Dr Gareth Llewelyn, RCP vice president for Wales, looks at how we could do more to support these doctors by offering different routes to a consultant post and ensuring protected time for research, teaching and professional development.
‘I always thought that being a specialty doctor would end up being a negative thing, but actually, now I’m doing it, I love it.’
More and more doctors are opting to take time out of ‘run-through’ training. Maybe they want a better work–life balance; perhaps they want some time away from the fast-paced training pathway, or gain new experiences before they specialise. Many choose to be associate specialists, working in senior positions within the NHS.
These doctors are often known as specialty and associate specialist (SAS) doctors, who are in non-training senior roles with at least four years of postgraduate medical training. There are SAS doctors in every hospital specialty, as well as in primary and community care. Many SAS doctors have made a positive choice to step into an SAS position and away from the traditional consultant training pathway, maybe for geographical stability or the chance to work regular hours in a chosen specialty.
These posts can often provide a better work-life balance than the traditional training pathway. SAS doctors can work towards a Certificate of Eligibility for Specialist Registration (CESR) or apply for a training post if they wish to become a consultant, although many prefer a career as a SAS doctor.
From very early on in medical school, you are told you have to go into training, that there’s no other route.
‘From very early on in medical school, you are told you have to go into training, that there’s no other route,’ explains Dr Rachel Hood, a specialty doctor working in Cwm Taf Morgannwg University Health Board. ‘So I always thought that being a specialty doctor would end up being a negative thing, but actually, now I’m doing it, I love it. It works for me, it works for my life outside work. I’ve got stability, I don’t have to move around.’
However, Professor Andrew Goddard, RCP president has previously highlighted some current issues relating to SAS doctors. 'It is the more established specialty doctors and associate specialists where we are missing a trick. Many are the backbone of services, particularly in smaller hospitals.
'They often keep the medicine show on the road and we owe them a large debt of gratitude – my mum was an associate specialist and chose a different career path to allow her time with my brother and me when we were young.
'She could run rings around me academically! However, the lack of career structure and a clear identity for SAS doctors has meant their voice is muted. This is not so much a lost tribe as an ignored one.’
Dr Frauke Pelz is an associate specialist in clinical genetics. ‘Many of us are the spouses – mostly wives – of consultants,’ she explains. ‘Like Professor Goddard's mother, many of us were bright graduates who took on the lion’s share of bringing the children up, providing family stability when moving around with our partners’ posts, and supporting the consultant in the family.’
Women, as well as black, Asian and minority ethnic (BAME) doctors are often overrepresented among SAS doctors. Many have more than 25 years of experience and postgraduate qualifications.
In her role as SAS tutor for Cardiff and Vale University Health Board, Dr Pelz has seen some of these challenges first-hand. ‘Women, as well as black, Asian and minority ethnic (BAME) doctors are often overrepresented among SAS doctors. Many have more than 25 years of experience and postgraduate qualifications. As a caring profession, we should recognise the huge contribution of these doctors who have dedicated their careers to their patients and to working in the NHS, and who deserve our full support in order to maximise their potential.’
However, it is still the case that many NHS bodies in Wales find it hard to retain SAS doctors owing to low morale. Unless issues of career development and progression, CESR process, recognition, status, pay and workload are addressed, it is unlikely that doctors will either want to join or remain in the SAS grade in significant numbers.
Dr Hood acknowledges that this is a problem, ‘I do feel a little bit like I haven’t got job security … I feel a bit like a long-term locum, and that’s the worst thing … There’s no peer support, I don’t have an educational supervisor.’
As Dr Jacob Daniel, an associate specialist physician and the Wales representative on the RCP SAS Regional Representative Network says, ‘many doctors, including consultant colleagues, perceive these posts to be the end of career progression … There’s no real dedicated time for professional activity, mainly because there is nobody else to cover me. I can’t leave the hospital for any reason.’
This why the RCP in Wales has been working to highlight these issues with the recently established Health Education and Improvement Wales (HEIW). For example, we’ve called on health boards to send job descriptions to the RCP before advertising new posts so that our regional advisers can check that the job is properly structured with time to undertake professional activities that will enhance the post.
As Professor Goddard says, ‘I often wonder how the SAS doctors keep up to date as many have 9:1 contracts. This seems wrong as surely their CPD needs are the same as trainees and consultants.’
As RCP vice president for Wales, I recently met with Professor Peter Donnelly at HEIW to talk about some of our key recommendations, published in our recent report, Doing things differently.
Health boards should:
- ensure that SAS doctors are part of a supportive team with senior consultant support
- develop and invest in structured CESR courses with mentoring and support for SAS doctors
- ensure that SAS doctors have protected time for career development, including education and research
- implement the SAS Charter (2014), which sets out optimal working conditions for SAS doctors
- ensure that all SAS doctors receive a job plan and an annual review with a study budget attached
- send all SAS job descriptions to the RCP for approval by elected officers before advertisement
- work together to develop a national mentor network and leadership training for SAS doctors
- encourage SAS doctors to take part in medical directorate meetings and senior board committees
- put systems in place to support SAS doctors who report bullying and harassment.
The RCP will:
- gather evidence and data through surveys of SAS doctors to ensure that their voice is heard
- encourage SAS doctors to become fellows of the RCP and have a greater say in the RCP’s work
- work with health boards to approve job descriptions for SAS doctors
- consider running CESR workshops in Wales, if there is enough demand
- continue to offer SAS doctors the opportunity to serve on committees and working parties
- encourage the use of the CPD diary and the ePortfolio to prepare for appraisals and CESR applications.
Dr Pelz is cautiously positive about the future for SAS doctors in Wales. ‘We have made some good progress in implementing the SAS charter for Wales over the last two years and in raising the profile and the professional opportunities for SAS doctors although we still have a long way to go in order to achieve full implementation of the charter.’
That is one thing that is very much lacking – leadership training. If specialty doctors have the opportunity to get onto the leadership career ladder, starting with some training … That will help, I think.
HEIW are hoping to take forward some of this work in the coming months. Professor Donnelly talked to us about investing in CESR support, leadership training and peer support for SAS doctors working in Wales, which Dr Daniel agrees is important. ‘That is one thing that is very much lacking – leadership training. If specialty doctors have the opportunity to get onto the leadership career ladder, starting with some training … That will help, I think.’
His words are echoed by Dr Pelz, ‘Many SAS doctors have sought introductory courses in leadership and management. We have run such courses for years and they are always full. What we lack is more active support from clinical directors and department managers who can facilitate the professional development of those SAS doctors who want to seek careers in senior management. We need a culture change that encourages an equal playing field for consultants and SAS doctors to develop their portfolios and apply for such posts.’
It’s encouraging that HEIW are planning to invest in this vitally important group of doctors. There are over 1,000 SAS doctors in Wales, making up around 20% of the hospital NHS medical workforce. We can, and must do more to support them.
The RCP will continue to campaign for improvements to the SAS doctor work-life balance and for more career development opportunities. We are working to establish a regional network of SAS leads through the hard work of Dr Waleed Arshad, the RCP SAS lead, and the Wales representative, Dr Jacob Daniel.
We are also encouraging associate specialists and senior specialty doctors to apply or be nominated to become a fellow of the RCP.
Find out about how to get involved with the RCP Staff and Associate Specialist Regional Representative Network by contacting membershipqueries@rcplondon.ac.uk. To learn more about our campaigns work in Wales, please contact Lowri.Jackson@rcplondon.ac.uk or our website.