Leng Review Webinar - Anaesthetists

Gillian Leng (01:27)
Good evening everybody. It's just on 7 PM and we've got an hour for this webinar to talk about the review, my review into the role of physician associates and anaesthesia associates and tonight it's focused on the letter. We're here to talk about the role of anaesthesia associates and the group that's been selected to attend the webinar should be anaesthetists. So I hope you're in the right webinar here. What we're going...

I'm going to just describe what we're going to cover. So if I could have the next slide, please. So I am Gillian Leng. I'm the lead reviewer and my background's in medicine. I specialised in public health, but probably fair to say that most of my career has been spent not formally practising in standard public health, but ⁓ in evidence-based medicine, working 20 years at NICE. And probably if you

If you cut me through the middle, I'd have evidence through me like a stick of rock. And at NICE, I've been involved in many of the controversial areas, particularly some of the controversial guidelines. And hopefully that stands me in good stead for leading this review, which is, of course, also rather controversial. I'm pleased that I'm joined here this evening by Claire Shannon, who I'm sure is known to all of you. But Claire, if you could just briefly introduce yourself, that would be lovely.

President RCoA (02:53)
Yeah, thank you Jillian and thank you very much for inviting me to come and facilitate the questions ⁓ for this webinar. I'm really pleased that the webinars been scheduled because it's really important that anaesthetists and members of the Royal College of Anaesthetists are able to bring their concerns and questions and comments directly to the review team and to you.

so that their voice is heard. ⁓ So thank you very much for that. ⁓ All of these things really matter and I'm pleased to be here to help facilitate.

Gillian Leng (03:34)
Thanks Claire, and I really appreciate you joining. Also here on the call are some members of the Secretariat, the team helping me and they're in the background moving things to select the slides and hopefully there won't be any technical issues, but if there are, they will be there to help. And what I'm going to do is to give a brief overview of the approach being taken with the review, the timeline, progress to date.

and then we'll end up with plenty of time for questions and answers because I think that's the most important bit and I'll talk in a moment about how you ask those questions and it's great to see so many already there and Claire will be helping by reading out those questions.

So in relation to asking questions, obviously keep them within the scope of the review, but otherwise ask whatever's on your mind. And you might wish to ask them anonymously. Be aware that we've had from some of the previous webinars that we've done, people taking screenshots and then tweeting or X-ing whatever the verb is these days, those questions. So that might be a reason to keep.

Keep your name out of it if you prefer. Use the Q &A function to ask questions, which I think people are already doing. The chat function isn't working for this webinar. And if you don't want to ask your own question, but you want to up vote someone else's, that's really quite helpful for us because it means Claire can prioritise the questions that have got the most votes and she'll work through those rather than trying to pick and choose.

And if you want to up vote, use the arrow at the bottom left of the question, not the thumbs up. The thumbs up gives it a like, but it doesn't help to up vote it. And also for some reason, if things are liked, it seems that you can hover over it and find out who liked it. You can read the name. So again, just be aware of anonymity if you're bothered by it.

we've had some questions sent in advance. So just to flag that up as well. And of course, don't use any personal, private or privileged information because we won't be able to read these out and don't use any inappropriate language. So those are the rules for asking questions. And I'll move on now to give an overview of the question that I was given in relation to this review. So the main question.

set by the Secretary of State was, the roles of physician associate and anesthesia associate safe and effective as members of a multidisciplinary team across all tasks, roles and settings? So it came pretty much like that as a single sentence, but we are being clear that there are quite significant differences between what PAs and AAs do. So although I'm going to come out

at the end of this review with a report, it will be one report. There will be separate sections in relation to PAs and AAs because we'll have different types of evidence, different questions, different conclusions. So they're not all being lumped together. And I'm emphasising that because I heard quite loud and clear at the start of this from some anaesthetists that that point was really important. So.

look at the evidence and I'll say a bit more about that in a moment. And there could be a spectrum of conclusions. It could be that the roles are not safe. They should never be used again in the future. That's the sort of left-hand end of this. That's a very stark end. Or it might be, yes, they're really safe. We should be rolling them out more. We should be using them much more. Or something in the middle with some modifications to the role. And again, I'm laboring this to make it clear.

that the review is being open minded and objective and not having any preconceived ideas. So the next slide, please.

We've been doing a number of things to pull together as much evidence as we can. And I think it's fair to say that it won't be a big surprise to you to know that there is more evidence, more data available in relation to PAs than AAs. But there's not nothing. There has been some information that we've received that is useful and will help us draw some conclusions. So we had a call for evidence.

and we were asking particularly for data, summarized data, unpublished evidence, et cetera, et cetera. And from that call for evidence, we had 87 responses. Now that might not sound very much because that's responses from 87 organizations. And within each of those responses, there was usually a multitude of different bits of information that we were sent. So there's quite a lot.

of evidence that the team has been distilling and sifting against some pre-agreed criteria, looking at quality of that evidence in order to determine what we can and can't rely on. We carried out a survey, two surveys actually, one for PAs, one for AAs. The survey closed on the 30th of March with over 80,000 responses. And I realise they don't have a figure here for the number of responses for the survey about

and a Caesar associates, but perhaps someone in the team can let us know. The survey was very much designed to be about AAs or PAs and the teams that worked with them. But as probably might be inevitable in the heat of this area, we're aware that there were some...

There was pressure for others to respond to the survey. So we'll have to look closely at the responses that we received to determine whether or not they're valid. I think I'll leave that point there. We've had a number of webinars. This is the last one today. In fact, the very first one I did was for the anesthesia associates. So it's good to be closing also with anesthetic issues. I've done a number of visits. I did visits to three acute trusts.

face-to-face and I did one virtually and they were very keen to talk to me about how AA's are being used in particular in a couple of those trusts where they've done a lot of work on the roles but you know it's important tonight to hear views from others who perhaps are less closely involved in rolling out the PA and the AA activity. We commissioned a systematic

review which is nearing completion. ⁓ Most of that evidence is in relation to PAs not AAs and we're also doing some focus groups through third parties with patients to get a patient perspective. So that's all the information that we're pulling together.

And the next slide, please. The next slide shows how we're aiming to put all of this together because it is quite a task. So you've got the bits on the left there, the blobs from the research, the published research. Sorry, it's building rather rapidly, but never mind. The research, the data, and the survey. Now, this is all key elements of potentially quantitative data.

And we're aiming to pull that together in various strands. And you'll see that in the next table.

So if you remember the review question, we need to distill out what we have from those sources that that relate to safety. Elements that look to effectiveness of the role, the patient perspective, cost and cost effectiveness, and we've picked up some evidence around cost and cost effectiveness in relation to AAs and education and training. And you'll see here the columns for physician associates and anesthesia associates, and that's making the point that I'd

I said at the very beginning about treating them separately. So hard data as much as we can and under we have had data based on audits from some acute trusts specifically looking at the AA roles. We've also got information on never events around safety. None of this is perfect, but we're doing the best we can and putting together as much information as there is to draw some conclusions.

Alongside hard data, there's informal feedback from stakeholder conversations I've been having listening to experts and the visits that I mentioned. And we are then going to pull all of this together to refine the themes that came out at the beginning. So what you see on the slide here are themes that we were told were important right at the start, things in relation to education and training.

location and settings, etc. Things around day to day working, supervision, scope of practice, staff ratios, naming ⁓ and impact on the wider team. So that's what we heard at the beginning and then questions about regulation and governance too. When we've been through all the feedback and survey results, it might be that we refine some of that, but that was what, that's where the emphasis appeared to be most needed.

at the start. I then want to have a few expert panel sessions because undoubtedly there will be some gaps in the hard evidence and talking to experts both nationally and internationally at this point will help clarify my final thoughts and then at the end some recommendations and the aim

for publishing these recommendations is in June, in ⁓ around about the same time as the 10-year plan and feeding into the workforce plan that I think is scheduled for later in the year because that's crucial. There's no point doing this work, spending all this time if the conclusions are not picked up and feeding them into workforce planning is clearly what needs to happen.

So the next slide, please.

I'm sure the audience in this virtual room is all aware of the interim scope of practice published by the College. And this was a significant piece of work it was consulted on and aiming to provide a platform for the role moving forwards and its interim while I go through this process. And it's helpful that the College has set out

on its website, its role in relation to Anasazi Associates and providing leadership and guidance, because clearly that leadership and guidance will be important, assuming the role moves forwards. But as I said at the beginning, you know, there's an open mind on what's the best way to take this forwards. So the next slide.

In a way, this is a summary of some other things that I've already said, but there have been five webinars with these various different groups of professions, PAs, AAs, President, doctors, other healthcare professionals. And this is the last one tonight, the focus groups with patients. And they really are important in terms of me getting a perspective from the profession, because although I have a stakeholder group that includes Claire as a

as the lead from the college includes other professional bodies. That's not quite the same as talking to people who are working out in the system on a day to day basis. So hearing your questions and understanding your perspective is really, really helpful. And I hope it will also make sure you feel informed about how the review is being taken forward and the approach that is being taken. So.

Claire said at the beginning, we might not have enough questions for an hour. I suspect we will. However, we may therefore not have time to get through them, but rest assured we will take all the questions away and review them, even if we don't have time to look at them now. So the next slide, please. These are some things that I thought might be interesting, but do ask anything. So.

Bearing in mind there's the existing scape of practice. Do you think that stands as it is? Perhaps that's a question I shouldn't be asking, Claire, but I'm sure people will tell me if they think it's perfect or if they think anything needs to change. Do you think there are any changes to the AA role that you think is essential for patient safety? And where might or might not AA's fit into a vision for an anesthesia service in the 21st century? And finally, there's a little figure on the tightrope.

And it's that's perhaps me because as the review moves further forwards, as I hear more about what's required in the future, it becomes more difficult for me not to say what I think and what I think the review might conclude because it's not quite time to do that. I haven't finished looking at all the data. So if you're listening and you think

she's being really cagey, she's not giving me a clear answer. It's because I am being cagey. I am being circumspect. That might be a better word than cagey. I'm being circumspect about what I can say. And there's another reason for the tightrope feeling. It's because there are lots of different perspectives and I have to be very careful to be treading the independent tightrope here and not being pulled in any particular directions.

and looking at what the evidence says, listening to what all those parties say. that's, I just wanted to explain that because that is very important about my independence and about being circumspect at this stage of the process. As we manage to distill all the evidence together in the net, pull all that evidence together in the next few weeks, we will be in a position to at least share some of the evidence and then the recommendations will come.

after that. So I think it's probably time for me to stop talking and to start answering some of these questions. So Claire, where are we going to start?

President RCoA (19:11)
Right, well thank you very much Jill and ⁓ thank you for ⁓ taking everybody through the process that you're following to reach your conclusions and your outcomes and so that will help very much interpret what comes out of the review. So ⁓ first of all, ⁓ for those online, please forgive me if I am a bit slow with

ordering the questions. This is my first time with this system and so I've had a five minute ⁓ introduction. So hopefully if I get a bit stuck somewhere along the line ⁓ with the ordering of the questions, ⁓ Chloe or the team can help me with that. ⁓ anyway, I will start with the first question, which ⁓ is posed by an anonymous participant.

and has had been up voted ⁓ many times. And the question is, why can an AA start anaesthetics after a two year postgraduate diploma, but a doctor needs a full medical degree and two years foundation training before doing anaesthetics?

Gillian Leng (20:30)
Well, I think that's a good question and I don't know the answer because it wasn't me that decided that that was the approach that should be taken. there are parallels in relation to the way the physician associates have been rolled out, being able to go and work in general practice in roles that are not quite the same as a GP but similar.

So there seems to be, seem to have created a route where there's one group of professionals having more of a hands-on apprenticeship and the medical profession having a different formalized route. the answer I've been given is that the doctors are training because they are going to be consultants and they will have more responsibility and that's the route. But I think that is a fundamental question and I...

I genuinely don't know the answer as to what was behind that. mean, you might know, Claire, and you're welcome to answer it if you do, but it's how the system has evolved, I think. I think it was probably evolution rather than creation.

President RCoA (21:46)
Yeah, ⁓ so I don't think I know that question either, but certainly AAs have been around for quite a long time and the rules have evolved, ⁓ but the initial premise seems to be unclear. So I think I'll move on to the next question and thank you very much, which is another very good question. ⁓ Again, I've voted many times. Given that

anesthesia associates must be directly supervised at a two to one ratio by a consultant and that they cost more than half of one consultant's salary. Will the review comment on the cost effectiveness or lack of it of anesthesia associates?

Gillian Leng (22:35)
The short answer to that is yes. Yes, I've been very clear that we did need to look at cost and cost effectiveness as far as we can, as far as the data will allow us to. Having been at NICE for 20 years, people would probably be surprised if I didn't want to look at cost effectiveness. And I know that the issue that's put in the question here about supervision by a consultant means that perhaps it's not

it's not an obvious equation. think the counter to that, just to put that counter argument, is that anaesthesia associates do do other roles that aren't just about being in the operating room, that they do do work on the ward with patients prior and after anaesthesia, which you also have to put into that cost equation.

President RCoA (23:31)
Okay, thank you very much. So the next question comes from Tim Cook. Thank you very much, Tim, for being assigning your name to this question. That's really valuable. And Tim asks, the review needs to be evidence based where evidence exists. It's been stated that there are no comparisons of AA performance with anesthetists. The NAP7, which

I don't know whether you're familiar with the national audit projects, Jill, but NAP7 looked at ⁓ chronic arrest under anesthesia and it was a national audit, so a big data set. The NAP7 paper which he sent to you, so it'll be within your data pack, it does exactly that, i.e. produce evidence on a national level and it is importantly

It is important that data such as this is included. Will you do so?

Gillian Leng (24:35)
I haven't personally yet looked at that data. I'm aware that we've got it. I've got a whole day session on Wednesday going through the evidence that we've sifted out with the team and it sounds like we will include that data. People used to think that NICE worked on randomised control trials and then we always had randomised control trials. Sadly, much, much of medical practice in healthcare is not informed by randomised controlled trials and you always have to look at the best available evidence and it sounds as though this paper is going to give us pretty much that. It'll be good data and perhaps the best that we've got so definitely we'll be looking at that.

President RCoA (25:25)
Thank you very much. So moving on to our next question. ⁓ I'm just refreshing again just to check it's in order. Yeah, OK, so the next question by an anonymous ⁓ participant is as follows. As a consultant anaesthetist, I am very cautious leaving a CT1 stroke CT2 anaesthetist in training.

solo in a theatre list unless I need a quick comfort break until they reach CT3 stroke CT4. So how can the government and the RCOA think leaving an AA with only two years training without a medical degree to manage a case independently? It's a two tier system and a lottery for patients on who is going to care for them.

Gillian Leng (26:25)
Well, again, it's not not it's not been my decision to introduce the AA role, but I think the people but I think the key is that an AA needs to be supervised. So there does need to be somebody available to be there should any any additional help be required. So, you know, the question has used the phrase to manage a case independently.

which perhaps is correct, but independently within that supervisory framework of having a consultant available. not entirely right, perhaps. Yeah, yeah, I think the supervision is key. And I know that people who are supporters of the AA role and the PA role,

get to know that person. So they work quite consistently with a particular AA and they know them and they know what their capabilities are and therefore that builds trust. It's not like someone who just pops into the theatre that they've never come across before and they have to rely upon. It's that building up of a relationship and trust that helps, I think.

President RCoA (27:49)
OK, thank you very much. So moving on. ⁓ We have a question from another anonymous participant. ⁓ Who I believe is probably an anesthesist in training by the way the question is asked and the question is I've worked really hard to become an anaesthetic registrar, including exams, etc. Why should it be appropriate for somebody who's not a doctor?

to come through and do the job I've spent years training for. There is a dearth of anaesthetic consultants and there is an awful bottleneck into anaesthetics training. Why spend the money on AA places, sorry, why spend the money on AA's rather than increasing training places?

Gillian Leng (28:43)
The key question, perhaps underpinning this, is what's been the driver for creating the AA role? Why have we got it? Why haven't we done as the question suggests, you know, increase training places? And I've been trying to get to that, answer to that question in some of the visits and conversations that I've had both for AAs and PAs.

And in general, the answer seems to be about gaps. Places where it's been difficult to employ doctors, places where it's been difficult to get doctors in training. Partly about money, but probably more about consistency and gaps. I've also been

trying to find out from NHS England what the driver was there and of course there aren't that many anaesthesia associates in the country, there are only 200 and they are focused in particular areas, more than others. And they were early adopters, you talk to the early adopters and they're very enthusiastic and I think part of it is that ability to have somebody that you work with regularly who you build up.

build up trust, but you know what you've put in your question is the other side of the argument probably relates more to training of doctors and the issues that relate to that. So I'm pleased that while I've been starting this review Chris Whitty, the CMO and ⁓ Steve Powis have launched a review into training of doctors, because I think that's a really important part of the puzzle. You know, I'm focusing on AAs and PAs, but actually there are

significant issues around training of doctors that we perhaps want to be sorting out, or we need to be sorting out, then perhaps about it.

President RCoA (30:45)
Thank you very much, Jill. ⁓ Right, moving on. ⁓ There's another question from an anonymous ⁓ participant ⁓ that has been popular and it is this. I work with five AA's, three of which have been qualified for over 10 years. I cannot leave them unsupervised even for two minutes as they're

decision making is so unsafe. I find an error or an omission in their pre-assessment or clinical decision making in almost every list that I work with them. This is a matter of national urgency to protect patients.

Gillian Leng (31:32)
That's probably less of a question, isn't it? And more of a comment. But I suppose my question to that would be, if their decision making is so unsafe, is there not something that should be happening within the trust about how these, you know, about retraining, ⁓ how they're being managed, about the roles that they're carrying out? It doesn't feel

It doesn't feel ideal, that's a bit of British understatement, that if there is such concerns about what those members of staff are doing.

President RCoA (32:10)
Yeah. Okay. Thank you very much. ⁓ So the next question is a little bit around the GMC and it is the GMC officially stated that associates do not study medicine or practice medicine. Do you think it's misleading to the public to call PAs and AAs

as medical professionals.

Gillian Leng (32:43)
It sounds as though the questioner thinks that it's misleading to the public.

President RCoA (32:50)
Perhaps there's a wider question here around what introductions and defining the names of the team members.

Gillian Leng (33:01)
I,

I, I. You might remember that the slide where I was talking about the themes that I'd heard at the start of the review. One of those themes was very much around naming and nomenclature of both the PAs and the AAs and part of that is about the the word associate. Some people think it should be anesthesia assistance rather anesthesia associates.

And the term medical professionals is an interesting one. I've heard less about that rather than the actual name given to PAs and AAs. I think there is something about the brand, if you like. Brand sounds a bit trite, but it's about how the role is described, how people present themselves. And it will be something that I will comment on.

in the review.

President RCoA (34:02)
Great, thank you very much, Jill. OK, moving on. The next question again from an anonymous participant, which is if there is a shortage of anaesthetic consultants, why is the answer anaesthesia associates?

Gillian Leng (34:21)
Well, it's...

It's an important question and I haven't been asked to answer that question. It goes back to the remit of my review. The remit of my review. Are they safe and effective as part of a wider multidisciplinary team? So we'll look at the data that we have to answer that question. We'll feed that into the reviews conclusion and that will feed into the workforce planning.

And it sounds as though, know, most people on this call probably would agree there's a shortage of anesthetic consultants and...

that's not for me to comment on and you are probably better placed Claire to make comments on that than I am.

President RCoA (35:13)
Yeah, OK, well, I think the. I think the people on the call know the college's position on increasing ⁓ training places and ⁓ consultant numbers. We continue to lobby about that. However, I don't wish to get involved in that kind of conversation because this again isn't the remit of the webinar, which is important for.

⁓ people to bring what they want to say and questions they feel they need answered if there are answers to you and the team. ⁓ if anybody on the call wants to ⁓ contact me directly about what we're doing around increasing consultants and training places, do feel free to do so. Thank you. Okay.

So ⁓ the next question ⁓ is ⁓ as follows. As a college tutor, I frequently have to fight for training opportunities for resident anaesthetists, which are being taken away by AA's. This will only get worse with expansion of the role. Why are we not protecting the training opportunities of the anaesthetists of the future?

Gillian Leng (36:42)
I think we should, we have to protect the training opportunities of the anesthetists of the future. I would absolutely, absolutely support that. And I don't think it's always the case that AAs are taking away those opportunities. In some cases they might be, but in other cases the AAs have been put into post because a particular trust couldn't get.

any trainee, any any anesthetist trainees. So it's a complicated picture and it does take you back to workforce, to workforce planning. What is the ideal team that we should be having? What is the role of AAs? If we want them, where do they work? Where don't they work? And absolutely not taking away training opportunities.

I've heard more about this in relation to physician associates, because of course there are a lot more, so it's been more of an issue. it's not a straightforward black and white picture, as you might expect. And when you talk to PAs, sometimes they have expertise and they are happy to train doctors on those particular procedures. And that might be appropriate. It might not be appropriate, but you know that

The fundamental thing is we have to protect training opportunities for an estus of the future. I'd agree with that.

President RCoA (38:14)
Thank you very much. Now the next question ⁓ is something that I'm very familiar with because this is something that strikes me as being very interesting ⁓ and is a conundrum that I have to deal with a lot. And this anonymous participant is asking a question as follows.

Please explain to me, like I'm five years old, why anaesthetics associates are needed in the NHS given the vast numbers of doctors desperate to do anaesthetics.

Gillian Leng (38:56)
Again, this isn't the focus of the review because the focus of the review assumes that we've got them. And I've been asked to look at, they safe? Are they effective? And as I said earlier, are they cost effective? But just trying to unpick your question from first principles for a moment. It's in some ways a philosophical question, isn't it? It's about what should a team look like?

And if you want to change the team, what would be your drivers? It might be money. You know, I'm not convinced that there's a huge equation around money, but it might be money. As I said earlier, it's often the fact that there are gaps in the service in relation to where you can get doctors in training and where you can get consultants, places where people don't want to work. It might be continuity because that is...

That's an issue that we're all aware of that the Chris Witty Review is aware of, which is about doctors in training moving around a lot and not having continuity. So I think I think it's that sort of complicated picture. And I also think and I'm giving you secondhand information because this wasn't my decision about bringing them in. But I have heard I have had one or two anaesthetists talking to me quite eloquently about models abroad.

about other countries where they don't have so many consultants and ethotists, is that better? I don't know. And I don't know if that was the driver or not, but there was obviously some of that thinking in relation to this. And there were also some enthusiastic places that wanted to bring in a different role, perhaps to provide some more flexibility. And we are where we are and I'm looking at safety and effectiveness.

and we'll comment on that and we'll do my best to make some sensible judgment for the future.

President RCoA (40:58)
Thank you. Now moving on. ⁓ Another participant is asking a question as follows. Have you seen the Lancaster University video whereby AAs were boasting about working unsupervised and that trusts will in inverted commas bend the rules? Does that not worry you that there appears to be no national rules?

Gillian Leng (41:29)
I haven't seen that video. Perhaps somebody could send me a link and I will watch it. If they are talking about working unsupervised, then that's clearly not in line with the advice that the college has produced, ⁓ Claire, and it doesn't seem appropriate at all because both the PA and the AA roles have been developed as supervised roles.

So how this video has been produced, don't know if it's been produced with the support of the university or not. ⁓

President RCoA (42:11)
I have to say I think it was, I don't know whether it was, ⁓ I think it may have been recorded without the person's knowledge. I'm not entirely sure, but.

Gillian Leng (42:25)
Yeah, okay. All right. Okay, so it's a sort of unofficial video, is it someone speaking about how they work?

President RCoA (42:34)
I'm not entirely sure. Well, in fact, I think it may have been an off the cuff remark, but I'm not entirely sure. But it would be useful, I think, for the review team to see it.

Gillian Leng (42:49)
Yeah,

it would, and you know, does it does that not worry you that there appears to be no national rules? I mean, there are there is there are clear rules about the AAR role not being not working independently, not working unsupervised. I think that it has been quite clear from the beginning. So. So.

clearly not an appropriate comment for someone to have made and indeed not an appropriate way of working.

President RCoA (43:22)
and I presume scope of practice will be within the remit of the review.

Gillian Leng (43:27)
Yes, scope of practices within the remit of the review. Yes.

President RCoA (43:31)
you, OK. OK, moving on. So the next question from another participant. ⁓ actually, this is a question about training opportunities for resident doctors. I think that question has been asked. That may be my mistake. OK, the next question is as follows. I was concerned by a comment you made at your previous consultants session.

where you said that your impression was that consultants were in favour of maps, whereas resident doctors were against. The AA experiment has been running for nearly 20 years and there are only around 200 AAs. The vast majority, 88.9 % of Royal College of Inestis members voted against expansion.

Surely that demonstrates that the vast majority of consultants are not in favour.

Gillian Leng (44:38)
The comment that I made was focused on physician associates and the physician associate role. And the. The impression that I've had from consultants that work with physician associates need to make sure that that caveat is in there. The consultants that work with physician associates are obviously a selected group. They work with them, but they they.

will be very supportive of the role because of the consistency, because they have somebody on the ward who knows the patients, who provides continuity both for them and for patients. know, one of the things about being a patient when you're on a ward is that you see so many different people, so many different professionals and the physician associates on a ward.

will be a bit like the glue in the system that we currently have set up. You when I was a houseman many moons ago, I think I was that glue. I was the one that knew all the patients. But the way ⁓ younger doctors, residents work these days, it's different. It's different. So that comment about consultants finding PAs helpful was what I was covering. Whereas in that scenario, the residents can find it quite, quite

tricky because their roles are sometimes a butting and...

I could go on, but that was the context that I was referring to in relation to what you're describing here about an Acesia Associates. You're right, there are around only 200 AAs, so although there are clearly some pockets where people are working and the AAs are integrated well into the team, it's not really rolled out, and I'm assuming it's not really rolled out for the reason that you've put

hear that the majority of anesthetists do not feel the need to have the role. I'm looking now at Claire, she perhaps can't see, I'm looking at her, but I'm assuming that that's why, you you voted against expansion and that therefore in this scenario, the majority of consultants are not in favour.

President RCoA (46:54)
Yeah, and I think it follows on for the next and I think the next ⁓ question actually really isn't a question, it's a comment and it follows on probably from what you just said and it is as follows. Can we please put to bed this concept of the vocal minority opposed to AA's? Surely the results of the EGM motions that was at the Royal College of Anesthis in 2023.

⁓ and the recent elections in the association of anesathists give light to this concept. Perhaps vocal majority would be more apt.

So I think that follows on.

Gillian Leng (47:37)
Yeah, I think that follows on, it? That's making the same point.

President RCoA (47:42)
Yeah, OK. All right, so moving on, the next question is as follows. If the Leng review strongly deviates from the current position of the college, will the college defer to the conclusion of the Leng review?

Gillian Leng (48:04)
That's a question for you.

President RCoA (48:06)
Well,

that's a question. ⁓ I mean, I think I think that sort of is outside this evening's conversation. You know, second guess is a whole lot of things and ⁓ certainly, you know, any change to the decision of college will have to be considered in its entirety by council. So I don't think I'm in a position to make any comment about that.

and I don't think the time is right to make any comment about that, but ⁓ the only thing to say is when the review ⁓ finishes, we get to see the report, ⁓ the recommendations in the report will be fully considered by council.

Gillian Leng (48:57)
Yes, thanks Claire and.

What shall I say about this? ⁓ I am aiming to produce a review where the conclusions are implemented. There are quite a lot of people that are asked to produce reviews, independent reviews for government where things aren't implemented. And, you know, the effort that I'm going to, that the team's going to, that the people listening have contributed to this review.

I feel it duty bound to listen to all of that and create some recommendations that are useful to everyone and that hopefully are wise and sensible. And I'm involving the key stakeholders in the work that I'm doing. The next stage needs to be sharing some of the evidence, sharing a summary of the evidence of all that data that I described.

and I'm planning a session with the college and others in the anesthetic world to talk through that, to expose that without me saying, well, and this now means whatever it means in terms of recommendations, but to take people on that journey so we can all see what the data says. ⁓ you know, I will talk to the people that I need to talk to as I go through this process.

President RCoA (50:19)
Thank you very much. ⁓ The next question asks as a consultant, I have been through medical and anesthetic training, i.e. I have an idea of what my level of trainees are. ⁓ Sorry, have. I have a level of what my level of trainees are. That is the depth of their knowledge.

How can I safely supervise an AA without assuming they know very little and therefore the whole role being undermined, not cost effective, if I won't trust them to do anything?

Gillian Leng (51:03)
Well, I want to answer this question in a general way, rather than making any specific comment about what we think about the AA role. it's about multidisciplinary team working and it's about the role of the doctor, because the doctor is, you know, a highly trained, highly skilled, highly intelligent part of a healthcare team. And I've worked

I've worked in organisations with multidisciplinary teams with clear line management structure where I've line managed people from completely different backgrounds to myself, know, project managers, analysts, various types of individuals. And I've enjoyed managing those teams and I know enough about what those people can do and what they can't do and the tasks that I can ask them to do and that I can't ask them to do. And I think if I'd gone through my career,

only supervising people who were a clone of myself, it would have been really quite dull. But that is all about having multidisciplinary teams. And I know that the task of being an anaesthetist is quite a defined task. So with my comments, as I prelude them, they're general comments. But I think that the medical team and the medical leadership of multidisciplinary teams is really important in general.

the future. think it's important that the doctors are not just little cogs in a wheel, big cogs in a wheel, but they have oversight of and responsibility of wider roles. That's what I think and that's beyond what the review is going to look at. You know, I go back to the review is safety and effectiveness of the roles, but I think I would advise all of us to think

beyond only being able to supervise people that are like us and that we should have enough understanding of people in our teams doing different roles with different training and being aware of what is safe for them to do and what isn't. Hope that makes sense.

President RCoA (53:11)
Thank you, that's great. Thank you very much. So another good question coming now. The next question is from a consultant in a university teaching hospital who says even in lists which are theoretically straightforward, there are usually complex patients. Consequently, it can be challenging to find appropriate lists for even very senior trainees to run as the solo anesthetist.

Is this really an environment where non-physician anaesthesia providers should be encouraged?

Gillian Leng (53:49)
⁓ I don't think I can find this question. I've been reading them out as you've been.

President RCoA (53:54)
48

minutes ago. ⁓

Gillian Leng (53:57)
minutes ago. So sorry, can't find it. you give me the

President RCoA (54:03)
So the bones of it again, consultant in a university teaching hospital commenting that even in lists that are straightforward, there are complex patients and it can be challenging to find lists even for very senior trainees to run as solos. So is this the environment to bring in non-doctors basically?

Gillian Leng (54:25)
Yeah, and that's. That's something that I've heard quite quite a few times going through the review process that the complexity of the cases is is increasing and that that as you as you've said that it's harder to find more straightforward cases. I suppose people you know the counter to that is the role is a supervised one and that there will always be a consultant and ecitist available so.

What I'm going to try and do is to see what data there are to see how the role stacks up in terms of safety and effectiveness.

But I've heard what you've said. ⁓

President RCoA (55:10)
OK, so moving on. Doctors have been accused of being toxic during this debate. However, many doctors have had to fight to expose the truth about the misuse of AA's, for example whistleblowing, anon accounts or FOI requests. From the evidence submitted to your review, will you be clearly identifying examples of bad practice or inappropriate use of the AA role? And can you give one example today?

Gillian Leng (55:46)
just wondering where to start with this because there's a number of elements. I think...

I think there's an issue around fighting to expose the truth that I might describe as having data to expose the truth. Already touched on this to a certain extent, the need to draw on as much information as I can because there's no perfect source of the truth. And it's interesting that we've gone down a road for all the right reasons in relation to reporting patient safety incidents that do not

that are not attributed to any particular individual on the basis that safety incidents are usually about system errors. They're usually about team working. You can't usually point a finger. that's why the patient safety data is tricky in relation to a particular professional group. I may well say something about that and the challenge of data to demonstrate where there are risks in the review.

And I think the bit about being toxic during the debate, to be fair, has related to making comments about individuals when perhaps it wasn't particularly directed at someone who deserved the comments. I'm going to say this on their behalf because the first webinar that I did

was with the anesthesia associates. And the only word I can really use to describe that webinar was sad.

It was a very sad group of people who were worried about their future and their livelihood. And I noticed we had the comment about a video at Lancaster and people boasting. The people on that webinar were not in that sort of mindset. They were sad and miserable and didn't know if they had a future and were worried about their incomes and whether they were going to be made redundant. So I do need to say that just so you're aware.

from the evidence submitted to the review. Will I be identifying examples of bad practice? I will certainly put examples into the ⁓ into the report because I think it's always helpful to have examples, but I think ⁓ it would be good to balance good examples with bad examples.

President RCoA (58:27)
Yeah, thank you. Thank you very much. How are we doing for time? ⁓ I had a flash up that there were five minutes left in the.

Gillian Leng (58:37)
Oh,

yes. Oh, goodness me. Yes, I was getting carried away with the question. Yeah, we've got three minutes left. So we haven't run out of questions, Claire. OK.

President RCoA (58:46)
⁓

we certainly haven't. ⁓

Gillian Leng (58:49)
Do we want to do one more?

President RCoA (58:50)
I'll

one more. I'll do the next most up voted. ⁓ So, ⁓ all right, here we go. I'm concerned that you won't find evidence of increased errors made by AA's because these errors are being caught by supervising consultants. It feels like there is only a matter of time before a patient comes to harm.

Supervising AAs and repeating their work is putting additional stress on me as an NHS consultant. Why are we training and funding a position whose work needs to be duplicated?

Gillian Leng (59:31)
Yeah, I mean, it's certainly not efficient. If it turns out that we are funding work that is being duplicated, it's not going to be cost effective. We need to be getting more value, don't we, out of additional posts and a multidisciplinary team. And it's, you know, it's a fair comment about errors and are we going to pick these up or not. Of course, the point of supervising is that someone else is there to pick up a challenge and...

you know, trying to be fair in this debate, trying to remember what it was like as a doctor in training. You know, everybody makes mistakes. I'm sure resident doctors also are at risk of making mistakes too. But it's about that equation. It's about the overall balance of safety, effectiveness and cost effectiveness. So I will be absolutely alert to the points that you've made there. And I think that probably does one minute to me and I need to.

wind it up. So what I need to say at this point is many, many thanks to Claire. You've been brilliant at helping me through these questions and indeed are answering some of it. And thanks to everybody that's joined the webinar. You've given me some very challenging feedback, some really helpful comments and thoughts. And I think the perspective is clear. I've heard what you're saying.

And the next thing that you're likely to hear from the review process is some summaries of the evidence and what we've found, because I think it's important that we all look at that. So thanks so much and thanks for the team for making this happen in the background. Thank you. Good night.

President RCoA (1:01:15)
Good night.