I read with interest the article regarding the clinical activity of anaesthesia associates, as reported to the 7th National Audit Project [1], which raises many questions about their current and future roles.

Anaesthesia associates have a nationally defined scope of practice on qualification, published by the Royal College of Anaesthetists (RCoA) in 2016 [2]. This limits their supervision ratios to a maximum of 1:2, with the proviso that the patients must be American Society of Anesthesiologists physical status 1–2 undergoing minor to intermediate surgery in adjacent operating theatres. This scope of practice excludes anaesthesia associates from performing regional anaesthesia (both central neuraxial and peripheral techniques). The RCoA does not currently support local opt-outs of this scope of practice, sometimes termed as ‘enhanced’ roles. The work by Cook et al. shows that many anaesthesia associates are working outside of this scope of practice, as 24% of cases were major or complex surgery with an anaesthesia associate as the senior provider [1]. In 21% and 25% of spinal and regional anaesthesia cases, respectively, an anaesthesia associate was the senior provider.

There is concern that these enhanced roles may lead to loss of training opportunities. Evans et al. reported that 35.5% of anaesthetists in training who had worked with anaesthesia associates felt they had a negative impact on their training [3]. Their thematic analysis showed that ‘loss of regional anaesthesia experience’ and ‘trainees covering emergency work so that anaesthesia associates can do elective work’ were among trainees' chief concerns. Elective surgery lists with healthy patients undergoing low-complexity surgery are ideal for anaesthetic trainees to gain vital experience in independent practice conducted under consultant supervision. These lists, likely decreasing in number as the patient population becomes more complex, may not be available for anaesthetic trainees if there is an expansion in anaesthesia associate numbers.

Financial modelling by Hanmer et al. suggests that expansion of the anaesthesia associate workforce, as outlined in the NHS Long Term Workforce Plan, is not financially viable without a relaxation in supervision ratios beyond the 1:2 currently accepted by the RCoA, or other less plausible alternatives [4]. This has led to concerns that supervision ratios may relax, and anaesthesia may begin to move from being physician-delivered to physician-supervised. These concerns, among others, resulted in an emergency general meeting of the RCoA in October 2023, where a motion to pause the expansion of anaesthesia associate numbers passed with 88.9% of a vote that totalled more than 5000 respondents overall [5]. A subsequent survey by the RCoA showed that 78% of over 6000 anaesthetists, of all grades, held negative views about the expansion of the anaesthesia associate workforce [6].

The National Audit Projects have shown that patients are becoming more complex, with higher rates of frailty, obesity, and comorbidity [7]. In the face of this, and concerns raised about anaesthesia specialist training, the expansion of an alternative, lesser trained workforce, with a paucity of evidence to support it, must be challenged. Anaesthetists in training are, rightly, asking why rotational training, countless out-of-hours shifts and rigorous examinations are required if anaesthesia associates are given carte blanche to deliver any anaesthetic they please, to any patient group, via local opt-outs.

If the expansion of anaesthesia associates is to go ahead, despite well-founded concerns, a national scope of practice, without local opt-outs, is essential for their safe utilisation. I eagerly await the publication of the revised scope of anaesthesia associate practice from the RCoA and hope the concerns of the anaesthetic community are reflected within it.

我饶有兴趣地阅读了向第 7 个国家审计项目 [1] 报告的关于麻醉助理临床活动的文章，该文章对他们当前和未来的角色提出了许多问题。

麻醉助理医师具有国家定义的资格执业范围，由皇家麻醉师学院 （RCoA） 于 2016 年发布 [2]。这将他们的监督比例限制为最大 1：2，但条件是患者必须是美国麻醉医师协会身体状况 1-2 岁，在相邻手术室接受小到中度手术。该实践范围不包括麻醉助理进行区域麻醉（中枢椎管内和外周技术）。RCoA 目前不支持本地选择退出此实践范围，有时称为“增强”角色。Cook 等人的工作表明，许多麻醉助理人员在此实践范围之外工作，因为 24% 的病例是大手术或复杂手术，麻醉助理是高级提供者 [1]。在分别 21% 和 25% 的脊髓和区域麻醉病例中，麻醉助理是高级提供者。

人们担心这些增强的角色可能会导致失去培训机会。Evans 等人报告说，在与麻醉助理合作的培训麻醉师中，有 35.5% 的人认为他们对培训有负面影响 [3]。他们的主题分析表明，“区域麻醉经验的丧失”和“受训者负责紧急工作，以便麻醉助理可以进行选择性工作”是受训者的主要关注点。接受低复杂度手术的健康患者的择期手术清单非常适合麻醉实习生在顾问监督下进行独立实践中获得重要经验。这些列表可能会随着患者群体变得更加复杂而减少，如果麻醉助理人数增加，则麻醉实习生可能无法获得这些列表。

Hanmer 等人的财务模型表明，如果不放宽超过 RCoA 目前接受的 1：2 或其他不太合理的替代方案，那么 NHS 长期劳动力计划中概述的麻醉助理劳动力的扩大在财务上是不可行的 [4]。这导致人们担心监督比率可能会放宽，麻醉可能开始从医生交付转变为医生监督。除其他外，这些担忧导致 RCoA 于 2023 年 10 月召开紧急大会，其中以 88.9% 的投票通过了暂停扩大麻醉助理人数的动议，总共有 5000 多名受访者 [5]。RCoA 随后的一项调查显示，在 6000 多名各级麻醉师中，有 78% 的人对麻醉助理劳动力的扩大持负面看法 [6]。

国家审计项目显示，患者变得越来越复杂，虚弱、肥胖和合并症的发生率更高 [7]。面对这种情况，以及对麻醉专家培训的担忧，在缺乏证据支持的情况下，扩大替代性的、训练有素的劳动力必须受到挑战。接受培训的麻醉师正确地问，如果麻醉助理被全权委托通过当地选择退出，向任何患者群体提供他们想要的任何麻醉剂，为什么还需要轮换培训、无数的非工作时间轮班和严格的检查。

如果要继续扩大麻醉助理，尽管存在有充分理由的担忧，但没有当地选择退出的全国实践范围对于其安全使用至关重要。我热切期待 RCoA 修订后的麻醉助理执业范围的发布，并希望麻醉界的担忧能反映在其中。