The Scottish Perspective

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The Scottish Perspective

• HM Robb
• Clinical Co-ordinator for AP Project
• NHS Education for Scotland

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Anaesthesia Practitioners in Scotland

• Background
• RCA
• Educational aspects
• Practical experience
• Regulatory issues
• Future
• Patients perspective

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Background - March 1996
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Background - October 2002
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Royal College of Anaesthetists 2002
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General Medical Council

• 46. Delegation involves asking a nurse, doctor,
  medical student or other health care worker to
  provide treatment or care on your behalf. When
  you delegate care or treatment you must be sure
  that the person to whom you delegate is competent
  to carry out the procedure or provide the therapy
  involved. You must always pass on enough
  information about the patient and the treatment
  needed. You will still be responsible for the
  overall management of the patient.

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English dimension

• NWWA taking forward a pilot study
• Phase I (January 2004)
• Phase II (January 2005)
• Phase III (September 2006)

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Scottish dimension

• Scotland
• Scottish Executive commissioned NES to develop
  the role of anaesthesia practitioner
• National Steering Group
• Representing all key stakeholder Groups

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Representation on Steering Group
Education for Scotland
Association of Anaesthetists of Great Britain
Ireland
The University of Edinburgh
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Representation on the Steering Group

• Chief Medical Officer
• Scottish Association of Directors of Nursing
• NWWA
• Association of ODPs
• Association of Peri-operative Practice
• Patient public representation

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Project Initiation Document

• Objectives
• To develop and deliver the phased introduction of
  Anaesthesia Practitioners to NHS Scotland while
  ensuring the maintenance of clinical standards
  and patient safety
• To make recommendations in relation to the
  sustainability and a future way forward for the
  new role.
• Assumptions
• Shortage of other Health Care Practitioners
  therefore utilise Science graduates to increase
  pool
• Implementation will require a major cultural
  change within anaesthetic profession and the
  delivery organisation of anaesthetic services

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Developing the role

• Develop Educational package
• Select initial 14 (14 year 2) students (ideally)
• 50 Science Graduates
• 50 Health Care Professionals
• Select appropriate sites
• Initially through letters to Chief Executives BUT
• Strong support from the anaesthetic department
• Support from management
• Educational record (SpR accreditation)
• Access to appropriate range of surgical services
• Different types of provider (DGH, Teaching
  Hospital etc)

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Boards expressing interest
Borders Fife Forth Valley
Greater Glasgow Lanarkshire
Lothian
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Timeline
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Timeline
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Evaluation of the project

• Has the training package delivered APs capable of
  delivering the roles envisioned?
• Is there appropriate awareness and understanding
  of the role by other health care professionals as
  well as the public?
• Can aspects of the surgical service within the
  Scottish NHS can be suitably reconfigured to
  allow APs to effectively contribute to the
  service e.g. by servicing lists running
  concurrently, supervised by a single medically
  qualified anaesthetist?

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Why is this not a pilot?

• What is a pilot?
• English project will involve some 50 Trusts when
  Phase 3 starts in September
• NES PID
• To make recommendations in relation to the
  sustainability and a future way forward for the
  new role.
• Semantics

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• Graduates to replace anaesthetists in surgery
  Safety concerns over new practitioners
• Helen Puttick (June 6th 2005)
• Consultants are divided about the scheme,
  which will create anaesthesia practitioners by
  training nurses, surgical department assistants
  and science graduates in such as biochemistry and
  physiology to take over some patient monitoring
  during surgery from consultant anaesthetists.
• They are concerned about the safety of it.
  They are concerned that patients may suffer. That
  is why we need to do it cautiously

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• Passing the bar to pass the gas
• Jennifer Veitch (30th March 2006)
• From this autumn, science graduates in
  Scotland will have a new career option open to
  them - they can train as anaesthesia
  practitioners (APs) at Edinburgh University.
• The institution will be the first north of
  the border to train APs for the NHS in Scotland.
  Officially, and perhaps controversially, there
  will be no Scottish pilot project - while the
  pilot projects running in England are still some
  way from being concluded, let alone evaluated

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• Training changes a wake-up call for
  anaesthesiologists?
• Introducing anaesthesia practitioners to meet
  a staffing shortage is dividing the profession,
  says JENNIFER VEITCH (17th April 2006)
• WHEN the British Association of Day Surgery
  holds its annual scientific meeting in Glasgow
  this June, there is little doubt about the most
  controversial issue on the agenda for debate. The
  introduction of anaesthesia practitioners (APs)
  to the NHS is dividing the profession. Some
  doctors completely oppose anyone other than
  highly trained...

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Whats the press saying?

• Purpose of a newspaper article is to sell
  newspapers. Controversy, disagreement and safety
  issues will always be emphasised.
• The role is controversial
• Concerns are raised about
• safety
• standards
• no pilot
• manpower planning
• The introduction of APs is about change and
  people dislike change

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A controversial development?

• RCoA AAGBI Statement February 2006
• We believe that the pilot project must continue
  to be clearly and unambiguously supported, to
  ensure that all the questions about the
  suitability and practicability of APs working in
  the UK are properly answered
• Those opposed to the project believe that if the
  College and the Association simply withdrew their
  support, the project and APs would cease to
  exist, but this is simply not the case

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The NHS of old
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Foundation hospitals
Trusts
Treatment Centres
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Actively Managing Hospital Admissions/Planned Care
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Anaesthesia Practitioner

• One solution to manpower shortages
• Recognised by DH and SEHD
• In other countries non medical staff work well
  within the anaesthesia team
• The role of non-medical staff in the delivery
  of anaesthesia services
• RCoA October 2002
• There appears no strong evidence of significant
  differences in critical incidents or death
  between different provider types in modern
  anaesthesia practice. In our view if there is a
  difference is unlikely to be substantial
• Smith et al (2004) Exploring Professional
  boundaries in Anaesthesia. British Journal of
  Anaesthesia 93 540-5

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UK MMC Career Framework Proposal
Continuing Professional Development
Senior Medical Appointments
Specialist and GP Registers
Article 14/11 route
CCT route
Postgraduate Medical Training
Continuing Professional Development
Specialty training inSpecialty/GP training
schools
Career posts
Specialist and GP training programmes (Run-through
training)
Fixed term specialist training
Foundation training in foundation schools
F2
F1
Undergraduate medical training in medical school
Arrows indicate competitive
entry
Medical school 4-6 years
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UK MMC Career Framework Proposal
Continuing Professional Development
Senior Medical Appointments
CONSULTANT
Specialist and GP Registers
Article 14/11 route
CCT route
Postgraduate Medical Training
Continuing Professional Development
Specialty training inSpecialty/GP training
schools
Career posts
Specialist and GP training programmes (Run-through
training)
Fixed term specialist training
Foundation training in foundation schools
F2
F1
Undergraduate medical training in medical school
Arrows indicate competitive
entry
Medical school 4-6 years
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Anaesthesia Practitioner Role

• First Scottish Presentation
• Tightly controlled curriculum development
• Role must be mapped to respond to the
  requirements of the evolving service
• Flexible means of delivering high quality patient
  care with the anaesthesia team
• A shared vision where Professionalism meets
  flexibility

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Anaesthesia Practitioner Role

• Drivers
• Reduction in working hours by primarily medical
  staff
• Consultant contract and pay modernisation
• Requirements of a flexible workforce
• Increasing pressure from lots of sick patients
• Increasing move to day surgery
• Impact of modernising careers in the health
  service
• Demographics increasing older population not
  necessarily healthier
• Decreasing birth rates

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Anaesthesia Practitioner Role

• The ways in which anaesthesia services in the UK
  are currently delivered are not sufficient to
  maintain and increase future surgical throughput
• Visit to centres in 2002 to USA, Netherlands and
  Sweden by
• Royal College of Anaesthetists
• Changing Workforce Programme
• Department of Health

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Anaesthesia Practitioner

• A Royal College of Anaesthetists and
  Association of Anaesthetists of Great Britain and
  Ireland Statement
• Only Anaesthetic Practitioners trained within
  the nationally recognised Anaesthesia
  practitioner programme based on the curricular
  framework developed will be able to share the
  clinical care of anaesthetised patients with
  medically qualified anaesthetists

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New Ways in Working Programme Aims

• To develop an advanced practitioner role within
  the anaesthetic team that will
• allow more staff to work differently
• maintain patient safety
• have transparency to the public, with particular
  reference to responsibility, delegation and the
  referral of patients
• be supported by appropriate education and
  training
• be part of the team working with medically
  qualified anaesthetic staff in a supervised
  capacity

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English Situation

• The role within the anaesthesia team
• One theatre
• Increased throughput of surgery
• More flexible ways of working for consultant
  anaesthetist
• Two theatre approach
• Increased throughput of surgery
• More flexible ways of working for consultant
  anaesthetist
• Pre assessment
• Pain Medicine
• Cardiac arrest team

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7 Cluster Networks

• Avon, Gloucestershire Wiltshire
• Birmingham the Black Country
• Norfolk, Suffolk Cambridge
• North East Yorkshire Northern Lincolnshire
• North West London
• Northumberland, Tyne Wear
• Thames Valley

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Role Definition

• The Anaesthesia Practitioner (AP) is a new member
  of the anaesthesia team
• The AP may undertake the induction and emergence
  from general anaesthesia under direct supervision
  of a consultant or senior anaesthetist but will
  make clinical decisions themselves under indirect
  supervision while established anaesthesia is
  maintained
• The clinical responsibilities of the AP include
  administering anaesthesia and caring for the
  patient during surgical procedures. The range of
  practice extends from pre-operative to
  postoperative anaesthetic care.

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Role Definition (continued)

• The role is primarily defined by the scope of
  work undertaken in the operating theatre where
  the Anaesthesia Practitioner will, in a
  supervised capacity, participate in induction,
  maintenance and reversal of anaesthesia using
  skills and knowledge that are based on in-depth
  understanding and application of physiology and
  pharmacology

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National Curriculum Framework

• The Contents
• 27 month course
• 12 x 2 month modules
• Diploma in anaesthesia practice
• MCQ OSCE
• 3 month observed practice
• Associate of RCA
• www.wise.nhs.uk/sites/workforce/practitioners

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Anaesthesia Practitioner Rolein Scotland

• Who is eligible to undertake the role
• Nurses
• ODPs
• Science Graduates
• 20 Students annually across Scotland
• On-site training by Consultant Anaesthetists
• E-Learning
• Student APs planned to start in September 2006

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Anaesthesia Practitioner Rolein Scotland

• Most Anaesthesia Departments have expressed an
  interest in being involved
• One Higher Education Institute will be chosen to
  collaborate develop the curriculum in Scotland
• Awareness raising events
• Support from all stakeholders

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Summary

• This is an exciting opportunity to shape and
  develop the anaesthesia team for the future
• This new role development would contribute to a
  more flexible approach to service requirements
• The support of major stakeholders in the
  development of the role will ensure continuing
  high standards of care are provided within the
  speciality

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Contact details

• Programme Director
• Dorothy.Armstrong_at_nes.scot.nhs.uk
• 0131 220 8681
• Project Lead
• Sybil.lang_at_nhs.net
• Mobile [phone]

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