Comment Blog 20 September, 2023

Unleashing the potential of SAS doctors to ease the workforce crisis

James Hadlow
Associate Medical Director, East Kent Hospitals University NHS Foundation Trust

With the publication of the NHS’s Long Term Workforce plan in early July, the needs and shape of the future workforce has come into sharp focus.  As the NHS continues to recover after the pandemic, an expansion of the medical workforce is needed more than ever to serve an ageing population with more complex health problems. Some areas, such as remote, rural and coastal areas, face even greater challenges with particular difficulties recruiting doctors and a higher level of health need.

Solving the current workforce crisis is complex and will take time – the plan predicts it will take 15 years to put the NHS on a more sustainable footing. Although concrete measures such as an increase in medical school places are welcome and will be important, the sad reality is that this will make no impact to the current situation. Whilst the plan promises to review the projections and workforce needs every 2 years, it lacks detail on measures that can be instigated in the short term to maximise the medical workforce we already have and boost capacity.

One immediate focus should be valuing, developing and rewarding existing doctors to prioritise retention and improve future recruitment. SAS doctors (Specialist and Specialty Doctors) and locally employed doctors are an excellent example of a group that can be supported to boost capacity within the NHS immediately.

SAS doctors and locally employed doctors are a vital and large part of the medical workforce but are too often a forgotten group.  Many are working in senior roles and providing vital clinical services on a daily basis.  Sadly, many are not working at the level they should be and are not offered the same development opportunities as their consultant colleagues and doctors in training. This is often simply due to their grade which negatively impacts morale and retention. This is acknowledged in the plan which highlights that these roles have traditionally been focused on service and that feedback indicates a desire to be involved in other non-clinical activity such as leadership.

Whilst SAS doctors do feature in the plan, it does not set out specific ways to support and develop this group.  Instead, the plan provides broad statements such as NHSEI being “committed to working with DHSC, legislators and employers to support SAS doctors to have a better professional experience, by improving equitable promotion and ensuring options for career diversification”. 

Whilst these statements are welcome these doctors are already active within our healthcare system and with some simple measures could be better supported to develop as senior clinicians working alongside consultant colleagues, boosting capacity and improving patient care immediately. There are three steps that should be prioritised in the short term:

Promote - by use of the specialist grade. This senior grade was created in 2021 to replace the older Associate Specialist grade.  This is a senior grade of doctor which can supplement senior medical rotas which may be important in geographical areas or specialties that face particular challenges with recruitment.  Not only should trusts advertise for specialist grades to improve recruitment on senior medical workforce rotas but NHS organisations should actively seek opportunities to promote and develop existing staff to be appointed to this senior role, improving retention.

Develop – SAS doctors with equitable, rewarding and aspirational personal and professional development opportunities. As stated in the plan, this should include equal opportunities for positions of leadership, teaching and research both locally and nationally. It may also involve relevant reward schemes for this work including national and local financial reward schemes such as, though not without controversy, clinical impact awards.  These measures would demonstrate that SAS careers are valued and improve both recruitment and retention in this vital group.  It would show the SAS grade is not a barrier to a fulfilling and rewarding career both inside and outside of the clinical environment.

Reform to CESR - CESR (Certificate of Eligibility for Specialist Registration) is a GMC regulated process which certifies an individual to work as a consultant in the UK if they haven’t completed a GMC-approved training programme. In the UK, these are formal programmes for ‘doctors in training’. Traditionally, the CESR process has been used for international medical graduates.  However, the process is lengthy and arduous.  The GMC have recently announced much needed reform to the CESR programme from 30th November 2023 where it will become known as the ‘portfolio pathway’.

The new process removes reference to ‘equivalence’ and instead moves to evidence of 'knowledge, skills and experience required for practicing as an eligible specialist or GP in the UK’. The devil will be in the detail as to how different this will be from current processes and much will depend on employing trusts properly supporting these individuals. But if well implemented, it has the potential to open up an entirely new entry route for UK trained doctors outside of formal ‘traditional’ training programmes.  Given the bottlenecks that already exist, the ability for doctors to continue their progression via an alternative GMC-regulated path should be an absolute priority to boost capacity in the short, medium and long term.  Reform of CESR in the form of the ‘portfolio pathway’ has potential to offer a viable and attractive alternative route.

 Whilst the NHS Workforce Plan maps out steps for the longer term sustainability of the medical workforce, more urgent measures are needed in the short term.  SAS and locally employed doctors are already active within our NHS workforce.  With better support, we can truly harness the potential of this group to grow the medical workforce in the short, medium and long term.