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Long read

Reflections of specialty and specialist and locally employed doctors in the NHS

Authors

I was trained in anaesthetics from one of the reputed hospitals in my home country and the training is rigorous. When I first applied here, I had finished my MD [specialist qualification] in anaesthetics. When I first came, I was an SHO [senior house officer]1 but because I had done my masters in anaesthetics, I joined on a Wednesday and by Friday I was on call [as a specialist]. It did worry me because I didn’t even know the layout of the hospital. I told the consultant in charge of trainees, ‘I'm on call this weekend… how will I survive?’
Specialist doctor on joining the NHS

Introduction

Specialty and specialist (SAS) and locally employed (LE) doctors make up a significant percentage of the NHS workforce yet are often underappreciated within the health care system. In 2023, we discussed some of the challenges facing SAS and LE doctors and called on the NHS to better support this group of doctors. In this long read we share the reflections of a small group of SAS and LE doctors we spoke to in early 2023 about their experiences. We surveyed 11 SAS doctors – some from The King’s Fund’s Emerging Clinical Leaders programme and some who attended a regional teaching day. We undertook in-depth semi-structured interviews with four SAS doctors and three LE doctors.

What are SAS and LE doctors?

Specialty and specialist (SAS) doctors are two groups of doctors with differing levels of clinical experience who tend to be grouped together because they are both employed under the nationally agreed SAS contract for each UK nation. Specialty doctors have at least four years of clinical experience with at least two years working in a relevant specialty. Specialist doctors have at least 12 years of clinical experience with at least six of those years spent working within a specialism. SAS doctors have not completed NHS England training programmes that lead to consultancy but have worked within NHS hospitals and within a chosen specialty.

Locally employed (LE) doctors are recruited by individual NHS trusts on locally agreed contracts and there are no nationally agreed requirements regarding previous experience or length of practice. In contrast, doctors on NHS England training programmes work within regional deaneries and move between trusts, with NHS England contributing to their salaries. 

SAS and LE doctors form a sizeable and increasing proportion of the NHS workforce, accounting for more than 25% of licensed doctors registered with the General Medical Council, and will continue to make up a significant share of the workforce for the foreseeable future. Many internationally recruited medical graduates choose SAS or LE roles as they provide a route for them to work within the NHS. Although the NHS Long Term Workforce Plan aims to reduce the reliance on overseas recruits, the plan still predicts that 9%–10.5% of all new NHS joiners will be from overseas by 2036/37.

Why people choose to work as SAS and LE doctors

Doctors we spoke to explained that the SAS contract provides an opportunity to develop a fulfilling career based in one area of the UK and tailored to personal life circumstances. SAS doctors do not have to rotate through different hospitals in the same way that NHS England trainee doctors have to, can negotiate personalised work schedules, and are able to develop a portfolio career with broad interests. This has the potential to improve work–life balance for these doctors.

“This is the decision we made, and I personally think I have no regrets with the career… it helped me stay with the family and see my kids grow up. ”

Author: SAS doctor

For doctors who have completed their foundation training, roles for LE doctors can provide an opportunity to gain experience in specialties they have not been exposed to previously. The LE doctors we spoke to explained how LE roles can also provide an entry route into the NHS for internationally trained doctors (who have not trained on an NHS England programme or may not have the NHS experience required for an SAS role).

What are the challenges of being an SAS or LE doctor?

Many of the SAS and LE doctors we spoke to have faced significant barriers and obstacles in their careers, often related to a lack of knowledge, awareness and recognition of their roles and the experience they bring to the NHS. These barriers can be perpetuated by medical colleagues, trusts and health care bodies at a national level.

Lack of awareness and knowledge of the SAS role

“Recognition of seniority and experience is not always present. We have to work harder to impress within the same framework. Fighting for rights can sometimes be demoralising.”

Author: SAS doctor

A recurring theme was a lack of awareness and recognition of the SAS role. Despite the nationally agreed contract for SAS doctors, many felt that colleagues, particularly consultants and NHS England trainee doctors, do not understand their role or the level of experience they have. 

"An entry-level consultant, they may understand little or nothing about the SAS career pathway and they understand nothing about what an SAS doctor might be able to contribute to a service."
SAS doctor

This lack of understanding leads to tension over the day-to-day responsibilities and opportunities for SAS doctors. Interviewees said that they had been made to feel their roles were purely for service provision at a junior level and they were not entitled to access training, management or leadership opportunities. A recent report from the General Medical Council (GMC) on workplace experiences revealed that SAS doctors are often likely to carry out work usually done by more junior colleagues. In addition, a 2022 report by brap and the British Medical Association (BMA), Why are we still here?, noted that SAS doctors are often incorrectly referred to as ‘middle grade’ doctors. The report notes that many find these terms demeaning and that their use contributes to a culture in which SAS doctors are seen as workhorses to fill a rota and that it is harder for SAS doctors to gain recognition as senior decision-makers alongside consultants.

Relationships with colleagues 

The locally employed doctors we spoke to described variable relationships with colleagues. Some colleagues, both consultants and resident doctors, were very supportive and worked hard to improve the settling-in process.

"The clinical lead was very supportive so whenever he was on the shop floor he would explain and show how it should be done. Rather than telling, he would show me. "
LE doctor

However, not all senior clinicians were so supportive.

 "They are like, ‘How come you don’t know this?’ Why would I know? No one taught me, how could I know? Everyone knows because someone taught them. Yeah, that was the most unpleasant experience."
LE doctor

LE doctors also told of instances where they were expected to deliver a higher workload than other doctors in the department, with the threat of being reported if they did not reach a certain standard. These doctors felt their employment terms were more insecure and that they had less recourse to advocate for themselves.

“It is difficult to say no, they kind of tell you other things, like I heard consultants saying to my colleagues that they would give a bad review of me to my clinical supervisor.”

Author: LE doctor

Induction

Many SAS and LE doctors are internationally trained. For some LE doctors this may be their first role within the NHS. The report Why are we still here? found that without a frame of reference and previous NHS experience, these new recruits are vulnerable to poor or non-existent induction periods, unfair pay scales and rotas, and lack of educational development and progression. This is particularly true for LE doctors who have been recruited internationally and are often not supported through proper induction processes or told about options for professional development, including the SAS roles.

"I did not have a structured induction. It's like for you to understand how the trust is set up and how it operates. I was just thrown in and asked to shadow someone for a few days, then after that everybody was wondering why you don't know this and why you don't know that."
LE doctor

"As a clinical fellow [on a locally agreed contract] … the trust can basically do whatever they please with your contract and put in or remove stuff they don't want in that contract. So I feel there's a hesitancy or reluctance to actively promote moving [from an LE role] to the SAS role."
LE doctor

All the LE doctors we spoke to started their jobs without an official job description or detailed contract outlining their responsibilities, work schedule, or any detail about how to book annual or study leave.

Career development

Limitations on training, management and leadership opportunities can affect career development for SAS and LE doctors. We heard examples of competition for access to training and development between NHS England trainee doctors and SAS doctors. One SAS doctor described a situation in which NHS England trainee doctors and SAS doctors were left competing for access to training theatre lists and NHS England trainee doctors were given preferential access.

This feeling of competition can also affect SAS and LE doctors’ access to study leave and study budget.

"...I have found there is a difference in getting study leave and annual leave... Just yesterday I had a discussion with our clinical director that you know some of our leave is not being given. Most of the time it's rejected even if it is mentioned it’s specifically for SAS development."
SAS doctor

Several interviewees emphasised how much self-direction is required to develop a career as an SAS doctor. SAS doctors are eligible for senior positions within leadership, teaching and advocacy; however, these roles are often advertised for consultants only. A GMC survey showed only 5.3% of SAS doctors are involved in service management and planning, and the Why are we still here? report noted that SAS and LE doctors experience ‘occupational segregation’ and reduced opportunities for career progression.

Several interviewees described the difficulties involved in proving themselves eligible for their roles, the challenges of gaining additional responsibilities within their departments, and a lack of recognition for their achievements.

"I had to sit down with my CD [clinical director]. They were totally at sea with it… We are going to sit down as per the [SAS recruitment] policy that we've just written. And we are going to go through every single item on that RCEM [Royal College of Emergency Medicine] curriculum and you're going tell me whether you think I can do that on my own or whether you would still wish to supervise me."
SAS doctor, describing having to prove their experience when attempting to move on to an associate specialist contract

The SAS contract provides a long-term career option for experienced clinicians within the NHS. Some, but not all, SAS doctors are on the GMC specialist register, although it is not a requirement to be on this to be an SAS doctor. One option to join the register as an SAS doctor is to complete the portfolio pathway (formerly known as certificate of eligibility for specialist registration (CESR) pathway). This requires a considerable amount of work from individual doctors and is very difficult without support from senior clinicians within the doctor’s own department.

"I was told this trust supports the CESR pathway… the impression that I was given by the recruitment agency and the trust initially was that after the initial period, six months of assessment or something, I would be assisted to take rotations in other departments to have my CESR done. [Portfolio pathway/CESR often requires experience in other specialties outside your own, eg A&E doctors need experience in intensive care and anaesthetics.] It didn't happen."
LE doctor

In addition, personal circumstances mean the portfolio pathway route is more difficult for some than others. NHS England trainee doctors are supported to gain the competencies they need. For example, if someone is struggling, extra support is put in place to help them, such as extra sessions with a supervisor to develop competencies. Interviewees told us that there was a lack of similar support for LE doctors and gave examples of how life circumstances were holding back career progression and that no support was put in place to mitigate this.

"…Our [LE doctor], she's been with us for 10 years, she predominantly works nights because of the age of her children and she probably should be a specialist, really. But she's refusing and she wants to CESR eventually. But it's too slow and it's not going to work for her."
SAS doctor

Doctors also talked about the importance of the specialist role being recognised as a senior independent autonomous position in its own right and not necessarily as a stepping stone to consultant positions.

"Health Education England [now NHS England] [needs] to say yes, we recognise there are different groups so we just don't want to be saying CESR outcome is the only successful outcome of your [SAS] career."
SAS doctor

Issues around career progression also affect LE doctors – a group of individuals with very varied backgrounds and levels of experience. LE roles do not necessarily lead to more senior positions. Among other options for career progression, LE doctors can apply for NHS England training programmes to become a GP or consultant or apply for SAS roles.

"The system [NHS England training programmes] is a little bit unfair for specialised doctors trained abroad because they cannot get into the system that easily. [For example, to become a surgeon] …you have to have MRCS [membership of the Royal College of Surgeons], then you have to work on CESR route because you become ineligible to get into the training route once you have a certain amount of surgical experience."
LE doctor

LE doctors we spoke to met the experience requirements for SAS roles but had not been offered SAS contracts within their own departments.

"They say we’ll just change your pay without changing the contract [from LE to specialty role]. So it'll still be a clinical fellow, but doing a different role, which is quite absurd."
LE doctor

Several doctors also mentioned the lack of succession planning for SAS and LE doctors. These doctors are often seen as service provision without career and educational development needs.

“…we had an associate specialist in the department who was near retirement… There was no succession planning for him. And his job didn’t change, so at 65 he was still doing nights.”

Author: SAS doctor

We also heard that LE doctors are not being introduced to clinical or educational supervisors promptly and the support they do receive is inconsistent.

"I got allocated a supervisor… after a while they introduced themselves to me and then they said, ‘Look, we're supposed to be meeting and seeing how you're progressing and things’. But that was six months or so down the line and obviously it would have made much more sense if I had known about this earlier."
LE doctor

"That support [from a supervisor] was very limited and it was always retrospective advice I got. So when I ran into a trouble, when I go to them then they were happy to dissect it and say ‘You should have done like this. You should have done like that. This is not how it should be done.’ But then in the moment when I need that help, they were nowhere to be found many of the times."
LE doctor

Racism, discrimination and bullying

The majority of SAS and LE doctors are from the global majority with around 65% from Black or minority ethnic backgrounds. This means that a high proportion of this group is exposed to issues faced by staff from Black and minority ethnic groups across the NHS. The Medical Workforce Race Equality Standard (MWRES) data showed that, for all grades, doctors from Black and minority ethnic backgrounds are most likely to have experienced harassment, bullying or abuse from staff in the previous 12 months.

Racism is the most common form of discrimination for SAS and LE doctors. We heard experiences of racism, bullying, discrimination and even physical abuse from the doctors we spoke to. Five of the 11 SAS doctors surveyed had experienced discrimination and bullying, and all had multiple stories and examples of discrimination that they or their colleagues had received from patients, colleagues, management and trust leads.

Below are some of their stories.

"Oh yes, there is a direct discrimination bullying. But in terms of ‘Am I in their club or out of their club’, that's always a difficult question."
SAS doctor asked about experiences of racism at work

"You can just sense it and can't say it in words, but you can just feel and get surprised and say, ‘I wonder if everybody's treated this way’, but because you don't have any evidence of what's happening to others, it's difficult to compare it."
LE doctor

"I'm not sure if it's discrimination or just a general reflex for anybody against female doctors is that they call you a nurse, especially if they see you're from a minority group and you're Asian, or if you're just female and a minority group then they call you that, even though you've introduced yourself as a doctor."
LE doctor

One LE doctor described how racism and discrimination can also be perpetuated by other international medical graduate (IMG) colleagues who have been working in the NHS for longer.

"It is the IMGs who have been born and brought up abroad and came here many years ago. Still, they have the baggage and force that on the newer junior doctors." 

One LE doctor described a situation where he was continually given more patients to review despite having a greater workload than a UK graduate doctor standing next to him. The same doctor also described discrimination based on accents.

 "If your accent is very British/Scottish/local, even if you are giving a bad referral, it is accepted. But as soon as they hear a different accent, they ask for all these extra unnecessary details. I would say initially I was having difficulty referring to other departments but by this point I know how to navigate that part. But I have heard more junior English colleagues give poor incomplete referrals and they are accepted easily. I have been wondering why? But I'm not sure. I'm not sure why that is?"

Discrimination based on disability

18% of UK graduate SAS doctors have a disability, compared with 4.7% of GMC-registered doctors overall. This perhaps reflects the inflexibility of NHS England national training programmes for disabled doctors and the opportunity that SAS roles provide for a more personalised career plan.

"And I went through a lot [of medical treatments] and my clinical director at the time was vile about that and used it against me. She was horrible and that nearly made me leave the profession altogether to be honest. Really insidious. Passive aggressive bullying."
SAS doctor

What next?

Given the NHS workforce crisis and the increasing reliance on international medical graduates – the majority of whom are employed in SAS and LE roles – the health care system urgently needs to assure recruitment, retention and progression of these doctors. Not only is this important for these doctors and for the health service, it is also the case that patient outcomes are better when they are cared for by a diverse representative workforce.

To make the most of the skills and ability of this important staff group, trusts should recognise the experience held by SAS doctors and actively support and encourage them into management and leadership roles.

NHS England, the GMC and the BMA, among others, have produced guidance for supporting LE and SAS doctors, with a particular focus on the induction and retention of international medical graduates. Trusts need to review whether they are following the guidelines (such as those from NHS Employers and the GMC) available for these roles and work quickly to implement them if not. To make the most of the skills and ability of this important staff group, trusts should recognise the experience held by SAS doctors and actively support and encourage them into management and leadership roles.

Many of the doctors we spoke to talked about a need for a culture change within the NHS with regard to how SAS and LE doctors are viewed and treated. NHS England published the NHS equality, diversity and inclusion improvement plan underlining the importance of a truly inclusive culture within the NHS for the benefit of both staff and patients. The commitment in this plan – implement a comprehensive induction, onboarding and development programme for internationally recruited staff is a welcome recognition of this issue. Action in this area will be particularly important in meaningfully improving the professional experiences of SAS and LE doctors as a high proportion are international medical graduates.

Is there a role for national bodies in proactively reviewing how SAS and LE doctors are inducted and supported through their career – especially for LE doctors whose experiences are dictated by local trust processes? The system needs to facilitate this rather than create barriers, and there has been some progress: The Royal College of Surgeons recently identified a six-point plan to support SAS doctors in reaching their full potential; the Royal College of Physicians has an SAS doctor strategy in place; and The Academy of Medical Royal Colleges SAS Committee is doing extensive work in this area. Importantly, the SAS collective – a group of SAS doctors formed to ‘improve the careers and retention of doctors in the UK’ – have launched an initiative ‘SASsix’ to roadmap what these improvements may look like. At a trust level, it is important that effort is put into understanding and improving staff experiences.

But this is only a beginning. Despite our small sample size, many of the issues raised in this long read warrant further examination and reflection.

Acknowledgements

Thanks to the SAS and LE doctors who gave their time and shared their experiences with us.

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