The modern anaesthesia team

Workforce predictions made in 2000 suggested that the UK would have too few medical anaesthetists to meet the expansion proposals of the NHS Plan of that time and the anticipated impact of the 2004 and 2009 implementation of elements of the European Working Time Directive (EWTD). An evaluation of how to address the potential anaesthetists shortfall resulted in the introduction of a new role for nonmedical staff in the delivery of anaesthesia.1 The ‘New Ways of Working in Anaesthesia Programme’ (NWWA) was established in 2003 to look at the development of a non-medical role within the anaesthesia team and the development of the Anaesthesia Practitioner role commenced in January 2004. This role is now titled Physicians’ Assistant (Anaesthesia) or PA(A). The role was developed with the aim of increasing the flexibility of medical anaesthetists and to build capacity in medically-led anaesthesia teams to meet patient needs. The original description of the role stated that ‘a PA(A) is a member of the anaesthetic team, who is trained in both the underlying scientific and medical knowledge pertinent to anaesthesia, and in the skills of administering anaesthesia’. Overarching standards were set such that PA(A)s cannot be on-call or practise independently from an anaesthetist; their supervising anaesthetist must be no more than two minutes away and present in the same operating suite.

Two-to-one working

The plan for the PA(A) role in the UK was to focus on the delivery of anaesthesia in a two-to-one working model, with two PA(A)s working under the simultaneous direction of one consultant anaesthetist, in line with guidance from the Royal College of Anaesthetists (RCA). In other countries, such as the US, Scandanavia and Switzerland, this is already an accepted practice and is no longer considered a novel anaesthesia model. In 2003, five Trusts became pilot sites for the programme and, in 2005, an additional 21 Trusts joined, with 34 trainees organised into seven clusters. The NHS University (NHSU) commissioned a PA(A) National Curriculum Framework from the University of Birmingham, and arrangements were proposed by which the RCA would undertake a final assessment of PA(A)s before their registration. However, concerns relating to this new role do continue to be expressed by some anaesthetists and these concerns were voiced by one consultant during a lively debate at the recent Association of Physicians’ Assistants (Anaesthesia) (APA(A)) AGM. Consultant anaesthetist, Dr Martina Bieker, said that she had seen no data which would demonstrate that the two-to-one working set up has shown any real efficiency benefits. “I have seen no concrete evidence that the use of PA(A)s offers any efficiency or cost savings and, at the present time, there is not enough evidence to convince me of the benefit of this role. Recruitment in anaesthesia is still strong and the anticipated skills shortage in anaesthesia has not materialised,” she said. Dr Bieker also voiced concern that a more widespread expansion of the PA(A) role could adversely affect the skill levels of training anaesthetists, excluding trainees from many of the more standard procedures.