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Who is supporting locally employed, specialty and specialist doctors? The NHS cannot afford to lose them

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I recently gave a presentation about locally employed LE (locally employed) and SAS (specialty and specialist) doctors. A number of people who came admitted they were expecting a talk about military medics, highlighting just how little is known about these doctors.

SAS and LE doctors make up at least 25 per cent of General Medical Council (GMC)-registered doctors in the NHS.  SAS doctors are experienced specialised doctors working in the NHS under a nationally agreed contract. LE doctors have a variety of experiences. For example, they may be UK-trained doctors who have finished the first two years of foundation training or recently recruited international medical graduates, among many other options. LE doctors are employed by individual trusts with locally agreed contract terms and conditions.

'Specialty doctors have been qualified for at least four years with two years’ specialty experience, and specialist doctors have been qualified 12 years with at least six years’ specialty experience.'

Despite these differences SAS and LE doctors are treated as a single group within GMC data and the GMC predicts that by 2030 they will be the largest cohort of GMC-registered doctors in the NHS, outnumbering consultants on the specialist register. However, while their numbers are increasing, these doctors face barriers and disadvantages that need to be urgently addressed.

About 65 per cent of SAS and LE doctors are internationally trained, although increasingly UK graduates are also choosing this career path as it has multiple advantages such as flexibility around working less than full-time, potentially better choices around work-life balance, as well as avoiding yearly transfers between different hospitals that may involve moving to different areas.

'The 2022 Medical Workforce Race Equality Standard (MWRES) reported doctors from Black or minority ethnic backgrounds are almost twice as likely as white doctors to have personally experienced discrimination at work from a manager, team leader or other colleagues'

65 per cent of LE and SAS doctors are from Black or minority ethnic backgrounds – this is particularly relevant given what we know about inequality and inclusion within the NHS workforce and the challenges and experiences staff from ethnic minority backgrounds have. The 2022 Medical Workforce Race Equality Standard (MWRES) reported doctors from Black or minority ethnic backgrounds are almost twice as likely as white doctors to have personally experienced discrimination at work from a manager, team leader or other colleagues; have a worse experience with examinations both during medical school and post-graduation; and are twice as likely to receive a complaint or be referred to the GMC compared to their white colleagues.

SAS and LE doctors – particularly those from minority ethnic groups – face a number of challenges. A 2020 survey revealed that 30 per cent of SAS doctors and 23 per cent of LE doctors had been bullied, undermined, or harassed at work in the past year, by colleagues or patients and their families. ‘Rudeness and incivility’ was the most common type of behaviour; and those surveyed reported this was most commonly linked to race.

SAS and LE doctors have told me about the racism – both overt and more ‘subtle’ – they experience from both colleagues and patients. For example, doctors for whom English is a second language being made to feel inferior and having to work harder to be treated with respect. There is plenty of awareness of the horrors of overt abusive racism but much less is being done to address the more insidious experiences – the ‘microaggressions’, lack of support, lack of career progression, harsher disciplinary actions. It will take real genuine reflection and some uncomfortable conversations for those in positions of leadership at all levels of the NHS to address these inequalities. But why has this discrimination been allowed to continue for so long? Who benefits? How do we change the power imbalances at play?

SAS and LE doctors also experience inadequate inductions, lack of recognition, access to training and career development. As one locally employed doctor put it, after being recruited internationally, he was promised a structured introduction to the NHS and instead was left to ‘sink or swim’.

The NHS medical workforce is hugely reliant on SAS and LE doctors, with more than 9,000 SAS and LE doctors joining the NHS in the past two years. The recent NHS workforce plan outlines a strategy to increase domestic education, training and recruitment by increasing medical school places. While this will be a great addition to the workforce in the long term, these doctors will not be qualified and working independently for at least another 10 or more years. SAS and LE doctors are a solution to our workforce crisis right now.

'SAS and LE doctors also experience inadequate inductions, lack of recognition, access to training and career development.'

The NHS must recognise the importance of SAS and LE doctors and work hard to improve their experiences. The current retention crisis within the NHS doctor workforce is particularly affecting SAS and LE doctors. Of the SAS and LE doctors who took up a licence to practise in 2013, 53 per cent had left the workforce by 2021. This is a huge loss of expertise and talent and comes at the expense of the public’s health.

The NHS would not function without these doctors and patient outcomes and experiences would suffer. The BMA, NHS England and GMC all have initiatives to support these doctors but it is clear these are not being implemented consistently throughout the country. As the NHS celebrates its 75th anniversary, it is unbelievable that these doctors have such a low visibility and are not receiving the support they deserve. Is this in keeping with NHS England business plan to ‘support the NHS to attract and retain more people, working differently in a compassionate and inclusive culture’?

The NHS must ask itself – who is responsible for holding the employers of these doctors accountable? What are the repercussions for employers for widespread discrimination, bullying, lack of support and progression? What is actively being done to retain these doctors? Is it morally acceptable to continue to actively recruit doctors internationally when they are coming to such difficult work environments?

At The King’s Fund, we are planning more work to highlight the experiences of both LE and SAS doctors working within the NHS and spotlight their voices. The NHS workforce plan sets out the need for a commitment to improve the experiences and support the careers of SAS and LE doctors; trusts, royal colleges and national NHS bodies need to focus on retaining and developing the careers of these doctors – our health services depend on them.