Chapter 1 – The ‘alternative career pathways’ | Association of Anaesthetists

Chapter 1 – The ‘alternative career pathways’

Chapter 1 – The ‘alternative career pathways’

By: Dr Rob Fleming

Doctors who are not consultants, or part of a recognised training programme, may be employed on a number of different contracts. These include the nationally negotiated contracts, which are currently the ‘Specialty Doctor’ and ‘Specialist.’ Some doctors are also still employed on historical national contracts, which include the ‘Staff Grade’ and ‘Associate Specialist.’ Together, these groups are ‘SAS doctors.’

There are also a group of doctors employed on non-standard, non-national contracts. These ‘locally- employed’ doctors have a variety of names, which vary from one organisation to the next, and include ‘Trust Doctor’ and ‘Clinical Fellow.’ It is the opinion of the Association of Anaesthetists that many of these doctors would be better served by being employed as SAS doctors, with the permanence and contractual protections associated with a substantive SAS contract.

Choosing a career as an SAS doctor should be a viable career choice, and offer several attractive additional pathways for a career in medicine. The SAS contracts potentially allow someone to have their career within one organisation, from an earlier stage, while working towards any one of a number of potential end points.

A new Specialty Doctor could choose to pursue any of the following: 

  • Remaining a Specialty Doctor, and broadening their role into the non-clinical 
  • Progressing to becoming a Specialist 
  • Progressing to becoming a consultant via entry into the Specialist register of the General Medical Council (GMC) through the Certificate of Eligibility for Specialist Registration (CESR)/portfolio pathway 
  • Progressing to becoming a consultant by (re-)entering a formal training programme

Each of the above reflects a different career pathway to the ‘conventional’ norm of formal training. Each career goal carries its own development needs, some of which overlap. Supporting each of these aspirations potentially benefits our services by improved recruitment and retention, as well as filling anticipatable future workforce need. These alternative career pathways therefore need ‘parity of esteem,’ and they should be an important part of future workforce planning.

The following sections cover the 2021 SAS contract reform in more detail. Unless otherwise stated, some of the detail within these sections is based around the contract negotiations in England. There are some small variations between these contracts, and the contracts in Scotland, Wales and Northern Ireland, but the themes remain the same.

The 2021 SAS contracts

Specialty Doctor (2021)


  • Full registration and a Licence to Practice with the GMC 
  • At least 4 years full-time postgraduate training (or equivalent gained on a part-time or flexible basis)
  • At least 2 years of which is in a specialty training programme in a relevant specialty (or equivalent experience and competencies)

The Specialty Doctor role is the less senior SAS role, and new entrants to the role require supervision and support to develop in keeping with their existing level of experience. Doctors working as Specialty Doctors will have differing supervision needs, and different developmental needs.

New starters from another national contract, including doctors in formal training, should have their basic pay matched in keeping with the contract terms and conditions. Locally-employed doctors who exceed the above eligibility can seek to have their additional experience recognised if they become Specialty Doctors, in order to start at an appropriate pay point; however, this is currently at the discretion of employers. The start of the Specialty Doctor pay scale roughly aligns with the CT3 nodal point in the trainee contract, and the contract assumes that new Specialty Doctors will have the above experience only. Additional experience and existing seniority can be recognised.

Specialty Doctors have contractual rights to a job plan and a minimum of one unit of supporting professional activities (SPA) time. Additional SPA should be encouraged, allocated in a way commensurate with the activity and agreed at job planning meetings, the Royal College of Anaesthetists (RCoA) and the Academy of Royal Medical Colleges (AoMRC) recommend an allocation of 1.5 PAs for SPA in all SAS and consultant job plans. There is an expectation of ongoing professional development to greater seniority, less direct supervision and broadening their role into non-clinical domains built into the contract structure. Professional development should be the norm, and not the exception.

Each year, every SAS doctor should have a job planning meeting and an appraisal. Doctors on a 2021 SAS contract also require pay progression meetings before each potential pay point change. Each of these presents an opportunity to discuss career aspirations, how these might be achieved and what support might be required.

Some organisations offer Educational Supervisors for their Specialty Doctors, which may be valuable to their ongoing professional development. This would potentially be most beneficial to those earliest in their careers. Mentoring could likewise be very valuable to some of these doctors and should be offered. The Association mentoring scheme has been set up so that members interested in having a mentor, or receiving coaching, can access a team of trained Association of Anaesthetists mentors across the UK. The Association mentoring scheme is voluntary for both mentors and mentees and all services are free of charge.

Pay progression within the Specialty Doctor contract

There are two forms of pay progression within the specialty doctor grade: standard pay progression and progression through the higher threshold.

Standard pay progression with require a doctor having participated satisfactorily in the job planning and medical appraisal processes and having completed the employing organisations mandatory training requirements. There should also be no formal capability process or live disciplinary sanction on the doctor’s record. Further details on the requirements and process can be found in the full Terms and Conditions of the Specialty doctor contract.

In order to pass through the higher threshold, doctors in addition should be able to demonstrate an increasing ability to take decisions and carry responsibility without direct supervision.

Doctors should also provide evidence to demonstrate their contributions to a wider role, for example, meaningful participation in or contribution to relevant: 

  • Management or leadership 
  • Teaching and training (of others)
  • Representative work 
  • Audit 
  • Service development and modernisation 
  • Committee work 
  • Innovation

Progressing through the higher payment threshold marks an increase in ‘seniority’ within the career of Specialty Doctor. Working with less direct supervision is a step towards working independently. This is therefore potentially a step towards becoming a Specialist. Likewise, contribution to non-clinical activity in multiple domains is required in the progression to becoming a Specialist or a consultant via CESR/portfolio pathway. Regardless of a doctor’s career aspirations, participation in non-clinical activity needs to be the norm, not the exception. Discussion of supervision arrangements, and progression to non-clinical activity therefore needs to be a normal part of job planning and appraisal.

Involvement in departmental business, leadership, delivering education, audit and quality improvement requires SAS doctors to be invited to departmental business and educational meetings, as well as this being factored into job planning.

Normalising progression in responsibility at this threshold, for example, by progression from a more ‘junior’ to a more ‘senior’ resident rota tier, would mark this threshold in a meaningful way for Specialty Doctors. This would be dependent on both the service need and the doctor in question.

Some organisations have policies for autonomous working for Specialty Doctors, which pre-date the creation of the Specialist role. Going forward, it is potentially more appropriate to normalise progression to a role that features an expectation of autonomy, such as becoming a Specialist (or consultant via CESR), than to normalise having autonomous Specialty Doctors.

The Specialist grade


  • Full registration and a Licence to Practice with the GMC 
  • A minimum of 12 years medical work (either continuous period or in aggregate) since obtaining a primary medical qualification 
  • A minimum of 6 years of which is in a relevant specialty in the Specialty Doctor and/or closed SAS grades (or equivalent years’ experience from other medical grades including from overseas) 
  • Meets the criteria set out in the Specialist grade generic capabilities framework*

The Specialist is the more senior SAS role and is defined as a ‘senior and experienced clinician who will work autonomously’ in a potentially narrower niche than a consultant. For some doctors, this niche may be as wide as that of a consultant colleague, allowing them to potentially progress to a ‘consultant’ non-resident on-call rota. Others may continue to contribute to a resident rota out of hours (OOH). On-call arrangements and frequency need to take into account the contractual protections, cost efficiency, the seniority of the doctors and their wellbeing and career sustainability. Some Specialists may have no OOH component to their role, as is the case for some existing Associate Specialists.

As with the higher payment threshold of the Specialty Doctor contract, becoming a Specialist reflects another progression in seniority, which ideally should be marked by a role that is distinct to Specialty Doctor colleagues. Progression should be visible in order to incentivise it for the next generation of SAS anaesthetists. Specialists also have contractual rights to a job plan and should have SPA time commensurate with their non-clinical activity and seniority.

The niche in which a Specialist works independently will vary from one individual to the next, and be based on the doctor, their background and the service need. Within many anaesthetic departments there are already doctors who are currently badged as Specialty Doctors, who would now be more appropriately be badged as Specialists. The most motivated Specialty Doctors may well have already met the criteria required to become Specialists, and already work independently within their clinical niche. This needs to be identified and addressed between the doctor and their line manager or clinical director.

In order for a Specialty Doctor to become a Specialist within their existing department, organisations need to identify them and create a process by which they are progressed to the right contract for their work. This should ideally be by advert, application and interview; however, there is no reason that these adverts cannot be internal, and a portfolio-based interview undertaken, where the doctor demonstrates they now meet the requirements. All processes for the creation of Specialists should be robust, transparent and fair. SAS doctors should be involved in the recruitment of SAS doctors.

The above is equally true for doctors currently employed within an organisation as ‘locum consultants’. If these doctors are not on the Specialist Register, but are able to work in a senior capacity and meet the Specialist eligibility requirements, facilitating them onto Specialist contract might be appropriate. Doctors may also choose to apply for a Specialist post advertised in another organisation.

*Meeting the requirements of the Specialist Generic Capabilities Framework requires being a well-rounded senior doctor, by demonstrating evidence mapped to the following domains: 

  • Professional values and behaviours, skills and knowledge 
  • Leadership and teamworking 
  • Patient safety and quality improvement 
  • Safeguarding vulnerable groups 
  • Education and training 
  • Research and scholarship

Job planning and rotas

The 2008 and 2021 SAS contracts contain a contractual right to a mutually agreed job plan, in the same manner as the 2003 consultant contract. Broadly speaking, processes should be the same as for consultants, and the resulting job plans should not disadvantage SAS doctors. SAS doctors should have an appropriate and mutually beneficial balance between fixed and flexible sessions, and any arrangements for OOH activity should be agreed, job planned and in keeping with the contractual protections outlined below. Supervision arrangements for doctors who are not working autonomously should be discussed and formalised. Specialty Doctors should have their ongoing development planned for, and sessions within their job plan for this may be included. The mediation processes for situations where agreement cannot be reached are the same as for consultant colleagues.

The 2021 SAS contracts contain contractual protections against excessive OOH working designed to reduce fatigue and make the rota patterns of Specialty Doctors and Specialists on resident rotas more sustainable. These compliment the Association’s ‘Fight Fatigue‘ campaign and the ‘Age and the Anaesthetist’ Guideline.

For doctors working a full shift rota, unless otherwise mutually agreed, the following will apply: 

  • a maximum of four consecutive nights, where at least three hours each night fall between 23:00 and 06:00 
  • a maximum of four consecutive long day shifts 
  • a minimum period of 46 hours before and after transition between day and night shifts

The majority (i.e. no less than 60%) of work should normally take place in standard working hours, which are defined as 07:00 to 21:00 Monday to Friday, rather than OOH, which is all other times, unless otherwise mutually agreed.

Where existing job plans contain in excess of 40% of work in OOH, the employer and doctor will work towards decreasing the percentage each year until a limit of 40% is reached, unless otherwise mutually agreed.

A doctor’s Job Plan will not require work for more than 13 weekends, in whole or in part, (defined for this purpose only as any period between 00:01 Saturday and 23:59 Sunday where work is undertaken during an on call or shift), per year, averaged over 2 years, unless mutually agreed.

Where higher frequency rotas already exist, they will be subject to annual review; unless mutually agreed, the shared intention would be for this frequency to be reduced to 13 weekends as a maximum by a date in the future to be agreed between the doctor and employer.

These clauses potentially should be included in Trust job planning documents, in addition to the other items mentioned elsewhere within the document. While some SAS doctors may choose to remain on their existing contracts in the short-term, all new appointments will be onto a 2021 contract, and any existing SAS doctors may choose to transition to a 2021 contract at any time. It therefore seems appropriate to apply these protections to the entire SAS workforce in anaesthesia. These clauses exist to make rotas safer, because tired doctors make mistakes and fatigue is a patient safety issue.

While some Specialists may work on non-resident ‘consultant’ type rotas, others may contribute to a resident rota longer-term. The age profile of the SAS workforce typically mirrors that of the consultant workforce, and it is important that job planning processes allow discussion of modification of rotas as doctors age to reflect this. Offering a reduced on-call frequency to older doctors, for example, may allow them to pace their careers and remain in our workforce. Likewise, processes for offering transition off an on-call rota as doctors age should be the same for SAS doctors as they are for consultants. Some existing SAS doctors do not contribute to OOH rotas.

The 2008 and 2021 SAS contracts contain a contractual minimum of one programmed activity (PA) of SPA time, specifically for job planning, and meeting the requirements of appraisal and revalidation. Any additional non-clinical activity should carry additional SPA time in the same manner that it would for consultants in the same department. There is no contractual reason why SAS doctors undertaking the same non-clinical work should receive less SPA time for that work. As discussed elsewhere in this document, it is important that SAS doctors have the opportunity to progress their role into non-clinical domains and their SPA allocation should reflect this.

Language and culture

Arguably the single biggest barrier to the viability of alternative career pathways is existing culture, and this is reflected in the language that we use. The Association have produced a style guide for describing types of anaesthetists and staff groups. The following are described as ‘derogatory’ in national documents and should not be used to describe SAS doctors.

‘Non-consultant career grades’ (NCCGs)

This is a historical term that is still used occasionally but should not be. It is self-evidently better to be defined by what you are than what you are not. When describing all SAS doctors, the collective term ‘SAS doctors’ is preferable. Otherwise referring to doctors by their individual contract of employment e.g. ‘Specialty Doctor,’ ‘Specialist’ or ‘Associate Specialist’ is better.


As with the above example, this defines doctors by what they are not and is unhelpful in the context of trying to normalise the importance of ongoing professional development and progression.

‘Middle grades’

Defining the entire cohort as one group of perpetual ‘middle grade’ doctors is unhelpful in the context of the differing levels of seniority, independence and experience described by the 2021 SAS contract reform.

An early career Specialty Doctor, a mid-career Specialty Doctor and a Specialist each have different needs and abilities and should be managed as such. Where it is convenient to describe all the doctors contributing to a given rota, saying ‘doctors on the middle tier rota’ would be acceptable.

‘Service roles’/‘just for service’

The ongoing professional development of every doctor is important. This is reflected in the need for appraisal, revalidation and the formation of annual personal development plans. The 2021 SAS contract reform is reliant on SAS doctors being able to progress and develop, and achieve their individual potential. Although there is a vital service component to the role of any permanent employee, no one is ‘just for service,’ and the future service is increasingly dependent on the professional development of our existing anaesthetic workforce.

Exclusion by omission

The SAS workforce are frequently overlooked, and this leads to an assumption of exclusion when none was intended. Emails and other communications may currently be targeted to ‘consultants,’ or to ‘consultants and trainees,’ without realising that this excludes the Trust’s SAS (and also potentially also its locally-employed) workforce. In the context of offering development opportunity or undertaking non-clinical roles, excluding Specialty Doctors may block their career progression. In the context of offering leadership opportunities, excluding Specialists and Associate Specialists will unnecessarily limit the pool of candidates applying for a role. Each of these may need a concerted effort to change existing culture, involving education of both medical and non-medical leaders with an organisation.

Appendix 1 – Further reading