What is a SAS doctor? - demystifying the terminology
Within the world of medical
careers, it is fairly easy to define
a trainee or a consultant, and it
is likely that if you are either of
these things, your work ID badge
will say so, and reflect your level
of experience. However, doctors
who are neither consultants nor
trainees make up 20% of the
workforce [1] and have a wide
range of job titles. Many members
of this group would identify
themselves as ‘SAS’ doctors, but
very few will have an ID badge
that says this. The purpose of this
article is to explore the history
of the grades, demystify the
terminology, and explain why it is
important to use the correct job
titles and contracts.
The term SAS doctor has been around for at least two decades.
Originally it was short for ‘Staff grade and Associate Specialist’, but
also grouped together other nationally recognised grades including
clinical medical officers, hospital practitioners and clinical assistants.
The clinical assistant grade was first introduced in 1964, and in 1981
was developed into the associate specialist grade, with both existing
for a time. These roles existed partly in response to an oversupply
of senior registrars, and these doctors worked at a very senior
level. Entry onto the associate specialist grade historically required
more experience than the other SAS contracts, and many associate
specialists continue to work on rotas alongside consultants. In 1998
the staff grade was introduced to slot below the associate specialist
grade, this time in response to an oversupply of more junior trainees.
Nationally, the number of SAS doctors rose sharply from 490 in 1991
to 2640 in 1999 as a result of changes to training. There are now
more than 10,000 SAS doctors working in the UK.
In 2008 a new SAS contract was launched, with most grades
replaced by the specialty doctor grade. New entry to the associate
specialist grade was closed, with pre-existing associate specialists
transferred to a new associate specialist contract. There was a
window of opportunity for existing staff grades to apply to be
regraded and become associate specialists, but then the grade was
closed to further applicants. There are many associate specialists still
working, but current specialty doctors have no formally recognised
opportunity to transfer, despite many working at a comparable level.
Unsurprisingly, many specialty doctors feel strongly about this. In
areas and specialties where recruitment of SAS doctors is difficult,
many trusts have introduced their own ‘Trust associate specialist’ jobs
to attract applicants. These commonly use the associate specialist
pay-scale, but with a variety of model contracts, and terms and
conditions.
Now that there are very few staff grades remaining, SAS is now
more commonly unabbreviated to ‘Specialty doctor and Associate
Specialist’. Another new national contract to replace the associate
specialist role is currently being negotiated, which will apparently
have another new name. We can only hope that when it appears,
it features the initials A and S, so we can continue to repurpose the
acronym.
In addition to the nationally recognised grades outlined above,
trusts are able to appoint doctors onto local contracts with nonstandard
terms and conditions. These locally employed doctors
may find themselves on a contract modelled on current or historical
versions of trainee contracts, or something else entirely. The holders
of such posts may have ID badges that say ‘Trust doctor’, ‘Trust
grade’, ‘Clinical fellow’, ‘Senior clinical fellow’, ‘Locum registrar’ and
many others. The use of the word ‘fellow’ is particularly problematic.
Locally employed clinical fellows are often very junior doctors, but
the term is more commonly used to describe someone who has
achieved fellowship of a college. Situations could easily arise where an inexperienced doctor is assumed to be doing a post-CCT
fellowship, and expected to work beyond their expertise.
Ideally, these locally employed doctor posts should be for
short-term roles with a planned end point, as any doctor
expected to become a long-term member of a department
should be offered a specialty doctor contract. However, because
these contracts have no national protections, employers may
preferentially recruit to them, and there is evidence that this
is happening. Between 2012 - 2017 the number of doctors
on temporary contracts increased by 40%, and the number of
locally employed doctors now exceeds the number of specialty
doctors and associate specialists combined. This rise in their
number has led to many organisations debating whether these
locally employed doctors are best considered as SAS doctors,
or as a separate group. At the Association of Anaesthetists
we have taken the pragmatic view that this group are best
represented by the SAS Committee unless individuals have
needs that are better met by the Trainee Committee. The SAS
Committee at the RCoA has taken a similar view.
Several other older terms are still used. ‘Non-consultant career
grade’ is occasionally still encountered as a catch-all term, but
most would now prefer SAS doctor. It is self-evidently preferable
to be defined by what we are than by what we are not.
Sometimes SAS doctors are also referred to as ‘middle grades’,
which many take issue with. A large number of SAS doctors
are SAS by choice, and may have decades of experience
and expertise as well as extended roles or organisational
responsibility. Middle grade is seen by some as a derogatory
term, hinting at mediocrity when we are aspiring to excellence.
As a result, it is BMA and NHS Employers policy not to use this
term, but to refer to this group of doctors as SAS or by the
individual contract they are employed on.
In Ireland, the equivalent of the SAS doctor is much less well
defined and there is no specific national contract. There are,
however, many doctors in Ireland who are neither consultants
nor working in a recognised training programme for the same
reasons as in the UK. Collectively these doctors are usually
known as ‘non-consultant hospital doctors’ (NCHDs).
To summarise, there are many job titles out there. The only
nationally recognised SAS grades are associate specialist and
specialty doctor; however do not assume that speciality doctors
are less capable. Locally employed doctors on non-standard
contracts may be labelled with many names, but these offer
little to indicate experience or ability. If you have colleagues in
your department on short-term contracts such as these, try and
support them to become speciality doctors.
Robert James Fleming
Elected Council Member, Association of Anaesthetists
Specialty Doctor, Nottingham University Hospitals
Thomas James
Chair of the SAS Committee, Association of Anaesthetists
Specialty Doctor, Harrogate District Hospital
Twitter: @robjimfleming; @SAS_gas_Thomas
References
- Health Education England. Maximising the potential: essential
measures to support SAS doctors, 2019 https://www.hee.nhs.uk/
sites/default/files/documents/SAS_Report_Web.pdf (accessed
5/8/2020).