Scope of practice: the first line of defence for Anaesthesia Associates

The review also set out a template for a the physician assistant role in anaesthesia:

Overview of the role

As a physician assistant in anaesthesia, you will work in the wider multidisciplinary team in the delivery of anaesthetic care for patients. Under the supervision of a consultant or autonomously practicing anaesthetist you will provide elements of perioperative care for patients including preoperative assessment, preparation and delivery of anaesthesia and immediate postoperative care.

You will be a central part of the team ensuring high-quality care for patients in the perioperative period and will use a wide range of technical and communication skills to ensure the smooth functioning of operations and care in the ward and operating theatre.

Accountability

Managerial accountability: named consultant.

Ongoing clinical advice during working hours: named consultant or autonomously practicing anaesthetist.

Principal duties and responsibilities

The anaesthesia assistant will be expected to carry out the following roles under supervision as outlined in the RCoA Anaesthesia Associate Scope of Practice 2024:

• perform preoperative assessment of the patient including taking a history and conducting an examination and airway assessment and reviewing tests and medication

• prior to theatre, obtain consent for anaesthesia, agree the plan for proceeding with anaesthesia with the supervising anaesthetist and insert a peripheral IV cannula

• prepare the operating theatre for anaesthesia, including full machine and equipment checks, preparing drugs and IV fluids

• perform induction of general anaesthesia including securing of the patients’ airways, perform spinal anaesthesia under direct supervision, and perform anaesthesia or sedation where required outside the operating room

• conduct intraoperative monitoring and maintenance of anaesthesia, monitor vital signs and administer IV fluids

• as necessary, manage routine emergence from anaesthesia, and provide immediate postoperative handover and recovery care

• perform ultrasound-guided midline or PICC line insertion

But what does Scope of Practice mean?

There are three layers to this.

Your Individual scope of practice. This is the outer edge of what you can do safely as an AA, grounded in your knowledge, clinical skills, experience and qualifications. It evolves over time as you develop in your role, experience new clinical areas and enhance your training.

The regulatory scope of practice. Each AA remains under the authority of the GMC. You would have to satisfy your regulator for example that you have not breached your scope of practice if something went wrong. 

The agreed scope of practice with your employer. This is the practical list of activities, duties and responsibilities that your organisation has formally authorised you to undertake in your current role. It should never exceed your individual scope.

It is really important to your position to ensure that all three aspects are operating in your daily practice. But your agreed scope of practice is particularly relevant, as it can be your first line of defence when things go wrong.

Why a locally agreed scope of practice is important. Main takeaways.

Your agreed scope of practice:

• Helps to ensure the right level of accountability and liability are established and applied in any patient safety review or legal proceedings.
• Allows you (or your medical defence organisation) to prove that you were practising within your authorised scope of practice.
• It provides you with the authority to say no if an employer instructs you to do something which is not within your SOP, at least until you receive appropriate training (documented) and supervision, and are signed off as competent.  If you agreed to act knowing you did not have the requisite skills, your regulatory standards could be compromised, even if you acted on your employer’s request.

It is also a good idea to:

• Be prepared and able to explain your level of competence to anyone who supervises you, including as a student /trainee on a placement, so you are not asked to do anything you are not trained to do.

• Document everything relevant to your agreed scope of practice. Contracts, relevant emails, agreement on the remit of the role, and anything else that should be documented.

What your agreed scope of practice should include

In line with the Leng report, your agreed scope of practice should include your annual job plan, appraisals and any Standard Operating Procedures relevant to your work; it should be a living document capable of appropriate amendment.

It should also include a record of who has authorised your role and any extensions to it, what training has been undertaken and where accountability and supervision sits, be that the Clinical Director, or a Consultant.

In addition, it should also include an acknowledgment of your existing qualifications and skills so there is a record of your competence and permission to practice. 

If, for example, you were called to a Coroner’s Inquest, you would possibly have to explain what was your scope of practice in caring for the patient concerned. Having the details in writing is really crucial so that your position is safeguarded. You can also record additional training etc on your PDP. 

The regulatory framework behind all this

After 12 December 2026, it will be mandatory for AAs and PAs to become registered with the GMC. Failure to be registered can have criminal law implications. 

AAs need to follow the standards set out in Good Medical Practice, and in the alternative adapted document called Achieving Good Medical practice: guidance for PA and AA associates.

The second document has several sections dedicated to AAs and PAs specifically, covering expected competence, understanding and being aware of its boundaries, asking for help and advice when necessary, and supervision requirements. 

Registered professionals must use their professional judgment to apply them in specific circumstances. 

Can I act outside my scope of practice in an emergency?

The guidance does state: PAs and AAs must offer help in an emergency, taking account of their own safety, competence, and the availability of other options for care.

Consider this scenario:

You are in theatre and the patient is mid-surgery. The anaesthetist suddenly falls ill, and has to be taken out of theatre for medical attention. The theatre staff call for another anaesthetist but there is a delay in them arriving. What do you do in the meantime? 

If you have to act beyond your scope of practice, as long as you are acting in the best interests of the patient, everything is documented (after the event) and ideally you have discussed it with the team and they agree that you have to step in, then you would most likely be able to justify your actions to the regulator if a concern was raised. And to be clear, a concern is not necessarily going to be raised, of course.

Ultimately you would have to decide in that clinical scenario whether you can keep the patient safe based on your knowledge, skills and experience.