STAFF GRADE AND ASSOCIATE SPECIALIST
DOCTORS
Changes to date
159. The problems affecting Staff Grade and Associate
Specialist (SAS) doctors were articulated in Choice and Opportunity
which criticised the absence of a recognised career structure
and the lack of formal training available for SAS doctors, as
well as the stigma attached to SAS posts. It recommended both
that SAS doctors be allowed to acquire formal competencies to
help with career progression and that more consistent training
and careers advice to be provided.[195]
160. Witnesses argued that some progress had been
made in improving the SAS grades since 2003. Dr Moira Livingston,
who previously worked at the Department of Health to implement
Choice and Opportunity, described the achievements to date:
…there are some things that we did manage
to achieve. One was to bring together a body of evidence for the
employer to understand how to ensure that doctors in these roles
could fully reach their potential…and how employers could
view them differently in terms of their contribution as clinical
leaders within organisations, so their role as managers, teachers,
their role in research.[196]
161. Meanwhile PMETB pointed out that the introduction
of a separate route to achieving specialist registration, by-passing
the formal training system, had improved prospects for SAS doctors.
The Certificate of Eligibility for Specialist Registration (CESR),
established in 2005, was praised by PMETB:
Doctors who have not completed a full training
programme can seek to demonstrate to the Board that they have
the same level of skills and knowledge as a doctor who has successfully
completed a specialist training course leading to the award of
Certificate of Completion of Training (CCT). If their application
is successful then they will be entered on to the specialist register
and be eligible to compete for consultant posts within the NHS.[197]
Limitations of progress
162. Despite these changes, however, the Committee
heard that overall progress on the reform of SAS posts had been
distinctly limited. Most importantly, Dr Moira Livingston argued
that the MMC programme had failed, and continued to fail, to prioritise
the reform of the SAS grades:
the reaffirmation of the principles of the MMC
Programme Board [in 2007], which were deemed MMC principles, actually
are MMT principles and actually modernising medical training principles
because they do not take account of Choice and Opportunity,
which was a key part of the whole programme…[198]
163. Dr Livingston also acknowledged specific limitations
to progress. She stated that the development of transferable competencies
and a "credentialing" system for SAS doctors, which
would allow experience gained in SAS posts to be recognised alongside
formal training, had not yet been achieved. The absence of a "credentialing"
system has limited the impact of the development of the new CESR
route, as there is no clear system whereby SAS doctors can demonstrate
that they meet the CESR requirements. Dr Livingston stated that:
Where we were unable to gain any momentum was
around the issue of credentialing. The origin aspiration had been
that doctors in the new career post would be able to get the credentialing
as they progressed within their job learning as they go for new
competences that they have gained, and there just is not a regulatory
structure in place to support that…. [199]
164. Dr Livingston pointed out that the planned implementation
of a new contract for SAS doctors had been delayed, preventing
other changes from being introduced:
…there has been a delay in that we felt
that the new contact was an essential component of Choice and
Opportunity, and whilst waiting for that to be agreed there
has been a hold on the publication of the work that we did within
the MMC team...[200]
165. The Tooke Inquiry also argued that the failure
to agree the new SAS contract had hampered progress. It stated
that the SAS grade would continued to be regarded as "a diversion
into a cul de sac" if further changes were not made.[201]
Aspiring to Excellence made recommendations which echoed
many of those put forward in Choice and Opportunity four
years earlier:
Staff grade positions must be destigmatised and
contract negotiations rapidly concluded…Doctors in these
posts should have access to training overseen by Postgraduate
Deaneries and CPD opportunities. They should be able to make a
reasonable limited number of applications to Higher Specialist
Training positions according to the normal mechanisms. The capacity
to achieve CESR through the Article 14 route and CEGP through
Article II should be retained.[202]
The new SAS contract
166. Sian Thomas of NHS Employers told the Committee
that the new contract for SAS doctors had been agreed in principle
by the BMA and the Department of Health in November 2006. She
pointed out, however, that the Government did not ratify the contract
until more than a year later in December 2007.[203]
In March 2008, 60% of SAS doctors voted to accept the new contract
with effect from April 2008.[204]
167. The Secretary of State acknowledged that ratifying
the contract had taken longer than expected, blaming this problem
on wider restrictions on public sector pay increases.[205]
He argued, however, that the new contract would bring significant
benefits for SAS doctors:
I am not suggesting that everything now is coming
up smelling of Chanel for this particular group but I do say that
we have paid some attention to their concerns and sought to get
a fair deal with their representatives which means that they are
not forgotten or left out of the huge changes and improvements
that have gone on in the NHS over the last ten years.[206]
Linking SAS posts to the training system
168. Witnesses emphasised that the ultimate aim of
the new contract and other changes to the SAS grade should be
to develop such roles into an effective supplement or alternative
to the formal training system. The Tooke Inquiry argued that SAS
posts should become a "parallel alternative career route".[207]
Aspiring to Excellence pointed out the potential benefits
to training doctors of working in SAS posts:
The advantages of the grade (accrual of experience
in chosen area of practice, consistent team environment) need
to be made clear. [208]
169. Dr Moira Livingston made a similar point, arguing
that the creation of a viable alternative to the specialty training
system would strengthen the medical workforce and make reform
of the training system less controversial.[209]
The English Postgraduate Deans agreed, but argued that progress
on achieving this had been limited:
…some trainees need an alternative career
structure within Medicine to that offered by the route to CCT
or CESR/CEGPR…The Staff and Associate specialist (SAS) grade
offers a potential alternative route but the present impasse over
the SAS contract is having a very negative effect on junior doctor's
perception of this grade. Choice and Opportunity offered
a mechanism to explore the educational infra-structure to support
this grade but this remains largely unexplored.[210]
170. As we have seen, Dr Livingston stated that little
progress had been made on such infrastructure developments, such
as the introduction of transferable competencies for SAS doctors.
She told the Committee that changes of this type would help to
develop the SAS grade as an alternative to training but had been
prevented by the lack of clarity regarding regulatory responsibility
for SAS doctors:
Because the doctors in the career posts are not
part of the training structure…they fell outwith the remit
of PMETB and, although we did work with Skills for Health to look
at a structured framework for their development, again it was
something that could not sit with the GMC in its remit and could
not sit with PMETB.[211]
Conclusions and Recommendations
171. Reforming the Staff Grade and Associate Specialist
(SAS) grades was one of the original aspirations of the MMC programme.
To this end, the establishment of a new way of achieving specialist
registration, the CESR route, is a welcome development. Wider
progress, however, has been limited and access to training and
CPD remains patchy. In particular, the failure to implement a
"credentialing" system has prevented training and experience
gained by SAS doctors from being formally recognised, meaning
that SAS posts continue to be regarded as inferior to traditional
training posts. The introduction of a new contract for SAS doctors
has also been delayed, further hampering progress. We recommend
that the introduction of this new contract be given a high priority
by the Department.
172. The failure to substantially reform the SAS
grade is highly disappointing, in particular because SAS posts
have the potential to provide an attractive alternative to the
formal training system. This potential must be realised in the
future. Such a development would not only belatedly improve prospects
for SAS doctors themselves, but would also reduce pressure on
the traditional training system. In order to achieve this, we
recommend that:
- The remit of the MMC Programme
Board be widened to include reform of the SAS grade;
- Responsibility for regulating the training
received by SAS doctors be given to PMETB, and subsequently to
the GMC;
- The regulator work with the relevant Royal
Colleges to develop a "credentialing" system to allow
experience and competence gained in SAS posts to be recognised
alongside formal training and to make it easier to achieve specialist
registration via the CESR route; and
- Employers make use of the new SAS contract
to ensure consistent access to and funding for training and development
and to develop extended roles for SAS doctors.
173. These changes would ensure that the SAS grades
become a recognised part of the training system, providing a genuine
alternative to traditional training posts and giving doctors the
opportunity to develop specific skills to a very high standard.
This would significantly increase the overall flexibility of the
training system and greatly reduce the need for temporary FTSTA
posts. It would also ensure that the UK no longer has a two-tier
medical workforce and that in future all doctors are either in
training or fully trained.
THE CONSULTANT GRADE
174. The principal aim of the specialty training
system is to produce doctors suitable for appointment as consultants.
Witnesses stressed that changes to the training system and the
SAS grade would in turn create a need for changes to the consultant
grade. Others called for reform of the consultant grade in response
to wider changes to the medical workforce and the health system.
Differentiation within the consultant grade
175. Sir John Tooke explained to the Committee how
the role of the consultant has changed in recent years, arguing
that the breadth of responsibilities covered by individual consultants
had decreased:
When I became a consultant in a district general
hospital nearly 20 years ago I was the only specialist in the
two specialties that I served…Therefore, I had to lead the
profession and run the training. I also ran a research programme…In
my service there are now five of me. We do not all do those things;
some operate as sub-specialists, some major on research and so
forth.[212]
176. He went on to argue that this change had created
a need for increasing differentiation, and the development of
distinct levels of seniority, within the consultant grade:
It is likely that there will need to be some
differentiation at the top end of the profession. It seems unlikely
to me that you can have the majority workforce made up of autonomous
practitioners operating in precisely the same role…A useful
analogy that has been put forward is that in clinical academia
you recognise at consultant level that you can have a senior lecturer,
reader and a professor. Therefore, there is a differentiation
within that hierarchy.[213]
177. Some witnesses felt that the best way to address
this issue would be to create a separate grade below the current
consultant grade. Professor Stephen O'Rahilly proposed that a
"sub-consultant or specialist grade" be created for
doctors to enter immediately upon completing training.[214]
178. Representatives of the BMA agreed on the need
for differentiation within the consultant grade, but did not feel
that the creation of a separate "sub-consultant" grade
would be the best way to achieve this. Dr Ian Wilson argued instead
that senior consultant posts should be created to offer the possibility
of progression within the grade:
What we believe …is rather than creating
a second grade which actually achieves nothing and delivers nothing
and has no place that cannot be dealt with in existing structures
is to create a portfolio within the consultant grade.[215]
179. Mr Bernard Ribeiro agreed, pointing out that
at present most consultants remain in much the same job role for
the whole of their working life. Like the BMA, he argued that
differentiation would best be achieved by introducing senior positions
above the existing consultant level:
We are more inclined… to look at how we
can take the established consultant body and look at means of
progression, not take the view that a consultant appointed at
35 will practise in the same way throughout the whole of his career.
He will have to demonstrate why that progression should occur.
That might well give some structure to the consultant level.[216]
Consultant-led or consultant-delivered care?
180. Witnesses also emphasised the importance of
deciding what proportion of care which should be provided by consultants.
It was stressed that if the NHS were to move from a primarily
consultant-led to a primarily consultant-delivered service then
this would significantly reduce the amount of care delivered by
doctors in training.[217]
It would also affect the overall number of consultants and training
doctors required by the NHS. A consultant-led service would also
increase the ratio of consultants to doctors in training, increasing
the number of consultants available to teach and supervise.
181. The Royal College of Surgeons argued that the
2000 NHS Plan had envisaged the creation of a consultant-delivered
NHS. However, it warned that this commitment was now in doubt:
The unprecedented growth in the medical workforce
offers a remarkable opportunity for the NHS to be a consultant-delivered
service. This was aspired to in the 2000 NHS Plan and has the
full support of the medical profession. Despite this, the uncertainty
created by current NHS reforms and the focus on fiscal matters
has jeopardised the chance to achieve a consultant delivered NHS…There
needs to be agreement and clarity from the Department of Health…as
to whether the NHS should be a consultant-delivered service or
a consultant-led service.[218]
182. When questioned by the Committee in 2007, David
Nicholson, NHS Chief Executive, stated that the issue of whether
to move towards consultant-delivered care was still being considered
by the Department of Health:
There are some really important issues here that
have not finally been teased out. The most obvious one is what
is the nature of the service that we are going to be taking forward
in the future? Is it going to be a consultant-led service or a
consultant-delivered service? That has a big impact in terms of
the numbers of staff that you want. We have not come to a conclusion
on all of that…[219]
183. The Secretary of State denied that the Department's
policy had changed since 2000, commenting cryptically that care
would be "clinician-led and locally driven" in the future.[220]
He subsequently stated that the specific question of whether to
offer consultant-led or consultant-delivered care would be considered
by the NHS Next Stage Review.[221]
Conclusions and Recommendations
184. The changes introduced by MMC also have significant
implications for the consultant workforce. Shorter overall training
times and increasing sub-specialisation both point to a need for
greater differentiation within the consultant grade. We recommend
that the Department of Health and the relevant medical Royal Colleges
examine the introduction of a hierarchy within the consultant
grade similar to that used in clinical academia.
185. We were surprised that the Secretary of State
was not able to say whether he remains committed to the NHS
Plan aspiration of moving from consultant-led to consultant-delivered
care in the NHS. This is a critical question with fundamental
implications for the size and nature of the consultant workforce,
and for the role of the training system. We recommend the Department
resolve this issue conclusively as part of the NHS Next Stage
Review. The Department must recognise that moving away from its
commitment to consultant-delivered care would have significant
implications, potentially throwing medical workforce planning
into still more confusion and further damaging relations with
the medical profession. This decision should not be taken lightly.
186. We are also concerned by the apparent absence
of any systematic basis for calculating postgraduate training
numbers, something which should have been established as part
of the MMC reforms. It is unclear whether the number of training
posts is determined by the number of doctors seeking training,
by the current capacity for training in the NHS, by the future
clinical needs of the health service, or by some combination of
these factors. We agree with Professor Tooke that "workforce
policy objectives must be integrated with training and service
objectives". We recommend that the Department of Health,
other relevant Government departments and the medical profession
work together to establish and publish and regularly update a
clear rationale for deciding future training numbers.
135 Aspiring to Excellence, pp.118-136. See
Chapter 3 for more details Back
136
Department of Health, The Secretary of State for Health's Response
to Aspiring for Excellence, pp.47-49 Back
137
It is notable that the traditional PRHO year generally gave new
graduates experience only of general medicine and general surgery
and that it did not have a formal curriculum Back
138
The inquiry's interim report, published in October 2007, criticised
the lack of relevance of some Foundation placements and inadequate
assessment processes for trainees Back
139
Ev 74 Back
140
Ev 87 Back
141
Ev 121 Back
142
See Q 660. Professor Rubin is head of the Education Committee
of the GMC as well as being chair of PMETB Back
143
Q 602 Back
144
Q 305 Back
145
Q 413 Back
146
See Ev 130 and Ev 185 Back
147
Ev 185 Back
148
See Ev 100-101 Back
149
Aspiring to Excellence, p.43 Back
150
Q 659 Back
151
Q 534 Back
152
Department of Health, The Secretary of State for Health's Response
to Aspiring for Excellence, p.48 Back
153
Aspiring to Excellence, p.46 Back
154
Ibid Back
155
Q 602 Back
156
Q 729 Back
157
See Ev 133, Ev 154, Ev 71 and Ev 140 respectively Back
158
Ev 164 Back
159
Ev 66 Back
160
Ev 10 Back
161
Ev 172 Back
162
Ev 142 Back
163
Ev 114 Back
164
See Aspiring to Excellence, p.88, Ev 114 and Ev 142 respectively Back
165
Ev 190 Back
166
Aspiring to Excellence, p.53 Back
167
See Aspiring to Excellence, p.146. The Inquiry stated that
some specialties should be continue to offer run-through contracts
for a limited period, but only during the transition to the new
system. Back
168
For full details, see GUIDANCE FROM THE DEPARTMENT OF HEALTH
TO SHAs ON MANAGING LOCAL RECRUITMENT TO SPECIALTY TRAINING IN
2008, 23 January 2008, p.3. It is notable that while there
was a mixed economy between different specialties in 2008,
there was no mixed economy within specialties. Back
169
Ev 111 Back
170
Department of Health, The Secretary of State for Health's Response
to Aspiring for Excellence, p.48 Back
171
Ev 54 Back
172
Ev 192 Back
173
Aspiring to Excellence, p.58 Back
174
Aspiring to Excellence, p.68 Back
175
Ev 192 Back
176
Aspiring to Excellence, p.147 Back
177
Department of Health, The Secretary of State for Health's Response
to Aspiring for Excellence, p.51 Back
178
Department of Health press release, LOCALLY LED, STAGGERED
RECRUITMENT FOR SPECIALTY TRAINING IN 2008, October 2007 Back
179
These include Cardiothoracic Surgery, Plastic Surgery and Neurosurgery Back
180
See http://www.mmc.nhs.uk/default.aspx?page=321 for further details Back
181
Q 477 Back
182
Ev 108 Back
183
Ev 189 Back
184
Q 180 Back
185
Q 181 Back
186
Ev 114 Back
187
Department of Health press release, LOCALLY LED, STAGGERED
RECRUITMENT FOR SPECIALTY TRAINING IN 2008, October 2007 Back
188
Department of Health, The Secretary of State for Health's Response
to Aspiring for Excellence, p.51 Back
189
Q 589 Back
190
Q 669 Back
191
Q 740 Back
192
Q 561 Back
193
Department of Health, The Secretary of State for Health's Response
to Aspiring for Excellence, p.21 Back
194
Staff Grade and Associate Specialist doctors are described in
more detail in Chapter 2 Back
195
Department of Health, Choice and Opportunity, pp.1-4. See
Chapter 1 for more details Back
196
Q 752 Back
197
Ev 105 Back
198
Q 752 Back
199
Q 752 Back
200
Q 752 Back
201
Aspiring to Excellence, p.47 Back
202
Aspiring to Excellence, p.146 Back
203
Q 755 Back
204
BMA Press Release, SAS Contract Vote, 17 March 2008 Back
205
Q 941 Back
206
See Q 939. Officials stated (Q 938) that the new contract would
offer 10% pay increases of 10% for Staff Grade and 4% for Associate
Specialist doctors Back
207
Aspiring to Excellence, p.47 Back
208
Aspiring to Excellence, p.146 Back
209
Q 752 Back
210
Ev 76 Back
211
Q 752 Back
212
Q 197 Back
213
Ibid Back
214
Q 217 Back
215
Q 416 Back
216
Q 543 Back
217
"Consultant-led" care would traditionally be provided
by a team of junior doctors, including doctors in training, working
under a single consultant. "Consultant-delivered" care
would be provided directly by consultants themselves. Back
218
Ev 115 Back
219
Public Expenditure Questionnaire 2006-07, Q54 Back
220
Public Expenditure Questionnaire 2006-07, Q258 Back
221
Q 947 Back
