienced AAs have developed extended roles which are outside of this scope of practice. As directed by the 2016 scope, these roles are currently covered by local governance arrangements and may often have been in place for many years and be functioning well for the benefit of patients.

Following the publication of the NHS Long Term Workforce Plan in 2023, concerns were raised by RCoA members in relation to the impact of further expansion of the AA role. Through resolutions presented by members at an extraordinary general meeting in October 2023, and our own member engagement, we recognised that members had concerns about patient safety, supervision of AAs, the capacity to train both anaesthetists in training and AAs, and about the lack of a scope of practice beyond qualification.  In response to the concerns of members we committed to a number of actions, one of which was to establish a working group to develop a scope of practice beyond qualification that would outline safe supervision levels and take effect when regulation is in place.

4. Approach taken in developing and writing the 2024 AA Scope of Practice

Following the EGM in October 2023 a group was formed to commence the writing of the new scope of practice. This group contained representatives from AAs, clinical leads for AAs, higher education institutions who train AA students, NHSE, GMC, RCoA, Association of Anaesthetists and the Association of Anaesthesia Associates (AAA). This group met twice and collated a list of preferences as to what any future scope of practice should contain. It was felt that this group would be too large to effectively draft a scope of practice so they were divided into a Core Writing Group (CWG) who would draft the scope of practice, and a Clinical Reference Group (CRG) who would review the draft and make recommendations as to its content and future direction.

The CWG (membership listed in Appendix 1) started meeting in June 2024, following the appointment of a clinical lead at the end of May,  and have liaised with the CRG (membership listed in Appendix 1) on 26 June ahead of RCoA Council on 3 July.

Following the completion of the second draft the 2024 AA Scope of Practice was reviewed by, and discussed with, the following stakeholders:

• Association of Anaesthetists Board
• RCoA Clinical Leaders in Anaesthesia Network Executive (CLAN)
• GMC
• AA Scope of Practice Clinical Reference Group
• Student AA representatives
• AARA representative
• RCoA AiT Committee
• PatientsVoices@RCoA
• RCoA Council

The final draft of the 2024 AA Scope of Practice is now being presented to the membership for formal consultation.

5. Approach to the use of evidence in developing the 2024 AA Scope of Practice

As part of the writing process, we have sought to collate the experiences of departments who work with AAs. We are grateful for those who were willing to submit evidence. We also took into consideration the following:

• RCoA member survey & clinical leaders survey
• RCoA published statements following EGM
• Association of Anaesthetists position statement on AAs
• AA draft curriculum
• AA Registration Assessment (AARA)
• NHSE, GMC & AoMRC published statements on medical associate professionals (MAPs)
• GMC Good Medical Practice
• RCoA commissioned Cochrane Response systematic review of the role of non-physician providers of anaesthesia
• BMA published guidance on MAPs
• Discussions held between the AA SoP CL and AAA President, HEI representative and Clinical Lead for AA representatives.
• Documents describing locally produced SoP and governance processes submitted by departments employing AAs
• Consultation with the Boards/Executive Committees of the Obstetric Anaesthetists’ Association (OAA), Association of Paediatric Anaesthetists (APAGBI), Neuro Anaesthesia and Critical Care Society (NACCS) and Association for Cardiothoracic Anaesthesia and Critical Care.

The following sections of this member briefing outline the approaches taken to specific aspects of the new 2024 Scope of Practice. They detail the rationale behind the decisions taken in including/excluding aspects of current AA practice. They also outline the process of transition proposed by the CWG.

6. Approach to the introduction of phases of practice post qualification

Following discussions with departments who have worked with newly qualified AAs, a common approach to introducing AAs into clinical practice emerged. This described a graduated introduction into 2:1 working over a period of between three to six months. To this end the CWG developed the principle of ‘Phases’ post qualification to better describe the graduated support that AAs may need as they develop their clinical competence and confidence.  

7. Approach to limitations on regional anaesthesia

The AA curriculum and AARA require an AA to learn how to deliver simple regional blocks (SRB), but the specific blocks required have remained undefined. Following the introduction of the 2021 anaesthetic curriculum, it has become clear that there is an issue with the availability of both training opportunities and trainers within the delivery of regional anaesthesia as a practical skill on a national level. To this end, the CWG and Regional Anaesthesia-UK (RA-UK), supported by discussions at RCoA Council, have taken the view that regional anaesthesia does not need to be within the remit of AAs in clinical practice. The priority should remain to train AiTs, SAS anaesthetists and anaesthetic consultants in the delivery of regional anaesthesia while this gap in training, experience and practice persists.

Furthermore, RA-UK are of the opinion that in the context of AA practice an SRB relates to an infra-inguinal fascia-iliaca block (IIFIB) only. To protect patients from loss of a service, and to support AAs in established practice who are already delivering regional anaesthesia, transition arrangements have been proposed which will allow this to continue under specified governance structures and defined levels of supervision.

8. Approach to inclusion of spinal anaesthesia

At the request of RCoA Council and the CRG, the CWG introduced spinal anaesthesia into the 2024 Scope of Practice. This matched the output of the AA draft curriculum and AARA. It was difficult to reach a consensus position regarding the supervision level required for spinal anaesthesia but it was eventually agreed that, like induction of anaesthesia, insertion of a spinal anaesthetic required direct supervision by the clinical supervisor. As with induction of anaesthesia, the involvement of the supervisor in delivering the procedure will become less as the AA becomes more senior, as described within the phases of the 2024 Scope of Practice.

9. Approach to ASA grade and required levels of supervision

A significant amount of time was spent discussing the use of ASA as an appropriate grading system for patient selection in relation to AA practice. While other options were considered, ASA grade was viewed as the most widely used system currently available. To this end it has been incorporated within the 2024 Scope of Practice to help departments plan ahead and select appropriate cases (ASA 1 and 2) for AAs to undertake within the 2:1 supervision model.  This cut-off reflects the wide range of patients who could be classed as ASA 3 and hence present with significant co-morbidities and would need the AA to be supervised 1:1. The decision on a patient’s ASA grading for elective surgery should be made by a clinical supervisor and in advance of admission. It was felt to be inappropriate to leave this decision to the clinical supervisor on the day due to the pressures to prevent on the day cancellations.

Other circumstances in which 1:1 supervision was also deemed appropriate were:

• non-elective work (patients whose care is not planned ahead and who have not undergone an appropriate pre-assessment process prior to admission)
• paediatric patients (<16 years of age)
• any activity involving general anaesthesia or deep sedation not within the theatre environment (remote sites).

10. Approach to transition of AAs post qualification onto the 2024 Scope of Practice

It is recognised that the changes written into the 2024 Scope of Practice will have an impact on those AAs in current clinical practice. This will be greatest for those who have been in practice the longest and who have developed extended roles beyond those outlined in the 2016 scope of practice on qualification. We are aware that any change or limit put on extended roles in the 2024 Scope of Practice will affect clinical activity undertaken by AAs, and if implemented in full at the onset of regulation, could have a significant impact on the delivery of services in some areas. This in turn could impact the patients who require those services.  To minimise this problem and enable services to transition to a reduction in the reliance on AA extended roles which sit outside of the 2024 Scope of Practice, we will implement a graduated transition as outlined within the scope of practice document.

11. Appendix 1

Membership of Core Writing Group

A Core Writing Group led on writing the scope of practice, with representation from the College, the Association of Anaesthetists and RA-UK. The group includes a clinical lead appointed following an open recruitment process. Further information on the relevant background and experience of the Core Writing Group can be found here. The members of the Core Writing Group are:

• Dr Satya Francis (Chair), RCoA Elected Council Member
• Dr Fiona Donald, Chair of the RCoA AA Committee and RCoA Elected Council Member (former RCoA President)
• Dr Jon Chambers, Clinical Lead for AA Scope of Practice and RCoA Elected Council Member
• Dr Ros Bacon, RCoA Elected Council Member
• Dr David Urwin, RCoA Co-opted Anaesthetist in Training Council Member
• Dr Tim Meek, Honorary Secretary and President Elect, Association of Anaesthetists
• Dr Emma Wain, Honorary Treasurer, Association of Anaesthetists
• Dr Nat Haslam, President, Regional Anaesthesia – United Kingdom (RA-UK)
• Dr Simon Heaney, Elected Member of the RCoA Scottish Board

Membership of Clinical Reference Group

The writing group is assisted by a larger, representative Clinical Reference Group, which provides input and feedback on the development of the scope of practice. The Clinical Reference Group currently comprises representatives from a number of groups and organisations, including:

• The Association of Anaesthetists
• The Association of Anaesthesia Associates
• Regional Anaesthesia United Kingdom (RA-UK)
• The RCoA Clinical Leaders in Anaesthesia Network (CLAN)
• Higher Education Institutions (HEIs) providing AA courses
• Relevant RCoA Boards, Committees and individuals (Devolved Nations Boards, Anaesthetist in Training Representative Group, SAS Committee, Bernard Johnson Adviser for Training and RCoA National Clinical Lead for AAs)
• PatientsVoices@RCoA
• NHS England
• General Medical Council