Leng Review Webinar - Anaesthesia Associates

Gillian Leng (00:50)
Good evening, everyone. It's 6pm. So welcome to this webinar about the Leng review and focusing on the role in particular on anesthesia associates. So I hope that's what you're expecting to have joined. If you're expecting something else, then you might have the wrong day. And I can't see anyone, but I do hope you can see and hear me. I'm sure there'll be more people.

joining but I do want to kick us off to make sure we have the opportunity to use a full hour. I'm speaking slowly because I can see numbers going up on the screen but as I say I think I will start because there's a few brief intros to go through. So if I can have the next slide please.

⁓ So I am hosting this session. I am Gillian Lang. I'm leading the review. For those who don't know me, I have a background in medicine. I specialised in public health. But most of my career has been at NICE where I worked on various programmes, including the guidelines programme, lots of controversial, tricky topics, lots of topics where you'd be surprised how limited evidence

that there was and the need to base some difficult decisions on that limited evidence. And I'm saying that because we might be in a similar scenario with this review. I do just want to introduce my co-host. So would you like to say hello, Scott?

President AoAA (02:23)
Hello, ⁓ for those of you that don't know me, my name is Scott Hepburn. I'm the current president of the Association of Anesthesia Associates. ⁓ I've been part of the stakeholders representing the AAA at various meetings down in London and I've been asked to obviously to go host and ask some of the questions that you'll all be providing. Thank you.

Gillian Leng (02:47)
And thanks, Scott, for helping out with this. And Scott's role is going to be reading out the written questions. And I've got a slide on asking questions in a moment. But I thought it would be easier, rather than me trying to do everything solo, read all the questions and blah, blah. Scott will help with that. So I'm going to begin, though, with a brief overview of the review and how it's going. I don't want to spend long talking because

Really, this is an opportunity to hear from you to get your comments and your questions. So next slide, please.

So this is about the questions which we'd like you to try and make sure are relevant to the scope of the review because I can't ask questions on everything that you might have an interest in in relation to the NHS. So do try and focus it on the review. But that said, ask whatever's on your mind. Don't feel constrained. You can ask the questions anonymously if you prefer.

You'll need to use the Q &A function rather than the chat. The chat is disabled because we want to make sure there's a focus on the Q &A and on the responses that I'm giving. So use the Q &A and very keen that if you see a question that you like, for it because that will help prioritise it. ⁓ And the vote button is the one with the arrow.

little thumb as well and the thumb is for liking it and that won't help the prioritisation so please use the voting button and Scott will make sure he then asks the questions from the top down so the ones with the most votes will get asked first. There have been a few questions sent in advance so if you look and you think we've pre-planted these questions we haven't but they were sent in advance and they've been entered into the system.

I'll do my best to respond to all the questions. If I can't, then we'll get back to you outside the meeting. The aim of today's session as well is to record the webinar so that it'll be available to those who didn't manage to come today. But as you might expect, don't include any personal, private or privileged information in your questions because

we want to make this widely available. And of course, don't use any inappropriate language. So that's the ground rules for asking questions. And next slide, please.

There were few basic points about the review and how it's working.

So the main question I was asked to consider was are the roles of physician associate and anesthesia associate safe and effective as members of a multidisciplinary team across all tasks, roles and settings? Sounds quite straightforward. However, when you start digging into the detail and looking at what information is available, it's not as straightforward as you might imagine. However, I do want to be clear that although

PAs and AAs appear in the same sentence here. We're aware that the issues are different and we are not trying to in any way merge PAs and AAs. We're looking at the role that you do with anesthesia associates separately because there are separate issues. So that's the key question. The line across the middle is to indicate that

there might not be an easy answer and there might be a spectrum of answers that could be, well, actually, we think the recruitment to the roles should be discontinued, know, a bit of a nuclear option on the left, or it might be that they need to be focused, or it might be that there needs to be more supervision, there needs to be more training, or in fact, the right hand of the scale, might be a response that there needs to be more investment in the roles.

and the role bolstered. So I'm putting that there to be absolutely explicit that I don't have any preconceived ideas. I do want to look at as much data as I can and will then judge where on that spectrum we should end up. And indeed, it might not be a binary answer. There might be different scenarios, different places, different roles that are covered that might be seen as safer or more effective than others.

So next slide, please.

This is a brief overview to give you a progress update on some of the things that we've put in place. You probably were aware that there was a call for evidence, particularly looking for data and local scopes of practice and anything that seemed relevant to the review. We've had 87 responses. That means 87 organisations.

or individuals have sent us some information. But within that 87, there is an awful lot of documents to review because each organization has sent us quite a lot of things. So the team is busy going through them, categorizing them. And of course, when there is anything that looks like a piece of research or a data analysis, we are screening that for quality in the way that you might expect and the way that I'm very familiar in terms of how nice has gone about that.

process because it's important that we are clear which bits of data analysis is more robust than others.

We've launched a survey, a separate one for the Anasisi Associate role, and that survey closes on the 30th of March. We've had about five and a half thousand questionnaires filled to date. There's also quite a few that people have started. That's quite a long survey, so hopefully they'll come back to it. We are aware that there is some gaming going on, which is unfortunate, but we will.

take that into account when we look at the results and it will have to be called out in the final report. Webinars launched. Well, this is the first webinar that we've done. So if you have any feedback on how it's working to inform the next set of webinars, that would be really useful. And I decided that we needed to do some webinars specifically with you as AAs, but also with PAs.

with the resident doctors, because there are groups that have been keen to hear from me and to ask me questions. And although I've met various individuals on the visits that I've done, can never, know, those are inevitably small and focused. So I thought the webinars would at least be a way of reaching more people. We've also commissioned a systematic review, which is now in draft form. We've commissioned it from

King's College in London. Some of you might have seen in the BMJ a review by Professor Trish Greenhalgh. And that was a helpful review, but we didn't commission that. If you read it, it looks as though we did, but we didn't commission that. There's also another review that's been done by a team in Nottingham. Again, we didn't commission that, but I think it's quite helpful to have a variety of people that have looked at this.

⁓ so that we've got a broader view. But of course, the one done by King specifically addressed the questions that we asked them to. And alongside this, we are also having a couple of focus groups to get views back from patients. Now, I think that's particularly about PAs. I think there's less in relation to patient feedback that we're expecting to get in relation to your AA roles.

So I've just got a couple more slides and then I'll be happy to take any of your comments or questions.

So the next slide aims to illustrate how we're bringing together all of this information to get to an answer. So at first, first bit here we are is bringing together the data in the types of data that we've looked at, the research, anything from trusts, that's additional data, the survey information. And we're going to analyze that in a standard framework that will look something like this. Hopefully it's going to arrive. Yes.

Separating out clearly, as I said at the beginning, the anaesthesia associates from the physician associates, PAs will be looking at setting more closely. And if you have any thoughts or comments today that you want to put into the Q &A function, then do, because it could be helpful to this analysis. within that column, we'll be looking at safety, effectiveness of the role.

patient perspective where relevant, cost and cost effectiveness, and anything that we see about education and training that might be relevant. So anything that comes out of the data. But if you think there are different ways of cutting the secondary care cake, if you like, then do let me know. So that's the data part. But then we're also gathering thoughts and views from various individuals.

feedback. There should be a box that's going to appear that says feedback. There we are from stakeholders, experts, visits. That's the softer stuff, if you like, but it's important. And I can't underestimate how useful the visits were to see how things actually work in practice. And then with all that information, I'll be able to refine some of the themes that we garnered.

right at the start. So at the start, people were keen to say you need to look at education and training, look at what happens in relation to CPD after people have qualified, look at day-to-day working, supervision, look at the ratios in which you work, identity and naming, particularly relevant perhaps to PAs, but also regulation and governance. So that list that you see there might not look like that.

once we've been through all the data, but that's just to give you a flavour of what we've heard since the start of the process. Having gone through all of that and begun to get a sense of where the recommendations will land, I do want to then have the opportunity to talk to some experts in the field who may well be international experts to help shape the final recommendations.

And there's a couple more things to appear on the slide. I hope at this point, yeah, expert panels and recommendations. So that seamlessly is going to flow out to recommendations that are due to be published in June. And it's important that they are because to have impact, they need to feed into the new NHS workforce plan. So that's why that timing matters. And of course, the new workforce plan will be

quite significant in terms of shaping the future of the NHS.

So next slide, please. This is bringing us back to this webinar and what we're trying to do now. There are four engagement sessions or webinars. We are clearly the one that's for anesthesia associates, the second there. Also talking to residents, PAs and other healthcare professionals and possibly one that we haven't yet scheduled, but I've had some feedback.

that says it might be helpful to do a separate one with anithsatists. So if you have any thoughts on that, then let me know. So that's what we're doing. And we want to respond to your questions here and now, but also pick up any views that you have that you might just want to enter a comment rather than a question. I want to make sure you feel better informed about how I'm taking it forward. And ⁓ so even if I

I don't get to answer all your questions or look at all your comments in this hour, because we've only got an hour and I'm sure it'll go very quickly. It is recorded, so we will take it away ⁓ and share it, as I've said, but we'll also have a record of the questions that you've raised.

And finally, finally, some suggested areas for discussion, but don't absolutely don't feel constrained by these things. You can ask whatever you like, as long as it's relevant to the review. How would you like to see your future role positioned? What would you like to be the outcome of the review? What sort of career progression or development would you ideally like to have?

What are your hopes and perhaps it should say hopes and fears regarding the future of regulation? And what do you think day-to-day supervision looks like when it's good and is appropriate and safe? And you'll see this poor little white figure there on a tightrope. Now that's intended to be me because I feel like I'm on a tightrope at the moment. I'm on a tightrope I think for two reasons. One is because it's quite a

quite a fraught area, shall we say, looking at PAs and AA roles at the moment. And there are different sides of that debate. And I am being very careful not to align myself with any of those different parties. have to stick on my own on the tightrope. And also the other part of this is that as I get further into the review, as I read more and learn more, I do begin to have opinions. But I am being very careful

not to say what I might think today because it might not be the same as what I think tomorrow or what I thought yesterday and it will start all sorts of hairs running. So if you think I'm being cagey it's because I'm actually being cautious about not saying the wrong thing at the wrong time. So that that was all I wanted to kick off with and are we going to take the slides down at this point so that we can we're a bit larger? Yeah, yeah that's great. So we've

got a few questions here. I hope everyone can see the Q &A and you can see where to up vote or down vote. I think I need to order them, I? Most up voted, that's better. I can see one with seven, but I'm going to shut up and let Scott read the questions out. It'll be a different voice for you to hear.

President AoAA (18:22)
Thank you, Joe. That's great. So yeah, just a reminder everybody to the the up voting function is the one that will get the questions at the top of the pile. And liking them is fine, but it will not bring the questions further up. need to use the arrows that basically are the upvotes and I'll keep trying to update my screens that I've got the most recent. It once the questions been asked if it's kind of covered something that other questions have, those will be archived.

If you really want to push something, put a fresh question in with a more specific point potentially, but we're going to try and keep this session going as much as we can. Are you happy Jill if I start the? Thank you so ⁓ the first question ⁓ at the top here is given the Royal College interim scope of practice for us, do you believe that current limitations within the scope might restrict the potential?

for role development? And the question also asks about the broader integration of AAs into the anesthesia team. Could that be affected? If so, what changes would you suggest? So it's about the college scope that we spoke about before. ⁓ Do you believe current limitations within it might restrict the role for development and integration into the anesthetic team?

Gillian Leng (19:48)
Well, one of the key things that the review was asked to look at right at the beginning was scope of practice. And it's actually one of the trickiest things to consider because you can set a scope of practice for the start of someone's career. But I think it would be quite an unhealthy professional role if there is no ongoing development of that role.

And I certainly don't think I can set a scope of practice for every little development that someone might have. Sorry, there's something slightly odd in your screen, Scott. That's better. was putting me off. No problem. don't have everyone else, sorry. So I do think it's important that every professional group has some ability to develop. And that needs to be considered as part of

President AoAA (20:26)
I apologize, sorry.

Gillian Leng (20:42)
as part of the review. And as I said just now, I can't tell you exactly what that might be, but I think professional development is inherently important. And of course, ⁓ it is an interim scope of practice, and the college has said that they will review it in the light of the recommendations from this review. So that's helpful. ⁓ I don't think I can say any more in terms of definitive answers at this point, but.

rest assured that we've logged the importance of scope of practice.

President AoAA (21:16)
And the other part of the question was what changes would you suggest to facilitate further professional growth for anesthesia associates? It's a bit of a tricky one really.

Gillian Leng (21:26)
Yeah, I don't think I think it's too. I think that's the sort of thing I can put in the review, but I I can't. I can't give you that answer now. If whoever's asked the question has some suggestions that would be a useful thing to to to either email afterwards about or to put here.

President AoAA (21:46)
⁓ The next question is saying that doctors are in larger numbers than AAs. How can you reassure us that our smaller voice will have equal weighting when conducting the review?

Gillian Leng (22:03)
That's one of the reasons why I've been absolutely clear that it's a separate group and that it's not all being lumped into PAs and AAs as a single voice. I think having a clear voice, having a group opinion, looking at the data that there is, I think will help make a more focused response from me when it comes to it.

So I'm not concerned about your smaller voice at all. I think that that will be clearer and easier. I'm not necessarily seeing the questions that you're seeing. I'm slightly discombobulated.

President AoAA (22:47)
I've just refreshed. ⁓

Gillian Leng (22:50)
I'm

refreshing it, too.

President AoAA (22:54)
And lovely. So I've got another one here with nine upvotes. So how can a safe profession after 20 years of cautious development ⁓ be derailed over a matter of months? ⁓ What does it say about the culture of the NHS? So that's a concern about about obviously the ongoing rhetoric about Anastasia Associates.

Gillian Leng (23:17)
Yeah, that's a really good question, isn't it? It's a really good question and it must be quite ⁓ depressing for you as a group to have seen that happen. do empathise with that. And what is the answer? Is it because of things like the junior doctor's strike? Is it because of pay pressures? Is it social media? I'm putting that last one in because

So many things are increasingly seen to have been escalated through social media in a way that didn't happen in the past. It's that rapid communication and things that I've personally seen over the last few months are ⁓ quite surprising, quite surprising and certainly misinformation sometimes, but it doesn't help. And in relation to the culture of the NHS, then ⁓ my review,

isn't designed to address that. However, I'm aware that the recommendations that I make will need to go into that NHS culture. So it certainly is a concern. And I'm looking carefully at how I land the review, how I get some traction when the review is published, because it's really important that it is taken seriously and taken forward and that

we all do whatever we need to do to improve the culture of the NHS because it doesn't help patient care at the end of the day.

President AoAA (24:49)
Thank you. Yes, no, I think it's quite important for a lot of us that it's recognized that the social media stuff has been very, very unpleasant for everybody involved. I've got another question here. It's asking if you could please seek the opinions of the consultant and ethos that supervise us. ⁓ Many of them are not Royal College members and they feel their voices are not being heard.

Gillian Leng (25:15)
I have them. I. Met quite a few anesthetists on on the visits that I've done to trusts who are very keen to explain how their processes work in their trusts. However, if you if you remember at the when I was going through the webinar topics, I did mention that perhaps I should do a separate webinar for any statistics as a group.

because otherwise they'll be there within other healthcare professionals and we might not be able to have a particularly focused conversation on your roles. I think bearing in mind what you've got here with 12 votes, I think they do have an important voice. And the comment earlier about, know, we're a small group, how can we get our opinions heard? It's a small group and it's yet a really important.

important to focus on the issues. So yeah, let's take that away team. can't see them, but we'll take it away and make sure we do a webinar with anesthetists.

President AoAA (26:26)
Thank you. Someone else has asked, we know that similar roles are successful in other high performing healthcare systems. Why would we not want the role in the UK?

Gillian Leng (26:47)
a good question and it's something that isn't as straightforward as you might think it is from reading that question and that's because of context. some, the previous question you just read out Scott, it talked about the culture in the NHS. The NHS might or might not be described as high performing at the moment. I wish I could say it were but it's

President AoAA (26:56)
Yes.

Gillian Leng (27:17)
It's not necessarily performing at its best at the moment. Let's hope it improves. However, the point of saying that, and this is something I have lots of experience of at NICE, is looking at an evidence base and working out how readily does what you see working well in other countries translate to our own healthcare system. And it's not always straightforward. You have to look at that context quite carefully. But I am looking carefully at it.

international experience and how things work elsewhere because if we can translate good models elsewhere then then we absolutely should but the context is important the NHS isn't unique in the way it works but it does have particular challenges.

President AoAA (28:05)
⁓ The next question ⁓ is asking about the survey. They want to know how are we ensuring that the responses to our legitimate and not just the an opinion piece from social media and what is the failsafe around this if survey results are going to influence the outcome of the report?

Gillian Leng (28:30)
think that's a good question. It's something we've been talking about a lot. There isn't an easy answer to this. We're going to triangulate as much information as we can. be, for instance, your particular group. We know how many AAs there are in the country. We'll be looking at how many people have responded to the questionnaire who claim to have that role. And where we can, we'll use technical mechanisms to see where the responses have

from, but it isn't going to be an exact science. However, it also isn't a referendum. So it's not just a numbers game. It's not just the case of, we've had this many people saying AA's are wonderful or the other. It's going to be more nuanced than that. And I'm particularly interested in any pretext comments, any thoughts and ideas that people might put into Questionnaire.

However, sadly, I am aware that there is gaming going on. that means I absolutely am not going to be able to look at that survey and think I've got a really good response here that I can rely completely on. It won't be that. So we will do our best to validate the answers, but it is disappointing. Originally, what I wanted to do was to direct the questionnaire

to AAs and PAs and ask for the people who worked with those people to be those that responded. So this isn't a broad, it was never intended to be a broad questionnaire like perhaps the BMA has done. Let's ask all doctors what they think. It was never intended to be that. It was targeted on the roles and the people working around them. Sadly, it wasn't easy to make that work. It was technically difficult, so great.

Great idea, I like to think, but technically it was difficult. So it's gone out the way it's gone out and we will validate as best we can. And I must admit, I've never heard of a social media troll called Platinum Pizza, but I'm obviously out of date.

President AoAA (30:41)
⁓ You're lucky you haven't heard of Platinum Pizza to be honest. It's unfortunately well known in our circle.

Gillian Leng (30:48)
⁓ dear. Right.

President AoAA (30:50)
we'll move on to our next question.

Gillian Leng (30:52)
I'll find out before I'm to my next webinar.

President AoAA (30:55)
And so the ⁓ next one is about redundancy. ⁓ Are we at genuine risk of redundancy similar to certain PA roles?

Gillian Leng (31:06)
Well, again, this puts me in a slightly difficult position on my tightrope because I could only answer that question with an absolute yes if I said, if I said, I'm going to decide that we shouldn't have AAs. Because if the review said, they're not safe, your roles are not safe, they're not effective, then people might phase them out. There was another route I could say, which is

I think the AAs are doing a great job, but we should be very careful about employing any more. That could be an outcome. And that would be less of a risk of redundancy. Or I might, if you remember my line, my spectrum, I might say, no, we need more of these. I've worked in the public sector for all my life, pretty much. And I think it's not helpful to have trained

healthcare professionals made redundant. That's sort of one of my core values. if, and it's a big if, but if that was a risk, I would really hope that there was some way of redeploying people rather than redundancies.

I can't say anymore at this point, but just be aware that I do think it would be foolish to make people redundant if you've been trained doing a good job.

President AoAA (32:36)
Thank you. think is my present hat on. I would recommend that obviously if anyone has major concerns with their current workplace, then they should get in touch with us and potentially join a union ⁓ and speak people who obviously understand the system a bit better ⁓ locally. ⁓ And obviously, as I said, we're hoping ⁓ that you know we are very intrinsic and a lot of.

places in the NHS and that we you know we are valued and it would be very difficult to make us redundant in the current system. But obviously we need to see what happens. So thank you very much. I'll get the next question up. Someone's asking will the outcome of your review for AAs be separate to that of PAs? I'm concerned that we will be lumped together unfairly. I think you've already kind of touched on this haven't you Joe?

Gillian Leng (33:29)
Yeah, I have. haven't. The short answer is yes. Slightly more detailed answer is that there will be one report. But within that, there'll be clearly separate analysis of all the data and all the information and considerations around what the future should look like and recommendations, because the roles take people with different levels of training at the start and

and you work in different ways. So it's been flagged up to me actually by consultants and neaths atists who were very vocal on your behalf that the roles needed to be kept separate. So that's absolutely going to happen. Do you feel, perhaps I'm asking you Scott as you're the only one with a voice, but is there a sense that you've already been lumped together with PAs?

President AoAA (34:22)
And for regulation we had to be just because of the numbers involved and we understood that ⁓ the association is always pushed for regulation of our role from day one of conception ⁓ and we knew that by being part of the PAs who are very different from us in some ways that we would be regulated together, but we may come up with other issues and obviously this is what has evolved from that. ⁓ But at the same time, I think.

from day one of meeting with yourself and other stakeholders, it's been made clear that we're probably going to be looked at separately in various ways. And it seemed very much that everybody in the room understood and agreed. I don't think of any stakeholder that disagreed with the fact that PAs and AAs work in very different ways and are very different roles. just end up attending this to be reassured that from my perspective, that seems to be.

in the case that we are, you know, there's a ⁓ maintaining a separation there as well.

We'll move on to the next question. Someone has asked why are we one of the only professions that has a scope of practice being determined by a Royal College that ultimately won't be responsible for looking after us?

Gillian Leng (35:42)
There's two bits to that question, I think. One about having a scope of practice determined by the Royal College and being one of the only professions. Actually, I've got a list that shows scopes of practice being set for AAs and PAs. And I would say you're in a clearer position than the PAs because you've got your scope of practice that's been set by the Royal College.

There are many other medical royal colleges and a lot of them have set scopes of practice for PAs in different settings and different parts of the system. There's a long list and some of those cover primary care, secondary care, bits of both. It's really quite confusing. I think it's helpful for you that it's from one organisation. told onto that. then you made that I think there's a comment isn't there about

about responsibility for looking after you and that that's an issue. And I would agree that that's an issue and it's something that I am considering as part of the review. Because it's not just what does escape of practice look like? How tight is it? Is it a ceiling? Is it ⁓ benchmark? How do you keep it up to date? How do you develop it? It's also who sets it.

Is it local? Is it national? Which organization? So there are definitely more questions and answers when it comes to setting a scope of practice.

President AoAA (37:18)
Yeah, no, I completely agree. I think ⁓ for us we've had previous scopes of practice from the college that have been more foundational. So from, you know, newly qualified anesthesia associate, this is what you can expect to be, but local, obviously local governance and practices vary and they previously would recommend that local areas would would, you know, obviously make sure that competence was maintained in advanced practice and unfortunately we.

We have a much more restrictive scope, but I understand what you mean about the fact that it's from a single organization and you know that there is a clearness there compared with maybe what the PAs are facing as well. I will see what our next question has. ⁓ Again, the college released a survey of clinical leaders of anesthesia departments a few years back, so this is the kind clinical director survey.

The interpretation of that data is there to be reviewed. Are you directly reaching out to these clinicians employing anesthesia associates because the person asking it thinks it will provide a wider response than individual perspective?

Gillian Leng (38:33)
Well, we're certainly certainly looking at any surveys that the colleges have done in the past. So we that that's part of the data gathering that I described earlier in terms of directly reaching out, think directly reaching out to clinicians employing AAs that was and indeed is not sure how well it's working. The aim of the survey that I said needed to go to AAs and those people working with them. I hope they've picked it up.

you guys on the call obviously have links with an anesthetist. So if there's any way you can prompt people that you're working with to respond, then do. I don't think there's much more that we can do other than having the webinar and we'll make sure that that gives an opportunity for an anesthetist to talk.

talk to me and I am engaging regularly with the college. So I've had lots of conversations with the college.

President AoAA (39:37)
And we I can just say that we've we've prompted the college to provide ⁓ the survey and its information to the review ⁓ and any ⁓ any work that's been done by the college that we've been involved with, we have provided to the review as part of our data submission as well, just to reassure anybody on the call today. And I've confirmed that it's been received so.

that should have been provided and as part of that data collection. ⁓ I would also encourage anybody who's on the call who hasn't got their colleagues to fill in the survey, people that work with AAs, should prompt your colleagues, nurses, ODPs and ethotists. These are people that work with us every day. Get them filling it in as well. It's important that their voices are heard. ⁓

Gillian Leng (40:30)
Yeah, no, thanks for saying that Scott. Absolutely. Yeah.

President AoAA (40:34)
Thank you. think I have. We have sent some messages out to members to encourage that. But again, since there's people on the call today, I would do would also encourage everybody to get people engaging. ⁓ So the next question is about university courses. ⁓ If they don't have students and can't train more AAs, how can the profession actually develop and grow in an appropriate fashion?

Gillian Leng (40:59)
Well, think, no pressure, I fear, but in some ways it's probably down to me and the review, isn't it? Because if the review concludes that there should be more AAs, that it's a really effective role, that it's great value for money, get through so many more patients, if it's a really strong positive outcome from my review, then there will be university courses with students.

As I said earlier, the outcome of the review will feed into the workforce plan and so it will all happen if the review concludes that.

President AoAA (41:40)
what we can have thought as well. mean it's the college has asked for a freeze on recruitment ⁓ but if the review is positive I don't think they can they can continue to ask for that freeze. So the

The next question is about how can we ensure that the minority voices of Anephetus that work with us are heard? Again, I think it's about it's about a webinar event. Could be a webinar hosting Anephetus, could be a majority of the Anephetus United group and college members that are against us or want to see a restricted scope. So that's.

That's a question about ⁓ if you were to host a webinar for an ethos, the concern would be that anyone that works with us might be drained out.

Gillian Leng (42:39)
Difficult one, isn't it? Because I don't think there's a magic bullet here. ⁓ I think you guys could help. So keep an eye on the gov.uk website to see what's happening, what's happening when, and just encourage people that work with you, sign up. Assuming the unities do work with a supportive of you and making that assumption. I'm assuming they are.

I... Yeah. Yes. It's a comment.

President AoAA (43:15)
I think it's important that you do hear from people that are working with us in an honest way, not just, ⁓ here's somebody that likes us, but people that do work with us so that you can get an ⁓ honest and biased reflection. But yeah, I think the concern there is about these voices that obviously don't like us. ⁓ Let's see. ⁓ So someone is asking if a nurse trains as an advanced critical care practitioner, so an ACCP.

⁓ There are empowered and encouraged to perform their optional skill frameworks. So basically, ACCPs are supported to do things that we would consider advanced skills. ⁓ One of the things listed is airway management. But then they retrain as an anaesthesia associate one day. ⁓ So when they work as an ACCP, the college would allow them to do all sorts of different things. So they've listed resuscitation.

intubating critically ill patients without direct supervision. But the next day when they're working as an anesthesia associate, the college defines them as not able to induce anesthesia in perfectly healthy patients. I think it's about the differences in ACCP role, anesthesia associate role, and how the college is treating these two.

Gillian Leng (44:41)
I'm aware of this rather, yeah.

Incongruous is that right word? Distinction in training and opportunities. ⁓ It was actually flagged up earlier today at a conversation I had. And I haven't, you know, I haven't. I haven't looked, I haven't done any direct comparison with different roles, although it occurred to me at the beginning when I was thinking about the questions I needed to ask.

Do I choose a comparator sort of group of professionals? And is it an advanced nurse practitioner? What is it for PAs and AAs? But it's more complicated than that. However, I agree that this doesn't seem logical. And if there's anything I can say in the review to reflect that, then I will. But I'm not responsible for all of the idiosyncrasies of health professional training.

President AoAA (45:33)
Yeah.

And I think that for myself as somebody who works in cardiothoracics, there's a lot of comparisons made between us and the CCPs because we do similar skill sets. In fact, somebody suggested we should just retrain as ACCPs and avoid the problem of being an anesthesia associate, which I think this really helped the profession, unfortunately, but ⁓ it is a very interesting question and kind of comparison to look at.

Lovely, so there's a question that cost effectiveness. How will this be determined? For example, two AAs and a consultant are not cheaper than two consultants, but having a two to one working list can get twice the number of lists covered per consultant session. ⁓ And the argument there is that there's a shortage of anesthetists, which is not going to be fixed particularly quickly, as well as a shortage of access to anesthesia for patients.

Gillian Leng (46:39)
Cost effectiveness will be determined with advice from a health economist. I it's important to say because although I worked at NICE for 20 years, I'm not trained as an economist. Most of the evaluations that NICE did around cost effectiveness were specifically about effectiveness. So to do that, you need a measure of effectiveness, which is quite difficult in...

in the evaluation of AAs. What are your outcomes? Are your outcomes throughput of patients? Are your outcomes mortality? It's difficult to define the effectiveness, let alone the cost effectiveness equation. And so what you put here is basically looking at the cost of certain groups of

clinicians versus others, but it isn't that straightforward. And it might be that productivity needs to be factored into that. And it is something that's an outcome in relation to throughput and safety of the patients. We haven't got to that point yet because you do need to have evaluated what data you've got around effectiveness to be clear around the cost effectiveness part of the equation.

President AoAA (47:53)
It's interesting because a lot of lot of departments have employed AAs originally because of the idea of cost effectiveness, but ⁓ I myself was employed to try and improve safety because of long cases without many breaks and also ⁓ to improve the lives of the anaesthetists that I work with in cardiothoracics. Otherwise we would have had quite an attrition rate of people leaving. I think there's there's cost effectiveness is.

is obviously a very important topic, but I think there's also a lot of us that maybe are employed for other reasons as well.

Gillian Leng (48:29)
I I did launch into a lecture about quality adjusted life years, you'll be pleased to know. But another way of looking at cost effectiveness is value for money. And whether people think that having AAs in the mix is better value because you get more for your money than that equation could work. Even if things cost a bit more, you might decide

President AoAA (48:40)
Yes.

Gillian Leng (48:59)
heaven forbid you want to the most expensive iPhone. Is that actually good value for money these days? I don't know. Are you getting so many new fantastic AI features that you think it is? Because your life is suddenly speeded up so much more. You know what I'm trying to say. It's that value for money that we need to look at.

President AoAA (49:16)
Yeah, fantastic. The next question ⁓ asks, will the review be addressing or calling out those involved in anonymous activity such as negative social media campaigning? ⁓ The various groups have already discussed ⁓ and they've been critical of the A role ⁓ and it's asked about given that obviously good medical practice is important.

How do you view the role of such social media discourse in maintaining professionalism?

Gillian Leng (49:52)
I feel I should say something in terms of context in the report. I'm not going to do any detailed analysis of what's gone on on social media. I'm not going to have lots of data or facts, but I'm aware enough about it and I'm aware of how unpleasant it is and that there's misinformation. And so I feel that I need to call that out in some way because it's part of the context and part of why things have become so difficult.

You can never, you can't turn the clock back and I can't prove it, but I suspect without social media I wouldn't be doing this review.

President AoAA (50:30)
I think we agree with that as well, that it's definitely changed the kind of playing field, to speak. ⁓ The next question is ⁓ to be a recognized role within the multidisciplinary team, so able to practice with training governance. ⁓ Why should pediatrics, ⁓ neuro, cardiovascular or obstetrics be restricted?

So I think this is in relation to the question of scope, the Royal College scope and about the restrictions that the scope has put on us at the moment. I don't know if you're happy to answer that.

Gillian Leng (51:13)
I mean I can't really answer it as it is. Another way of phrasing that question that perhaps you can confirm Scott is why has paediatrics, neurocardiovascular been restricted by the college and I'm assuming it's because they see those areas as higher risk.

President AoAA (51:34)
Yes, so eventually when the role was developed, heard here probably knows that kind of pediatrics and OBS were not on the table, so to speak, for being ⁓ left in any way as in like you could go in, but you would never be doing particularly much. Since then there are obviously A's that work in advanced practice. ⁓ In terms of well, cardiothoracics, I myself do cardiothoracics and ⁓

reason it was excluded was because the person the college asked to ⁓ basically be the expert on the panel said that he wasn't aware of any anaesthesia associates working in Cardiff-Rasks despite there being Sheffield and Patworth as two departments. So I think that was a problem with the scope being written and not including anaesthesia associates in the writing of it but we have made complaints about that anyway.

Gillian Leng (52:31)
yeah yep okay we've got how long have we got left we've got just under 10 minutes

President AoAA (52:39)
Lovely, ⁓ I will pop it up. ⁓ Someone else saying that they have lost faith in the college. They don't feel like they are acting the best interest of our role. ⁓ They're under pressure from their membership, ⁓ which is prioritizing doctors over the kind of future of anesthesia, how it's delivered, ⁓ and that's that seems to be a kind of statement of concern about the fact that the college isn't isn't looking after us.

⁓ or let's just say anesthesia delivery to patients is prioritizing doctors.

Gillian Leng (53:18)
Yes, I can see why that is frustrating and difficult. I suppose they are a membership body, aren't they? We tend to forget that with Royal Colleges, but they are membership bodies. They are in that way democratic and they have to respond to the views of their members. It really hit home with the Royal College of Physicians as I'm

I'm sure you know that story and that the president had to resign because the views that the senior fellows in the college were putting forward were not in line with the membership. And that's the thing about royal colleges. And there's been a lot written in these questions about the College of Anecdotes. And I absolutely understand why could they written that scope of practice. But something that I need to think about and I need to look at in the review is what other bodies are there in the system.

or what organisations might we need in future that provide the support that you need if you don't think it's going to be the College of Anesthis.

President AoAA (54:27)
Somebody else had mentioned under that as well that the the colleges at risk of a vote of no confidence ⁓ from its members. If it follows your recommendations, it may have a vote of no confidence because the membership don't feel, despite your review, ⁓ feel that they're happy with what the college is doing. ⁓ But again, I think that's unfortunately a problem for the college, isn't it?

Gillian Leng (54:53)
Yeah, it is, it is. And the colleges, I met with some of them today, they will have to take the report through their councils and see what the councils think. However, there are other players in healthcare. as I said, just now I need to look carefully at who those other organisations are and make sure that the recommendations have the teeth.

that they need to have and that I'm clear about who is going to take this forward on a recommendation by recommendation basis.

President AoAA (55:33)
Someone has posted not a question, but a comment that they were working as an AA in a department and due to the issues around the role it became untenable. They were redeployed, but not within theatres and they have worked in theatres for over 16 years and they're saying experienced theatre staff are being lost from the workforce because of all the issues that are going on around Anesthesia Associates.

Gillian Leng (56:05)
Yeah, no, thanks for flagging that up. And I can see that must be quite upsetting to be experienced and they're not working in the area that you've trained in.

President AoAA (56:16)
Someone else has said thank you for holding the webinar, it has provided them with reassurance that the review will be done with everyone's best intentions kept in mind and that the evidence will be reviewed properly with patients at the heart of it.

There's another one about the public. They're now concerned about our role and the care they receive from us. If the review is positive about our roles and patient safety, how will this message be sent? I assume we mean to the public how it will be presented.

Gillian Leng (56:54)
⁓ well, that's a good question because it is important. I'm beginning to think more and more as we get through it, how do we land this? Well, I it isn't an aeroplane, but it's got, you know, it's got to land well so that things are taken forward appropriately, so that there isn't so much unhappiness, so that people can see a way forwards. And that does include the public. As the Department of Health and Social Care team know, I've been

pain that we get some very good communication support because there's a lot of communications going on in this sphere and I need to make sure that there's good comms behind this and that's not just you know writing a press release here and there it's important that the results are communicated well and clearly and widely and it won't I

studied quite a lot of communications in my years at Nice. I've sort of got a sense of what needs to happen and you can have your Big Bang moment when the report's published, but that's not enough because people forget, you know, they forget once they've had the Big Bang. It's thinking about ongoing methods of communication, words that you might say to describe your roles, perhaps less important for you, but it's very important for PAs that they know how to describe their role. just, I don't know what these...

what these things might be. don't know what the review will conclude yet. However, that ongoing communication and messages will remain important. It won't just be a single piece.

President AoAA (58:23)
There are at least 12 more questions. don't think we're going to get through them all in four.

Gillian Leng (58:27)
Can we do one more, do you think? One more, what time is it? You have two minutes to go, so let's do one more.

President AoAA (58:33)
⁓ Let's see. So ⁓ there's a question about ⁓ cost effectiveness again. ⁓ There's been comparisons between full time consultants and AAs. Will the clinical patient contact time be included as a larger percentage of my working week is directly in theatre? So this is looking at the job that the AAs do compared with the

consultants because the job plans are different. ⁓ So it's all about patient contact.

Gillian Leng (59:08)
Yeah, that's a really good point. Really good point. It's not just apples and oranges in the operating theatre. It's things that happen around it. So thanks for flagging that up. And I think I need to start drawing it to a close because it's seven o'clock and I need to thank the team for arranging it. Thank you all for joining and for all the things that you've put in the Q &A because there's some really

Really good questions there, some quite hard questions. I hope I've given a reasonable answer and if even if even if I haven't been able to get to your question, note that we will take them away. And of course, many thanks to Scott. You've done a sterling job for keeping up with those questions and for indeed giving giving some answers to areas that you know more than more than I do. So thanks everyone for giving up an hour to join today.

President AoAA (1:00:02)
Thank you. Fantastic. Thank you very much.