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Editor—We read with interest the articles1,2 that you recently published in response to the Audit Commission’s Anaesthesia under Examination,3 which revisits the topic of nurse anaesthetists. We trained as anaesthetists in the United Kingdom but now work in the United States.
Nurse anaesthetists in the United States always work under the direction of a physician and, despite our initial reservations, we have all been pleasantly surprised by the experience of working with this highly qualified group of professionals. Minimal requirements for entry to the training programmes of two to three years are a nursing or basic science college degree and one year’s experience in critical care nursing. Fear of unemployment in recent years has produced a sharp fall in applications to anaesthesia residency programmes.4 Most programmes have downsized, and a few have closed altogether. Rather than appoint more consultants, many hospitals have recruited nurse anaesthetists to meet their commitments—an expensive solution as salaries for nurse anaesthetists, which average £50 000, are more than twice those of residents.
The US Health Care Financing Administration recently announced a proposal to eliminate the federal requirement for supervision of nurse anaesthetists by physicians. This move is being supported by the American Association of Nurse Anesthetists. If approved, the proposal could allow independent practice in some states. The American Society of Anesthesiologists has urged its members to respond “vigorously” to the proposal.
Why can’t nurses be a part of anaesthesia in Britain? The simple answer is: “It’s too late.” Assuming that a pool of sufficiently trained and motivated nurses who are willing to take up the challenge actually exists, will there be any jobs for them by the time they emerge from training? Who should train and accredit nurse anaesthetists—and could recruitment to nurse anaesthesia deprive other areas of its skilled practitioners? Unlike his or her American counterpart, the average British trainee in anaesthesia often works with little or no supervision. British trainees are paid less than their regular rates of pay for contractual overtime. We believe that it is unlikely that nurses would tolerate being used to replace trainees in anaesthesia under the same conditions. Employing nurses as replacements for consultants, which could conceivably happen in the United States, would threaten the fundamental involvement of the practice of medicine in anaesthesia.
The practice of anaesthesia is much more than the administration of anaesthetics and for this reason anaesthesia should remain, at least in the United Kingdom, a physician based service.
Editor—Smith’s editorial gives an overview of the Audit Commission’s report on anaesthetic services.1-1 Inevitably, however, headline reporting in both the lay and the medical press concentrated on the report’s recommendation to consider the introduction of non-physician anaesthetists into British practice. Smith points out the firm opposition of the Association of Anaesthetists to this—a result of concerns over the safety of patients, legal ambiguities, and cost.1-2 Rather than being seen as a threat, however, the report should act as an impetus for anaesthesia in the United Kingdom to reconsider this entrenched, “closed shop” attitude.
Much routine minor and intermediate surgery performed on fit patients does not require the presence of a fully trained consultant anaesthetist for the entire duration. The training guidelines of the Royal College of Anaesthetists1-3 suggest that, after an introductory module of 12 weeks, medically qualified trainees may have “level 2” supervision for some straightforward cases. This is defined as: “Trainer present in the operating theatre suite ... available to assist or advise.”
Historically, much routine work has been done by trainee anaesthetists under the (sometimes fairly distant) supervision of consultants. As a result of the Calman reforms and limits on working hours this service contribution from trainee doctors is being reduced drastically. At the same time, the demands on anaesthesia services are growing constantly. The answer to this problem should not be simply to seek ever increasing numbers of consultant anaesthetists to perform undemanding work, but rather to encourage the development of non-physician anaesthesia practitioners, trained and supervised by medically qualified anaesthetists. Surely, a nurse or other medical professional who would undertake two or three years’ training in anaesthesia could provide care at least equivalent to that of a trainee doctor.
This would provide consultant anaesthetists working both in and out of operating theatres time to concentrate on those patients who require the benefit of their medical training and extended specialist experience.
Editor—In his editorial2-1 Smith quoted a paper that I cowrote2-2 to support his argument that adverse outcomes in anaesthesia are more common when anaesthetics are given by nurse anaesthetists.
Our article did not mention anything of this sort. We had conducted a retrospective analysis of all reports that an anaesthetic department of a university hospital made to the faults, accidents and near accidents committee of that hospital over 10 years.
We did not analyse the data on the basis of who gave the anaesthetics. This was irrelevant for our study since it is the practice in all university hospitals in the Netherlands that anaesthesia is given by a team consisting of an anaesthesia trainee and an anaesthetic nurse under the direct supervision of a qualified specialist anaesthetist. It is unfortunate that our study has been misquoted in support of the argument that nurse anaesthetists are not as safe as medical anaesthesiologists.
2-2.Chopra V, Bovill JG, Spierdijk J. Accidents, near accidents and complications during anaesthesia. A retrospective analysis of a 10-year period in a teaching hospital. Anaesthesia. 1990;45:3–6. doi: 10.1111/j.1365-2044.1990.tb14492.x. [DOI] [PubMed] [Google Scholar]
BMJ. 1998 Jun 13;316(7147):1827.
Investment is required to increase number of consultant anaesthetists
Editor—I am used to seeing misrepresentative headlines in the tabloid press but am surprised to see one in the BMJ.3-1 The Audit Commission’s wide ranging report Anaesthesia under Examination makes no mention of urging the NHS to appoint nurse anaesthetists as the title of Wise’s article suggests.3-2
The report does recognise that one obvious way to reduce the demand for more doctors substantially is to allow non-medical staff to administer anaesthesia. This cannot be argued with. The actual recommendations, however, are much more tentative and suggest that hospitals such as small district general hospitals, with few trainees or perhaps none at all, might benefit from a trial of using non-physician anaesthetists (or physicians’ assistants, as they are called in some parts of the United States) to help the lone consultant. This would involve an extension of the role of the anaesthetic nurse or operating department assistant to a more active role in the maintenance of anaesthesia. In certain circumstances this might lead to the consultant supervising two operating theatres at one time, with suitable staff and a suitable case mix.
This system might well be acceptable to some consultants without any trainees, who must be willing to take on the additional responsibility and should be paid appropriately to do so. But it is patently not the traditional role of the nurse anaesthetist in the United States, where many small hospitals are virtually autonomous and only nominally under the charge of a surgeon, let alone an anaesthetist. I suspect that few patients in the United Kingdom would be willing to accept this arrangement.
A survey of staffing in anaesthesia showed that the United Kingdom (and the Republic of Ireland) has by far the lowest number of consultants per 100 000 population (4.6 in the UK v 10.8 in 17 European countries).3-3 Despite the much higher number of consultants (with fewer trainees) in the rest of Europe, however, greater use is made there of anaesthesia nurses (15.5/100 000 in Germany and about 23/100 000 in Norway and Sweden). So no cost savings are made.
Thus international evidence shows clearly that as (or if) the number of trainees is reduced a massive investment is required in consultant anaesthetists to bring the United Kingdom into line with the rest of Europe. Only when this has occurred is a trial with non-physician anaesthetists warranted.
References
3-1.Wise J. NHS urged to appoint nurse anaesthetists. BMJ. 1998;316:10. . (3 January.) [Google Scholar]
3-2.Audit Commission. Anaesthesia under examination. London: AC; 1997. [Google Scholar]
3-3.Rolly G, MacRae WR, Blunnie WP, Dupont M, Scherpereel P. Anaethesiological manpower in Europe. Eur J Anaesthesiol. 1996;13:325–332. doi: 10.1046/j.1365-2346.1996.00963.x. [DOI] [PubMed] [Google Scholar]
