The Ward Round: Not just another royal college row

On Tuesday evening, the Royal College of Anaesthetists held an extraordinary general meeting in which thousands of its members passed all six motions.

Three of the motions were focused on the future of anaesthesia associates – a role introduced in 2004 designed to “enhance the working lives of other members of the perioperative team” – and the other three on anaesthetics medical training reform.

Almost 90 per cent of the more than 4,300 RCOA members voted to pause the rollout of AAs, with very strong support on motions around supervision and communication with patients about the role. 

They also overwhelmingly supported reducing short-term medical training placements, making enquiries around repeated training administration disasters and exploring the possibility of regional recruitment.

But why this EGM now, when AAs have been working in the NHS for almost 20 years? Part of it is a pledge within the long-term workforce plan to increase AA numbers to 2,000 by 2036-37 (up from around 120 according to recent figures), which prompted concerns about the impact this would have on junior doctor training opportunities.

Meanwhile, scrutiny surrounding physician associations has heightened, following the death of Emily Chesterton after a PA failed to diagnose her deep vein thrombosis twice or seek advice from a doctor. This has again ignited the debate around increasing associate roles and public understanding of them.

Powerful mandate

The EGM has, according to RCOA vice president Helgi Johannsson, provided the college with a “clear and powerful mandate from our membership”.

“We now have a duty to act and will advocate for our doctors and patients to NHS England and other bodies,” Dr Johannsson said.

However, he stressed: “AAs have been providing a valuable service for more than 20 years but it’s vital that we protect our patients, doctors in training and the AAs themselves with regulation and a safe scope of practice.”

RCOA president Fiona Donald said in a statement after the EGM the college would “urgently” begin implementing the resolutions, but also stressed the college remains committed to supporting AAs who are currently working in the NHS or in training.

Richard Marks, co-founder of the group “Anaesthetists United” that campaigned for the EGM, said the result demonstrated the “strength of feeling amongst anaesthetists”, adding he suspects other colleges would vote similarly if they carried out an equivalent exercise. 

Perhaps NHSE is of the same view; The Ward Round understands it has already requested a meeting with all royal college presidents.

Growing associate roles

The EGM also taps into the wider debate about associate roles, whether they are the right investment and if they actually improve efficiency and productivity.

In the BMJ, the Nuffield Trust’s Rebecca Rosen and Billy Palmer argue that, in relation to the physician associate role, the lack of statutory regulation and growing recruitment of PAs trained outside the UK has meant that the role remains variable across the NHS.

They also note that public understanding of the PA is limited and said patients must be told clearly at booking what type of health professional they will see, along with options for requesting a review by a doctor. The authors also called for PAs to always work in clinical teams, so as to enable supervision by an experienced doctor, and said colleagues and supervisors must be clear about physician associates’ scope of practice and supervision arrangements.

The impact of the EGM on AAs should also not be underestimated – the debate on social media leading up to it rapidly turned nasty, and at times overshadowed the genuine safety and training quality concerns.

Although no one felt comfortable giving their name for this piece, the AAs I have spoken to are demoralised and uncertain about their future. It was also made clear: they view regulation and lines of supervision as absolutely critical and think the former is long overdue. 

The RCOA must repair fractures in its membership; AAs may be small in number but they are nonetheless part of the NHS family and are not responsible for workforce policy decisions. And the General Medical Council and NHSE must ensure regulation is fit for purpose and not delayed any further, as it is urgently needed to protect both staff and patients.