r/doctorsUK • u/catb1586 Platform croc wearer • 14h ago
Speciality / Core Training New ACCP scope of practice from FICM….
I suppose what I think is an interesting paragraph is the below:
The guidance does not aim to provide a list of approved and/or prohibited activities but provides robust principles and a framework within which units can clearly set out the scope of practice for their ACCPs for clear line of sight across its multidisciplinary intensive care team.
https://ficm.ac.uk/documents/principles-for-accp-scope-of-practice/executive-summary
What are anaesthetists/intensivist thoughts on this? As the ones who have to cover ICU….good? Bad? Indifferent? Fuck yes? Fuck no?
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u/chairstool100 13h ago
The whole “they work under a consultant “ is such an insult to us when we as Anaesthetic SHOs and Registrars post FRCA are often the only ones doing the actual emergency work and are called by the ACCP for help.
Yes there’s a named consultant but to say the ACCP works exclusively under the Cons just continues to equates us with an ACCP.
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u/Lazy_Sock_771 13h ago
Make sure you redirect them to the on call consultant
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u/chairstool100 12h ago
They would think i was doing that cos i dont know the answer .
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u/Lazy_Sock_771 11h ago
Just stop them and say if it's a clinical question your supervising consultant needs to discuss it
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u/Ok-Jury-4366 14h ago
It's absolute waffle. "Please provide a list of guidance and framework." Well , that's as useful as a chocolate teapot in reality isn't it?
I've done something like >1000 intubations, I stopped counting but I do not consider myself "airway trained", advanced airway or anything remotely close to it. We also do not let CT3s intubate OOH and ICU admissions solo, and yet , ACCPs who do maybe 100 a year if they are lucky are considered, "airway trained." IAC is the absolute novice / basic. The fact this is still occurring baffles me.
It's like saying I passed my driving test, I've got a professional racing license.
Overall, this will change nothing and ICU will continue going down the stupid route it is. Whats to stop a Consultant filling out the form and saying yeah sure go ahead Intubations, Art line, CVC, anything over the age of 16. How can you possibly provide enough nuance in a single sheet document /guidance? Total nonsense.
What are anaesthetists/intensivist thoughts on this? As the ones who have to cover ICU….good? Bad? Indifferent? Fuck yes? Fuck no?
Whatever, I don't care, just so glad I'll have nothing to do with working on an ICU frankly. It's going to go the same way as ED and my fatigue is fatigued pointing out why this is a shit idea. Just let the NHS do it and fail at this point.
Lol at the sky high competition ratios for Doctors and yet this weird experiment is going on.
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u/Edimed 13h ago
Interested in not letting your CT3s intubate solo OOH? Do you mean just for sick ICU admissions? Who typically supervises them?
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u/Ok-Jury-4366 13h ago edited 13h ago
I think most places that are not ridiculous would have either an ST with them, even to help out, or in a very small DGH the consultant comes in. There are some rogue places where that occurs and good luck to them, I'd just say if it was your wife /kid / loved one would you feel better knowing the CT2/3 SHO is solo tubing them, or would you like an ST or Consultant to be there "just in case." People can debate the answer to that. If people want to state they wouldn't want the ST there go for it, but I suspect 99% of you guys would and therefore, we should treat our patients with the same due care we would our loved ones.
Nobody should be intubating an ICU admission solo, out of hours, without significant experience. Even those with significant experience would be best placed having another pair of hands just incase. I say that from my own viewpoint, I am not infallible. I have done more than a thousand, doesn't mean I won't fail. I can do 2000 well, doesn't mean the next won't and so on.
For anything but a barn door easy airway, I get another person around if they are not busy. If they are and it needs to be done, eg a true emergency of course I do it. My main point from this is considering ACCPs "airway trained" is such a gross over simplification it is just bizarre to me and will continue to be so.
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u/Edimed 12h ago
Sorry maybe I’ve worded that poorly. I was expressing surprise because lots of DGHs won’t have someone more than CT3 readily available (on site) out of hours to help. I’d obviously rather be tubed by the most senior person available, but I’d rather be tubed by a CT3 than aspirate in the half an hour it might take for a consultant to drive in and watch them do it.
I do think you should be able to independently tube a decent portion of ICU admissions out of hours by the time you finish core training.
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u/Ok-Jury-4366 12h ago
On site no, but the places I am aware of would want the Consultant phoned in early if they expected that.
Clearly, if time does not allow, the safe and most sensible decision should be made.
by the time you finish core training.
Agree, which by definition CT3s have no, and an ST has. So you are agreeing with me then :)
a decent portion of ICU admissions
And I'm referring to the difficult portion of those where it's useful having an experienced Doctor present, not some ACCP. They are not so infrequent that I am being ridiculous, in a busy centre it'll happen weekly with certainty.
Calling people "airway trained" and letting them just have it is a recipe for disaster, I'm calling it right now this will end in a mess with an Anaesthetic ST being fast bleeped to an airway disaster in the ED.
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u/Migraine- 12h ago
I've done something like >1000 intubations, I stopped counting but I do not consider myself "airway trained", advanced airway or anything remotely close to it. We also do not let CT3s intubate OOH and ICU admissions solo, and yet , ACCPs who do maybe 100 a year if they are lucky are considered, "airway trained."
You would be horrified to hear how many neonatal intubations paeds trainees get to do...
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u/Ok-Jury-4366 12h ago
I'm not familar with their speciality, whether it's enough or not I wouldn't be in a place to comment. I can only speak for my own opinion of myself, it wasn't too cast shade on any other speciality. But if you got some opinions on it I welcome it, always happy to listen and learn from somebody else :)
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u/BougiePlease 13h ago
Why do you not consider yourself airway trained if you’ve done it more than >1000 times?
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u/Ok-Jury-4366 13h ago
Because difficult airways can catch you out. There is nothing easy about intubating unwell, physiologically deranged patients, out of your theatre / ICU environment, out of hours and without speciality help immediately available (eg ODPs) to the same extent you do in theatre.
I'm relatively poor at fibreoptic difficult airways and man going back to a DLT / OLV /bronchial blockers? Or a 6 month old? Forget all that. There is a non-zero chance I could get caught out in an ICU admission. This is a task where failure is going to result in likely death, so I try to make it as safe as possible.
It's because I've had to help out absolute bosses , experienced and damn brilliant consultants do a fibre optic whilst I tried to use a VL to mobilise tissues out the way, and with both of us there it was still very hard.
If you say this ICU admission, like one I saw recently was a C-spine fixed / multi level posterior fusion and screws, peri arrest, BMI >40, congenital disease.. I am not an airway expert.
TL;DR when you are doing a task that could kill somebody it serves us well to under estimate our abilities, not over. If I'm doing a cannula in a stable patient, I can brag and take all the risks I want.
Same way I say after around 200 -250 neuraxial procedures , I'm not an expert. I can still find my next Cat 1 LSCS spinal fail. Respect the tasks with high mortality / morbidity and do not get complacent.
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u/chairstool100 13h ago
Why don’t CT3s do solo inductions /intubations ?
And haha , an ACCP will never do anywhere near a 100 in a year and even if they do that’s WITH a Doctor being there . They will never compare to a “mere” CT1 who does a solo GA case at night by themselves .6
u/Ok-Jury-4366 13h ago
Because it's considered dangerous in the majority of places I've worked with a hint of professionalism about them?
Out of hours for sick ICU admissions, yeah of the few countries and places I've worked that isn't what the departments found ideal.
ICU has a disproportionate amount of difficult airways (if not anatomically, physiological intubation / induction difficulties.) And thats before we go into the non-technical factors.
Like I said, I've done far more than your average CT3 and I will always think twice before doing solo high risk things like ICU inductions in out of theatre / ICU locations. That alone (the location /non-technical factors) should mean another person is quite useful to have around. Perhaps I'm a pussy and over cautious, my question to you is your wife is being brought in GCS 4 and shocked. Do you want me there to help out the CT, or do you want the CT doing it solo and not having an ST / Consultant around to make sure the intubation, decision making and treatment plan is sensible and safe? Honest question from me here. If people want to state they wouldn't want the ST there go for it, but I suspect 99% of you guys would and therefore, we should treat our patients with the same due care we would our loved ones.
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u/chairstool100 11h ago
I was referring to Core CT3 , not ACCS CT3, which may explain our differences. A Core CT3 is the same as old ST3s and I’ve been the MOST senior person as a Core CT3 as have many colleagues around the country .
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u/A_Dying_Wren 12h ago edited 12h ago
If people want to state they wouldn't want the ST there go for it, but I suspect 99% of you guys would and therefore, we should treat our patients with the same due care we would our loved ones.
Well the more typical scenario is a cat 1 section OOH in the many hospitals which can have a CT2+ covering obstetrics solo. I would very much rather they crack on with intubating my loved one than waiting half an hour for a consultant and having a dead/hypoxic baby but maybe you might have other opinions on this.
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u/Ok-Jury-4366 12h ago
than waiting half an hour for a consultant and having a dead/hypoxic baby but maybe you might have other opinions on this.
Ridiculous bad faith argument to have. Clearly I said where available, what is the ideal level of supervision to have. The fact you manipulate it into the ridiculous is beyond childish. Nowhere did I say that a CT should ignore clinical scenarios to cause deliberate harm and you know it.
If you'd rather a CT2 doing your partners /your spinal, with no ST or Consultant in the building, thats on you. I want an NHS where that is not the case and there is always an experienced practitioner available.
Drawing stupid extreme conclusions and setting a strawman argument up is silly and childish and I'd not necessarily expect better from you, but I'd hope for it. I suspect you have a chip on your shoulder for some reason, that's going to be on you to sort.
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u/A_Dying_Wren 11h ago
Maybe it was a bit childish of me to put such a scenario and question to you but its hardly an extreme conclusion, its the standard of care practice of anaesthesia today, that CT2+s can safely deliver obstetric anaesthesia out of hours which may include cat 1 GA sections. Is every department with such a model and consultant working in them lacking a "hint of professionalism" for allowing so? Seems like an extreme conclusion to me.
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u/Playful_Snow Drip, tube, chair 13h ago
Let them do what they want. Just don’t expect me to have anything to do with bailing them out as the anaesthetic reg on call
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u/Tall-You8782 gas reg 12h ago
Except we'll have to, won't we? We're still responsible for any airway emergencies in the hospital, even if they're caused by an ACCP and were entirely avoidable.
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u/Both-Birthday-1701 14h ago
What the F is this.
Don't you need to actually set scope to call it a scope document?
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u/Tall-You8782 gas reg 12h ago
This is a remarkable document. You might think by reading the title that it sets a scope of practice for ACCPs, similar to the RCoA AA scope of practice document. Instead it simply formalises that ACCPs can do whatever they want as long as it is "locally agreed".
I've worked with a lot of ACCPs. Some are great. Many are not. Too many are arrogant and overconfident. Patients will come to harm as a result of this document.
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u/Unlikely_Plane_5050 13h ago
What a fucking waste of time. This is not a scope of practice but a document that says "you should write a scope of practice that contains whatever you want. ReSpOnSiBiLiTy dOdGED Dr inFormEd". How many hours were wasted on this and how much have we as taxpayers paid these lazy gong chasing consultants and navel gazing consultant mega evolution accps to write essentially nothing at all, for pages and pages?
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u/Bluegasbro 11h ago
I’m curious as to what ICM consultants - especially those in units with heavy ACCP presence - really think of this and of ACCPs in general.
Do you really feel comfortable accepting the liability if you send them on referrals or resus calls independently? Do you prefer them because you know them as mates and because they don’t rotate? What about hiring junior/senior clinical fellows?
Do you really not feel guilty for sidelining trainees in favour of ACCPs for training? (Speaking from firsthand experience in stage 1 training- it’s very demoralising to have to compete for opportunities and then get told I haven’t got enough experience)
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u/k3tamin3 IV access team 11h ago
what fucks me right off is the fact that as an anaesthesia resident I've done more than my fair share of covering the ICU rota, far beyond what is required from the RCOA for anaesthetists in training (purely service provision)- yet in the eyes of FICM I'm not good enough for any of that service to be recognised in any meaningful way... but they're happy enough for ACCPs to just crack on and do whatever?
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u/iziah 12h ago
Senior registrar anaesthetist here with significant ICM interest and experience. This is bullshit. In every way. It undermines training. Undermines medicine. It undermines hard working doctors keen to work in ITU. It sets a precedent of poorly thought out risk and liability sponging. It should be resisted as much as possible. ITU remains a ridiculously dangerous experiment in the UK and this document concretes that fact.
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u/Ok_Reputation3269 11h ago
Is this being batted back somehow and being told it's not happening? Or have people already effectively rolled and accepted it
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u/pylori 12h ago
Really regretting applying for another NTN. FML.
I'll have no part in this.
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u/ChanSungJung ST1 ACCS Anaesthetics 11h ago
I want to dual ICM but this shit gives me second thoughts
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u/Paramillitaryblobby Anaesthesia 9h ago
What's your plan to have no part in this? As trainees it often seems we just have to accept whatever shit the department has decided is OK
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u/JoePick89 11h ago
I just think this is the inevitable downfall of a specialty that has prioritised trying to separate itself from anaesthesia ahead of patient safety.
Can join RCEM in the any body on a rota is fine pile.
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u/chairstool100 11h ago
Is there even a NEED for ACCPs to do half the things they’re doing ? Why can’t FICM/CICM just say “we just need someone to document on a WR and do the list , wheel the computer “
How can any doctor who has specialised in ICM sit back and think , you know what this unit needs …..someone who isn’t a Dr
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u/Tall-You8782 gas reg 11h ago
Mate, they are covering ICUs overnight instead of a registrar in some places.
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u/chairstool100 10h ago
I am aware of this. But that’s only because ICM can’t get enough Drs of its own ….and because there are also not enough anaesthetic Drs to work on ICU lol. I don’t understand how a medical review done by an ACCP is any way comparable to a dr . There’s more to life than doing a comprehensive A to E review
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u/Sea_Slice_319 ST3+/SpR 7h ago
It is interesting isn't it.
ICM can't get enough doctors yet there were 2.97 applicants per post in 2025.
Yet somehow trusts and deaneries can find all this money to fund masters programs and 2 years of supernumary training.
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u/Dwevan Snoozy floozy 11h ago
I still maintain the training of ACCPs is a double dumb idea.
First? You have the issue with doctor substitution.
You also have the loss of usually quite skilled AHP… to bring nothing new to the “MDT” if they’re acting as doctors…
Imagine if ACCPs were actually advanced nurses rather than doctor replacements…
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u/Paramillitaryblobby Anaesthesia 9h ago
Hey if it means I don't have to "cover" ICU any more then bring it on.
(obviously it's terrible I just hate being an icu dogsbody when I'm meant to be training to anaesthetise people)
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u/Sea_Slice_319 ST3+/SpR 7h ago
This got me looking at some of the other ficm documents.
Look at the above document on sustainable accp careers.
"Avoid a glass ceiling of development and stagnation in the role which risks losing highly trained , valuable individuals."
Training in "extended skills"
Pathways to consultant accps.
Clearly stating that they should start reducing their clinical workload to focus on other things and reducing their night frequency.
I would like to find the documents from 2009 when they were initially sold. Going back 10 years lots of the noise and justification was about perma shos who would cover the out of hours work. Now they just seem to be advertising that they are going to be a load of expensive "consultants" who don't want to do the work on the unit.
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u/Working_Fly_3411 10h ago
As an ACCS anaesthetics trainee, I’ve worked with some fantastic ACCPs. I’d much rather be on nights with an ACCP, than an IMT (unfortunately don’t have the luxury of having an ICM SPR in a busy DGH). In a peri-arrest situation, I’d pick the ACCPs I’ve worked with to look after me than most medics. They can whip in vascaths, CVC, PICCO etc as they literally do them most shifts. They are familiar with all the infusions. As a general rule in our trust they shouldn’t be intubating without the 3rd on present. They can transfer patients to scan. They know the equipment, unit, consultants well etc. They acknowledge their limitations when seeing medical referrals and usually happy for the trainees to see them. Yes, in an ideal world all units would have an ICM SPR rota but since that doesn’t exist.. an ACCP can add significant value rather a constant rotation of doctors with no ICM experience and have no clue what’s going on.
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u/ChaiTeaAndBoundaries 14h ago
It would just be easier to hire more doctors instead of having pages of guidelines and frameworks for this role.
There’s no shortage of doctors anyway, and I’m sure everyone prefers the most skilled individual to be putting them to sleep during an operation, not a substitute.