The anaesthetic workforce – a SAS perspective
In early 2021, new contracts for SAS doctors were launched in England, Wales and
Northern Ireland (Box 1). In this article we describe the alternative career pathway that
these contracts provide, and hopefully convince you that recognising and developing
this pathway is an important part of future workforce strategy.
The current workforce
Anaesthetists who are neither consultants nor in a formal
training programme accounted for more than 2500 doctors, or
approximately 20% of anaesthetists, in the 2020 RCoA medical
workforce census report [1]. Doctors find themselves in this
group for a variety of reasons. It may be temporary as some
of these doctors may choose to re-renter a formal training
programme, or more permanent. This group is often treated as
one cohort, but is more usefully considered as two, that is ‘SAS
doctors’ and ‘Locally-Employed Doctors’.
Coming first to SAS doctors, these are mostly permanent
members of their departments working on nationally agreed
contracts. They have contractual rights to a job plan, SPA time
and pay progression. For the majority, this is their career. Most
of these doctors currently working are ‘Specialty Doctors’,
which was the only national SAS contract available for new
entrants between 2009 – 2021. The ‘Associate Specialist’ and
‘Staff Grade’ contracts are both now closed to new entrants,
but there are still many of these doctors in employment. The
new senior role for SAS doctors of ‘Specialist’ was part of the
2021 contract package, and there are also now a handful of
recently-appointed SAS Specialists.
We appear to have accepted at some point as a profession that doctors in this part of the workforce would not be offered the national contract for their work.
The second group are Locally-Employed Doctors. Members
of this broad group have a myriad of titles, including ‘Clinical
Fellow’ and ‘Trust Doctor’. These doctors work under the terms
of Trust-derived contracts, often based on a version of the
trainee contract. These jobs are frequently short term, and
without the permanence or contractual protections enjoyed
by SAS doctors. Across all specialties, this group of doctors is
the single most rapidly rising part of the workforce. Some of
these doctors are on planned short-term posts outside formal
training, gaining specific competencies or clinical experience,
before resuming training or applying for a consultant role.
However, many others are now in this position longer-term.
In the opinion of the authors at least, it would be more
appropriate for the latter group of doctors to be employed
as Specialty Doctors. We appear to have accepted at some
point as a profession that doctors in this part of the workforce
would not be offered the national contract for their work. This
is deeply concerning, and ought to be discussed far more than
at present.
Since the census was published, changes to the training
programme have created an additional group of CT3-
equivalent doctors who are also temporarily outside of formal
training, and on Trust-based contracts. It is possible that, for the
first time, the number of locally-employed anaesthetists now
exceeds the number of SAS anaesthetists in the UK.
The alternative pathway
The new contracts outlined above create an obvious, and very
viable alternative pathway to a more conventional medical
career. A doctor currently working as a clinical fellow might,
for example, become a Specialty Doctor. While working as a
Specialty Doctor, it should be normal for this doctor to acquire
experience, knowledge and skill, and to develop into an
independent, expert anaesthetist within their clinical niche.
This doctor should then have the opportunity to have this
progression recognised by applying for a Specialist post when
they meet the required criteria. Forward-thinking departments
could even anticipate future workforce gaps and develop
future senior colleagues to fill those gaps. Support for this
route should now be a normal expectation of being a Specialty
Doctor. Alternatively some doctors may choose to gather the
evidence required to enter the Specialist Register by CESR
in order to apply for a Consultant post. This too should be
facilitated.
For the promise of this pathway to be fully realised, these
doctors must be supported to develop, and these contracts
must be used appropriately. It is important that we reverse the
trend of this cohort of doctors being inadequately recognised
and rewarded for the work they do. As previously discussed,
there are a considerable number of locally-employed doctors
who would meet the eligibility to be Specialty Doctors. There
are also a number of experienced Specialty Doctors who meet
the eligibility and fulfil a role that would be more appropriately
badged as Specialists. This needs to now be recognised
and addressed, with these doctors being facilitated into the
appropriate contracts for their work.
If we truly care about the future of the workforce and retention of every anaesthetist, strengthening this alternative pathway must form part of the long term strategy within the Specialty.
Doctors must be supported to develop their careers within
a SAS role, and progression must be recognised when it has
occurred. To borrow a phrase from psychiatry, SAS careers need
‘parity of esteem’ with a more conventional medical career.
The trope that SAS doctors are ‘just for service’ is historical,
inaccurate, and goes against multiple national publications
relating to the grade. It is also counterproductive, as denying
SAS doctors the opportunity to reach their full potential self-evidently
comes at a greater eventual cost to the service.
There is a workforce crisis across the whole specialty. The RCoA
Anaesthesia – fit for the future
report in 2021 revealed that
25% of consultants and 20% of SAS anaesthetists are planning
to leave the NHS in the next five years [2]. The 2020 Census
stated that over 90% of departments had at least one consultant
vacancy. The real gap, taking account of the extra anaesthetists
that would be required to meet demand, was 11.8% for
consultants and 18.4% for SAS doctors. SAS anaesthetists are an
essential part of the solution to this problem, and they deserve
appropriate recognition and respect. By developing this cohort,
the number of future senior doctors does not need to be tied
entirely to the number of training posts. If we truly care about
the future of the workforce and retention of every anaesthetist, strengthening this alternative pathway must form part of the
long term strategy within the Specialty. This is a workforce issue.
Rob Fleming
Specialty Doctor Anaesthetist
Elected Board Member and Chair of SAS Committee
Emma Wain
Associate Specialist Anaesthetist
Elected Board Member
Twitter: @RobJimFleming; @Anaes_SAS
References
- Royal College of Anaesthetists. Medical Workforce census
report 2020, 2020. https://rcoa.ac.uk/training-careers/working-anaesthesia/workforce-planning/medical-workforce-census-report-2020 accessed 16/2/2022.
- Royal College of Anaesthetists. Anaesthesia – fit for
the future, 2021. https://rcoa.ac.uk/sites/default/files/documents/2021-09/Respected_valued_retained2021_0.
pdf accessed 16/2/2022.
Further reading