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BMJ No 7124 Volume 316 Editorial Saturday 3 January 1998 Audit Commission tackles anaesthetic services Flexibility, delegation, and changing roles may improve value for money Anaesthesia is the largest single hospital specialty. There are over 5,500 anaesthetists in England and Wales alone, just under half of whom are consultants. Yet, as the introduction to Anaesthesia under Examination,(1) published last month by the Audit Commission, points out, few mainstream medical specialties are as poorly understood. Many patients do not realise that anaesthetists are doctors or that they have responsibilities outside the operating theatre.(2) Anaesthetists now provide clinical skills in acute and chronic pain management, intensive care, obstetrics, interhospital transfer, trauma, and resuscitation. This new found diversity may be partly to blame for current difficulties in service provision, for consultants' job plans have often not changed to reflect their increased activities. Anaesthesia under Examination is based on a substantial amount of data. Most British hospitals replied to postal surveys on consultant shortages, maternity services, and services for pain after surgery; 39 randomly selected acute trusts underwent more extensive data collection, and in seven interviews were held with anaesthetists, managers, and patients. By highlighting anaesthetists' pivotal role within acute hospitals, the report has in many ways done the specialty a service: it reminds managers that anaesthetists' activities affect up to two thirds of a trust's income yet their salaries cost only 3% of this figure. Furthermore, although anaesthetists' numbers have risen, much of this increase is in response to demand created by other specialties. The report identifies wide variations in consultant job plans, anaesthesia costs per operating list, and matching of skill to complexity of surgical cases - with consequent variations in the value for money offered by anaesthetic services. These discrepancies are not explained solely by differing casemix. In looking at anaesthetists' roles outside the operating theatre (except for intensive care, which is the subject of another study due later this year) the report emphasises particularly pain services and obstetric anaesthesia. It highlights unacceptable variations in the management of postoperative pain, while obstetric anaesthetic services are criticised for the lack of good evidence to support dedicated anaesthetic cover. In obstetrics the report suggests a method of deploying staff according to anaesthetic workload, rather than number of deliveries, as at present.(3) It is an article of faith in British anaesthesia that a preoperative visit for assessment, information, and counselling is essential, but the Audit Commission found that, because of organisational difficulties, one fifth of patients were not seen by their anaesthetist before theatre. The commission suggests that nurses should perform some of these tasks. While this would not replace the courtesy of a visit by the anaesthetist, nurses should routinely provide the detailed information and assessment, while consultants could concentrate more efficiently on patients who present a greater perioperative risk than normal. The report also recommends wide use of written preoperative information; apart from supplementing what is said, this should help ensure consistency. In fact, assessment by nurses already works well in many day case surgical units. More controversially, the report revisits the concept of non-physician anaesthetists. Faced with shortages of consultants and reduced service contribution from Calman trainees, trusts may find that training nurses or operating department practitioners to give anaesthetics, as in America and some European countries, is an attractive option. This was considered, though not supported, by a recent NHS Executive study.(4) The Association of Anaesthetists is firmly opposed to nurse anaesthetists.(5) Its objections include difficulties in recruitment of nurses and in training opportunities, but the association's main concern is patient safety. Though historical comparisons in America have not suggested higher mortality when anaesthetics are given by nurse anaesthetists,(6) two European studies have found that adverse outcomes are more common.(7,8) Nevertheless, for uncomplicated cases death under anaesthesia is rare. The report quotes the view that this reflects the inherent safety of modern anaesthesia, whoever gives the anaesthetic. The "controlled research" that the commission advocates into the use of other staff for giving anaesthetics would have to be extensive indeed to show a difference in mortality, but it could be used to shed light on the commission's assumption that nurse anaesthetists would be cheaper to employ than anaesthetists. One of the commission's other concerns - of a lack of anaesthetists - might be resolved soon: the Royal College of Anaesthetists hopes that consultants will no longer be in short supply within the next few years.(9) The report makes many recommendations, such as strengthening the role of clinical directors and increasing the flexibility of the consultant contract. Delegation to nurses of tasks such as preoperative assessment and information and management of postoperative pain, together with guidelines to ensure that grades of anaesthetic staff are matched to complexity of cases, should help consultants to make the best use of their time. In many cases these suggestions have already been made by the National Confidential Enquiry into Perioperative Deaths(10) and by the anaesthetic organisations. The Audit Commission report has exposed wide variations in practice, including the fact that some trusts have successfully adopted newer ways of working. This knowledge, together with the commission's follow up local audits, should encourage the rest to follow suit, improve their services, and use their anaesthetists more efficiently and effectively. Andrew Smith Senior registrar in anaesthesia Royal Bolton Hospital, Bolton BL4 0JR References 1 Audit Commission. Anaesthesia under examination. London: Audit Commission, 1997. 2 Swinhoe C F, Groves E R. Patients' knowledge of anaesthetic practice and the role of anaesthetists. Anaesthesia 1994;49:165-6. 3 Obstetric Anaesthetists Association. Recommended minimum standards for obstetric anaesthesia services. Nottingham: OAA, 1995. 4 Reilly C. Professional roles in anaesthetics: a scoping study. Leeds: NHS Executive, 1996. 5 Association of Anaesthetists. Anaesthesia in Great Britain and Ireland: a physician only service. London: AAGBI, 1994. 6 Abenstein J P, Warner M A. Anaesthesia providers, patient outcomes, and costs. Anesthesia Analgesia 1996;82:1273-83. 7 Pedersen T. Complications and death following anaesthesia. A prospective study with reference to the influence of patient, anaesthesia, and surgery related risk factors. Danish Medical Bulletin 1994;41:319-31. 8 Chopron V, Bovill J G, 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. 9 Royal College of Anaesthetists and Association of Anaesthetists. Response to the Audit Commission report. London: RCA, 1997 (press release 16 December). 10 Campling E A, Devlin H B, Hoile R W, Lunn J N. Report of the National Confidential Enquiry into Perioperative Deaths 1992-3. London: NCEPOD, 1995. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline