Rowing upstream? SAS as a career choice and the SAS Charter

As we prepare for SAS week, I have been tasked with writing a blog to mark the occasion. There are lots of facts I could mention: that there were 64,000 SAS and LE doctors GMC registered in 2023 or that the workforce has grown by 40% in the last 5 years or that SAS and LE doctors are projected to be the largest employee group of doctors by 2030. While this is certainly all true and important, for many (most?) SAS doctors these facts don’t necessarily reflect their experience of working in the NHS where the role can feel isolated and a bit ‘other’ compared to more traditional medical student to foundation doctor to resident doctor to consultant pathways.

For myself, I have never had anyone refer to me as ‘SAS’ doctor in my workplace either among colleagues or patients. It’s a term that people often don’t understand or even recognise. I am variably called a registrar, fellow or a consultant and very occasionally an associate specialist. However, I am none of these things! There seems to be little understanding of my role as a senior and permanent part of our clinical team. For some, it seems almost inconceivable to envisage any senior non-consultant role that isn’t a registrar. This will be different in other settings as some specialties and trusts have much higher numbers of SAS doctors, but I suspect the feeling of ‘other’ is not unique even in sites with a good representation. This is further exacerbated by the large proportion of SAS doctors who are also international medical graduates (IMGs) like me. Even for locally trained doctors though, taking the step into this role may feel like rowing upstream against the expected norms. While the workforce is large and growing, within individual teams and care groups SAS doctors may be a minority at risk of being overlooked for training and development opportunities due to the competing priorities of foundation and specialty training programmes. We must remember that all doctors are training doctors – even consultants – because our knowledge base and treatment options continue to grow and expand at a (sometimes terrifyingly) fast rate. As such, all doctors should be provided time and financial support to undertake clinical and professional development as an integral part of their role, not just to achieve the bare minimum for revalidation.

Thankfully over the last 2 decades there has been much progress in defining the scope of the SAS role and recognising that this is both a viable and also highly needed alternative pathway within the NHS for many doctors. The SAS charter (the charter for England was originally published in 2014, followed by other nations) is among a growing number of documents published in the last decade describing the SAS role and responsibilities for both doctors and employers. The RCP has been leading in this with its 2022–24 strategy for SAS doctors, followed in 2023 with The widest possible pool of talent: Supporting SAS doctors to fulfil their potential and in June 2024 launching the Educational and career support for specialist, associate specialist and specialty (SAS) doctors. The 2020s have seen implementation of a new employment contract, creation of the new specialist role to facilitate career progression for the most experienced and/or aspirational SAS doctors  and repeated advocacy from multiple colleges and organisations. But despite all this some SAS doctors may still be seen as simply providers of direct clinical care who for some reason were unable or unwilling to become consultants. This is a sad and limited view of a workforce made up of mainly senior and experienced clinicians (83% with more than 10 years’ experience) who can bring so much breadth of skill and knowledge into both the clinical but also the broader educational, research and leadership spheres within the NHS. The #SASsix policy call developed by the SAS collective nicely summarises the key issues (see below). Their campaign has been endorsed or supported by the HCSA, Medical Protection, Association of Anaesthetists, Royal College of Anaesthetists, Royal College of Physicians, Med Ed Leaders UK and the Medical Women’s Federation.

The #SASsix policy calls are:

1. Every early career SAS doctor should have access to an educational supervisor.
2. All SAS doctors should have equity of access to professional development opportunities relevant to their stage of career.
3. All specialty doctors who meet the required capabilities should have the opportunity to become specialists.
4. Senior SAS doctors should be offered the opportunity to be educators at every level on a par with consultants, eg educational supervisors, clinical supervisors, directors of medical education.
5. All extended roles in leadership and management should be open to all substantive medical staff, ie consultants and appropriately experienced SAS doctors.
6. All LEDs employed for more than 2 years within one NHS employer should be offered the opportunity to transfer to the appropriate SAS contract.

So, what does this mean in practice? SAS doctors are an extremely diverse workforce group so it is difficult to generalise but one thing they have in common is a stable and growing NHS presence. Working as an SAS doctor was an ideal choice for me after having undertaken multiple years of training overseas and wanting stability for myself and my family in the UK. The flexibility of the role means I have been able to negotiate a job plan that reflects both the needs of the service but also allows flexibility to explore opportunities in my area of special interest (research) and to develop skills in leadership and governance. I work within an extremely supportive team but not all SAS doctors are as lucky. Previous workplace surveys have shown that many SAS doctors feel unsupported and are not provided opportunities for progression. This is something that can only change on the ground with a combined commitment from NHS employers and individual managers. The royal colleges (including the RCP) play a vital role in advocating for SAS doctors, providing opportunities for education and support through associate and collegiate membership as well as the chance to be awarded fellowship in recognition of service and career achievements. 

It is important to me to feel a part of a wider community that I am contributing to. The RCP, along with my specialty-specific national body and local trust department, all provide me with that. I am currently serving as the London South SAS rep to try to ensure that all SAS doctors in our region feel supported to grow in their professional roles as a part of this vital service. It should not be a ‘postcode lottery’ depending on simply having a helpful and supportive clinical director. We need to ensure that SAS advocates and tutors are present in all trusts to not only support the SAS doctors themselves but also to help the wider NHS community to understand the current opportunities and potential for this large section of our permanent workforce.