NHS England and Health Education England support the development of advanced roles, recognising those of Medical Associate Professionals such as Surgical Care Practitioners (SCPs) as being a key component in workforce planning to reduce service pressures^1,2. 

The training and education of practitioners, from a professional and ethical standpoint, should consider the following ethical principles established by Beauchamp and Childress: autonomy, justice, beneficence and non-maleficence³. The concepts of this ethical model can be seen running through the codes of conduct established by those healthcare regulators relevant to SCPs – the Health and Care Professions Council⁴, the NMC⁵, and the GMC⁶.

Autonomy

While patient autonomy is focused on the Mental Capacity Act (2005) supporting patient-led decision-making, autonomy will be further supported by informing patients of the involvement of non-medical assistants within their care⁷. Historically, the information given to patients was considered as the material risk deemed by physicians on the Bolam principle arising from the case of Bolam v Friern Hospital Management Committee (1957, 1 WLR 583). However, this has been challenged on numerous occasions by cases achieving the Bolam principle but failing autonomy (Chester v Afshar, 2004, UKHL 41; Border v Lewisham and Greenwich NHS Trust, 2015, EWCA Civ 8; Montgomery v Lanarkshire Health Board, 2015, UKSC 11). Albeit historical cases, they have demonstrated a breach in informed consent, despite the Bolam principle being established.

Montgomery v Lanarkshire (2015) revolutionised the information being discussed with patients judged on what a patient, rather than a panel of surgical peers, would classify as material risk. A study by Wald et al. (2019)⁸ found a fourfold increase in cases of failure to inform following Montgomery v Lanarkshire, resulting in a £62m per annum increase in litigation. Therefore, it could be argued that thorough training in the legal aspects of surgery is imperative to ensuring the SCP navigates the legal conundrums in a litigious society, while ensuring patient autonomy is upheld with informed consent of the involvement of non-medical practitioners within their care⁷.

Non-maleficence

A seminal report by the Institute of Medicine in 1999, To Err is Human: Building a Safer Health System⁹, demonstrated a growing demand for an improvement in patient safety initiatives. Subsequent publications by the World Health Organization (Guidelines for Safe Surgery, 2009¹⁰); the NHS (Five Year Forward View, 2014¹¹); and the Royal Colleges of Surgeons of England and Edinburgh (SCP National Curriculum, 2022¹²) have built upon principles established in 1999 surrounding the involvement of non-medically trained practitioners within patient care. Myint (2018)¹³ supports this by stating assistants improve the operating surgeon’s performance and patient safety by demonstrating an in-depth understanding of the procedure, leading to improved situational awareness. Lack of situational awareness has been linked to adverse patient outcomes in an integrative review within patient care¹⁴. Lowes et al (2016)¹⁵ introduced the notion of ‘bandwidth’ relating to an individual’s cognitive load. The narrowing of ‘bandwidth’ and subsequent deterioration of situational awareness is affected by psychological stressors such as increased cognitive load. Hotton et al. (2019)¹⁶ support this with investigations into performance anxiety and the negative effects on individual performance.

The synthesis of normal parameters based on knowledge acquired in training enables the SCP to demonstrate their understanding of human factors and situational awareness^{14, 15}. Therefore, it could be argued that comprehension of anatomy, physiology and procedural steps will improve situational awareness and subsequently reduce stress for the operating surgeon¹⁶.

Beneficence

Beneficence is not independent of autonomy whereby practitioners determine the limitations within their scope of practice and the care they provide¹⁷. The Dunning-Kruger effect, where individuals overestimate skill due to illusory superiority, is the result of being incompetently unaware of their incompetence¹⁸. Wilsher v Essex Area High Authority (1988, AC 1074) established material increase of risk and the resultant judgement, concluding that healthcare professionals undertaking training will be judged to the standard of a trained professional. With few legal cases relating to non-medical assistants on record, that from North America, published by Murphy¹⁹ in 1998, titled Intraoperative use of unlicensed assistive personnel, demonstrates the need for a robust knowledge of the relevant anatomy.

The limitations and scope of practice for practitioners working within extended roles such as that of the SCP is based on the General Medical Council’s Good Medical Practice guidelines addressed within clinical governance of the surgical care team^{7, 12}. Benner (1984)²⁰ produced her seminal work outlining the journey of competence from entry-level trainee to expert practitioner. As practitioners transition through Benner’s contextual framework, the level of supervision required can change from direct to indirect, indirect to proximal. Linking this with the SCP national curriculum framework, novice and advanced beginner would be achieved within the training cycle and competency reached at sign-off^{20, 12}. Ultimately, accountability and adherence to the scope of practice with awareness of limitations improves patient safety while ensuring the education process is transitional from novice to expert.

Justice

Justice ensures the equal allocation of resources and access to medical care¹⁷. The NHS (2020)²² reported a significant decrease in the availability of physicians with the NHS Five Year Forward View supporting advanced clinical roles such as the SCP to provide continuance to patient care^{11, 21}. It is imperative to establish a parity of education to consolidate the principles outlined and ensure the ethical principle of justice is enforced to allow equal healthcare standards to all patients.

Gibbs et al (2004)²³ introduced the original debate surrounding the difference between training and education within healthcare. The concept of education requires the synthesis of knowledge, skills and application within the contextual environment. In comparison, training is the application and mastery of a skill²³. To expand on this, training may be compared to education but forms one of the foundations of education and, in turn, clinical practice^{7, 23}. Clinical practice is assessed through a combination of education, skills and work-based assessments (WBAs)⁷. In a move away from ‘tick box’ assessment of competence, the volume and character of the evidence required to ensure the competence of SCP trainees has been updated^{12, 24}. This shift has seen a change in wording from WBA to learning events, focusing on the quality as opposed to the original focus of quantity^{12, 24}.

Health Education England (2022) proposes that the ethical practitioner should continue a similar portfolio of evidence post registration with 50 hours of continuing professional development annually. The evidence should be recorded alongside a surgical logbook and reflections to demonstrate practitioner growth by acting as a reflective tool^{12, 25}.

This aggregation of evidence could be assimilated to the Great British cycling marginal gains theory, whereby an accumulation of 1% in each area produces a cumulative improved outcome²⁶. Therefore, each of these assessments individually does not ascertain competence, but collectively the aggregation produces evidence of thorough training. So the application of marginal gains could support the argument that optimising each area within training and education is essential to producing the outcome of competence when combined collectively.

The development of competency is a transitional journey achieved by assimilating knowledge and practising skills, enabling practitioners to fulfil the educational requirements of those higher education institutions delivering the SCP curriculum. Validating the parity of competence required of practitioners performing a role historically undertaken by physicians is essential to ensure patient safety is upheld and a defined scope of practice relating to the ethicolegal issues addressed. Therefore, it could be posited that the SCP should be aware of the legal and ethical implications of the care they provide, and appropriate education in keeping with current national expectations will support this.