The evolving role of SASLED surgeons in cardiothoracic surgery
Cardiothoracic SAS and LE doctors are keen to take on more responsibility through alternative pathways and autonomous practice. Recognition will promote engagement and retention, write Nishan Fernando and Maheshi Gunasekara
The UK medical workforce is changing, with an increase in specialty doctors, (associate) specialists, and locally employed doctors (SASLED). Data from the General Medical Council (GMC) have shown a 46% increase in SASLED numbers between 2018 and 2022. There was a particularly large increase from 2021 to 2022 (11%) and SASLED now account for 28% of licensed doctors.
It is a diverse group of experienced professionals, often operating autonomously, managing complex cases, performing specialised procedures and providing continuity of care. Their diverse roles across acute medicine, surgery and psychiatry highlight their adaptability and broad skill sets, making them indispensable.
With a 63.7% expansion in numbers over the past decade, SASLED are predicted to be the largest contingent of the UK medical workforce by 2030. This underscores their vital role and the need to understand their challenges, and aspirations, especially in specialised fields like cardiothoracic surgery. The reliance on SASLED has implications for NHS workforce planning, training and career development. These doctors must be supported to meet evolving healthcare demands.
In a 2019 GMC survey of SASLED (6400 respondents), most engaged in activities additional to service provision, such as audit, teaching and governance (94.8% of SAS and 88.9% LED). Although 49% of LED and 74% of SAS participated in teaching other doctors, only 6.4% of SASLED were formally recognised through “recognition of trainer status”. Only 55.8% of SAS felt the working environment was fully supportive, compared with 82% of doctors in training. One-quarter of SASLED were planning to take the CESR or CEGPR routes (23% of SAS and 28.7% of LED).
The 2024 State of Medical Education and Practice in the UK: Workplace Experiences Report demonstrated that high workloads and low professional satisfaction were prevalent, saying “Locally employed (LE) doctors, often lack support for learning and development”. It concluded that “professional development opportunities for all doctors will help retention and patient care”.
The GMC workforce review shows that 22% were SASLED (10,349 SAS doctors and 22,576 LE doctors) in England and Wales in 2022. Forty per cent of the “Surgery group” were on the Specialist Register, 25% were doctors in training and 32% were SASLED (9% SAS and 23% LED). Job satisfaction was highest among SAS doctors at 63% (compared with 56% of LED and 50% of doctors in training). SAS doctors were “doing well” (40% versus 25% of all doctors surveyed), and only 24% of SAS doctors were “struggling” (compared with 38% of the whole cohort). Looking at burnout risk, only 22% were categorised as “high risk” and 43% categorised as “very low risk”.
The information from these whole-profession surveys is useful to give us broad-stroke pictures of the workforce and the professional landscape. However, it often lacks the granularity needed for specialty-specific planning. In specialised areas like cardiothoracic surgery, SASLED loss can significantly impact service provision. Therefore, understanding their needs is essential for effective workforce planning and retention strategies.
The evolution of cardiothoracic training, including (more accessible) routes to specialist registration and changes to curriculum and assessment, may better align with SASLED
surgeons’ skills, facilitating their progression and influencing their choices. The Society for Cardiothoracic Surgery (SCTS) data record 51 cardiothoracic units in the UK and 464 consultant cardiothoracic surgeons. The population of SASLED in cardiothoracics is unknown. Our survey aimed to answer this and other questions pertinent to cardiothoracic surgery.
Methods
A concise survey on Microsoft Forms was disseminated to all SCTS members (388) via their weekly newsletter. All members and fellows of the Royal College of Surgeons of Edinburgh who had stated cardiothoracic surgery as their primary specialty (287) were mailed directly. Simple distribution statistics were conducted in MS Forms and Excel.
Results
Thirty-four respondents answered questions on 218 colleagues and 400 outcomes in total.
The respondents were from 23 cardiothoracic units covering England, Scotland and Northern Ireland and one was working in Trinidad and Tobago. Two respondents did not specify a location. This gave us information
on 205 SASLED working in 22 cardiothoracic units in the UK (43% of all units on SCTS). Extrapolating our responses gave 475 SASLED working in cardiothoracic surgery (a similar number to consultants). The number of non-trainee colleagues varied from 1 to 18 per unit (median = 6, mode = 4).
Ninety-four colleagues (43.1%) intended to CESR, the number per unit ranged from 0 to 9 (median = 3, mode = 3). Autonomous practice attracted interest from 87 colleagues (39.9%), 0 to 9 per unit (median = 1, mode = 0).
Cardiac surgery attracted 106 colleagues (48.6%) and thoracic surgery 51 (23.4%), with the remainder looking at the sub-specialties.
Respondents stated that 64 colleagues (29.4%) intended to remain unchanged although whether this was on a short- or long-term basis was unclear.
‘SASLED - Planning FRCS C/Th’ by ‘SASLED-Planning FRCS C/Th’
Discussion
Our cohort indicated a significantly higher proportion of SASLED in cardiothoracic surgery have greater career aspirations compared with those in the 2022 GMC barometer survey, with a greater share wanting to sit the exam and double the number planning to CESR or attain further recognition and responsibility through autonomous practice.
The restriction of General Data Protection Regulations hampered the administration and cross-checking of the constituents of SCTS and RCSEd and the details of who received our survey. Our study had a few other limitations, including the low response rate and the potential unreliability of second-hand information. However, assuming the extrapolation of 475 SASLED, we captured (albeit second-hand) information on 43% of them. This allowed us to look at how these colleagues can be supported in their aspirations and gave us a glimpse of what a future workforce is likely to be. This is the first such specialty-specific survey of SASLED in the literature.
The distinctions between SAS and LED highlighted by the GMC suggest that training initiatives, development programmes and opportunities to progress to CESR, autonomous practice and the specialist grade should be more individualised and target these separate groups differently.
Cardiothoracic speciality training has moved to a run-through-only programme with very competitive entry at ST1. It will take a minimum of eight years to train a new cardiothoracic surgeon. The sub-group analysis by the GMC suggests that trainees and trainers are more stressed, more prone to burnout and less satisfied than SAS and non-trainers. The SAS doctors were more satisfied, keen to progress and, as the GMC states, “retention and development should be given as much, if not more focus and resource allocation, as recruitment”.
Further specialty-specific research and more comprehensive surveys are required to gain a deeper understanding of the SASLED workforce’s needs and aspirations. Close collaboration between the various surgical specialty boards, the Surgical Royal Colleges, specialty-specific societies and umbrella bodies will be essential to address these issues and ensure the continued development and support of this vital workforce.
Conclusions
The survey underscores the ambitious nature of the SASLED workforce in cardiothoracic surgery. Despite limitations in data collection, it is evident that these clinicians are crucial to the NHS and have significant career aspirations. There is a clear need for targeted support and developmental endeavours to enhance their contributions to the healthcare system.
Acknowledgement
The authors thank Steven Kerr, College Librarian at RCSEd, for providing some of the full text articles.
Further reading
General Medical Council. The state of medical education and practice in the UK: Workplace experiences 2024 [Internet]. London: General Medical Council; 2023 Nov. Available from: https://www.gmc-uk.org/-/media/documents/somep-workplace-report-2024-full-report_pdf-107930713.pdf
General Medical Council. Specialty, associate specialist and locally employed doctors workplace experiences survey: initial findings report. London: General Medical Council; [date unknown].
Carty E, Page M. “I brought that up in my appraisal... And my consultant said no.” Structure and agency in specialty and associate specialist (SAS) doctors’ experiences of appraisal. Clin Med (Lond). 2021 May;21(3):E252–6.
General Medical Council. Reference tables about the register of medical practitioners 2023 [Internet]. London: General Medical Council; [date unknown]. Available from: https://www.gmc-uk.org/-/media/documents/reference-tables-about-the-register-of-medical-practitioners-2023_xlsx-103845475.xlsx
General Medical Council. Spotlight on SAS doctors and LE doctors: analysis of Barometer survey 2022 results. Working paper 13. London: General Medical Council; 2023 Oct.
General Medical Council. Specialty, associate specialist and locally employed doctors workplace experiences survey: initial findings report [Internet]. London: General Medical Council; 2020 Jan. Available from: https://www.gmc-uk.org/-/media/documents/sas-and-le-doctors-survey-initial-findings-report-060120_pdf-81152021.pdf
British Medical Association (BMA) Scotland. Recognition, support and development: a charter for SAS doctors and dentists in Scotland [Internet]. 2024. Available from: https://www.bma.org.uk/media/fujppn5z/bma-scotland_sas-charter_may2024.pdf
The Society for Cardiothoracic Surgery. SAC & Training Programme [Internet]. Available from: https://scts.org/professionals/education/career_groups/ntn_trainees/sac_training_programme.aspx
The Society for Cardiothoracic Surgery. Hospitals [Internet]. Available from: https://scts.org/patients/hospitals/
The Society for Cardiothoracic Surgery. Find a Consultant [Internet]. Available from: https://scts.org/patients/consultants/
British Medical Association. New Scottish SAS contracts [Internet]. 2024. Available from: https://www.bma.org.uk/pay-and-contracts/contracts/sas-doctor-contract/new-scottish-sas-contracts
The Royal College of Surgeons of Edinburgh. SAS and Locums Committee. [Internet]. Available from: https://www.rcsed.ac.uk/the-college/leadership-steering/our-committees/sas-and-locums-committee
The UK medical workforce is changing, with an increase in specialty doctors, (associate) specialists, and locally employed doctors (SASLED). Data from the General Medical Council (GMC) have shown a 46% increase in SASLED numbers between 2018 and 2022. There was a particularly large increase from 2021 to 2022 (11%) and SASLED now account for 28% of licensed doctors.
It is a diverse group of experienced professionals, often operating autonomously, managing complex cases, performing specialised procedures and providing continuity of care. Their diverse roles across acute medicine, surgery and psychiatry highlight their adaptability and broad skill sets, making them indispensable.
With a 63.7% expansion in numbers over the past decade, SASLED are predicted to be the largest contingent of the UK medical workforce by 2030. This underscores their vital role and the need to understand their challenges, and aspirations, especially in specialised fields like cardiothoracic surgery. The reliance on SASLED has implications for NHS workforce planning, training and career development. These doctors must be supported to meet evolving healthcare demands.
In a 2019 GMC survey of SASLED (6400 respondents), most engaged in activities additional to service provision, such as audit, teaching and governance (94.8% of SAS and 88.9% LED). Although 49% of LED and 74% of SAS participated in teaching other doctors, only 6.4% of SASLED were formally recognised through “recognition of trainer status”. Only 55.8% of SAS felt the working environment was fully supportive, compared with 82% of doctors in training. One-quarter of SASLED were planning to take the CESR or CEGPR routes (23% of SAS and 28.7% of LED).
The 2024 State of Medical Education and Practice in the UK: Workplace Experiences Report demonstrated that high workloads and low professional satisfaction were prevalent, saying “Locally employed (LE) doctors, often lack support for learning and development”. It concluded that “professional development opportunities for all doctors will help retention and patient care”.
The GMC workforce review shows that 22% were SASLED (10,349 SAS doctors and 22,576 LE doctors) in England and Wales in 2022. Forty per cent of the “Surgery group” were on the Specialist Register, 25% were doctors in training and 32% were SASLED (9% SAS and 23% LED). Job satisfaction was highest among SAS doctors at 63% (compared with 56% of LED and 50% of doctors in training). SAS doctors were “doing well” (40% versus 25% of all doctors surveyed), and only 24% of SAS doctors were “struggling” (compared with 38% of the whole cohort). Looking at burnout risk, only 22% were categorised as “high risk” and 43% categorised as “very low risk”.
The information from these whole-profession surveys is useful to give us broad-stroke pictures of the workforce and the professional landscape. However, it often lacks the granularity needed for specialty-specific planning. In specialised areas like cardiothoracic surgery, SASLED loss can significantly impact service provision. Therefore, understanding their needs is essential for effective workforce planning and retention strategies.
The evolution of cardiothoracic training, including (more accessible) routes to specialist registration and changes to curriculum and assessment, may better align with SASLED
surgeons’ skills, facilitating their progression and influencing their choices. The Society for Cardiothoracic Surgery (SCTS) data record 51 cardiothoracic units in the UK and 464 consultant cardiothoracic surgeons. The population of SASLED in cardiothoracics is unknown. Our survey aimed to answer this and other questions pertinent to cardiothoracic surgery.
Methods
A concise survey on Microsoft Forms was disseminated to all SCTS members (388) via their weekly newsletter. All members and fellows of the Royal College of Surgeons of Edinburgh who had stated cardiothoracic surgery as their primary specialty (287) were mailed directly. Simple distribution statistics were conducted in MS Forms and Excel.
Results
Thirty-four respondents answered questions on 218 colleagues and 400 outcomes in total.
The respondents were from 23 cardiothoracic units covering England, Scotland and Northern Ireland and one was working in Trinidad and Tobago. Two respondents did not specify a location. This gave us information
on 205 SASLED working in 22 cardiothoracic units in the UK (43% of all units on SCTS). Extrapolating our responses gave 475 SASLED working in cardiothoracic surgery (a similar number to consultants). The number of non-trainee colleagues varied from 1 to 18 per unit (median = 6, mode = 4).
Ninety-four colleagues (43.1%) intended to CESR, the number per unit ranged from 0 to 9 (median = 3, mode = 3). Autonomous practice attracted interest from 87 colleagues (39.9%), 0 to 9 per unit (median = 1, mode = 0).
Cardiac surgery attracted 106 colleagues (48.6%) and thoracic surgery 51 (23.4%), with the remainder looking at the sub-specialties.
Respondents stated that 64 colleagues (29.4%) intended to remain unchanged although whether this was on a short- or long-term basis was unclear.
‘SASLED - Planning FRCS C/Th’ by ‘SASLED-Planning FRCS C/Th’
Discussion
Our cohort indicated a significantly higher proportion of SASLED in cardiothoracic surgery have greater career aspirations compared with those in the 2022 GMC barometer survey, with a greater share wanting to sit the exam and double the number planning to CESR or attain further recognition and responsibility through autonomous practice.
The restriction of General Data Protection Regulations hampered the administration and cross-checking of the constituents of SCTS and RCSEd and the details of who received our survey. Our study had a few other limitations, including the low response rate and the potential unreliability of second-hand information. However, assuming the extrapolation of 475 SASLED, we captured (albeit second-hand) information on 43% of them. This allowed us to look at how these colleagues can be supported in their aspirations and gave us a glimpse of what a future workforce is likely to be. This is the first such specialty-specific survey of SASLED in the literature.
The distinctions between SAS and LED highlighted by the GMC suggest that training initiatives, development programmes and opportunities to progress to CESR, autonomous practice and the specialist grade should be more individualised and target these separate groups differently.
Cardiothoracic speciality training has moved to a run-through-only programme with very competitive entry at ST1. It will take a minimum of eight years to train a new cardiothoracic surgeon. The sub-group analysis by the GMC suggests that trainees and trainers are more stressed, more prone to burnout and less satisfied than SAS and non-trainers. The SAS doctors were more satisfied, keen to progress and, as the GMC states, “retention and development should be given as much, if not more focus and resource allocation, as recruitment”.
Further specialty-specific research and more comprehensive surveys are required to gain a deeper understanding of the SASLED workforce’s needs and aspirations. Close collaboration between the various surgical specialty boards, the Surgical Royal Colleges, specialty-specific societies and umbrella bodies will be essential to address these issues and ensure the continued development and support of this vital workforce.
Conclusions
The survey underscores the ambitious nature of the SASLED workforce in cardiothoracic surgery. Despite limitations in data collection, it is evident that these clinicians are crucial to the NHS and have significant career aspirations. There is a clear need for targeted support and developmental endeavours to enhance their contributions to the healthcare system.
Acknowledgement
The authors thank Steven Kerr, College Librarian at RCSEd, for providing some of the full text articles.
Further reading
General Medical Council. The state of medical education and practice in the UK: Workplace experiences 2024 [Internet]. London: General Medical Council; 2023 Nov. Available from: https://www.gmc-uk.org/-/media/documents/somep-workplace-report-2024-full-report_pdf-107930713.pdf
General Medical Council. Specialty, associate specialist and locally employed doctors workplace experiences survey: initial findings report. London: General Medical Council; [date unknown].
Carty E, Page M. “I brought that up in my appraisal... And my consultant said no.” Structure and agency in specialty and associate specialist (SAS) doctors’ experiences of appraisal. Clin Med (Lond). 2021 May;21(3):E252–6.
General Medical Council. Reference tables about the register of medical practitioners 2023 [Internet]. London: General Medical Council; [date unknown]. Available from: https://www.gmc-uk.org/-/media/documents/reference-tables-about-the-register-of-medical-practitioners-2023_xlsx-103845475.xlsx
General Medical Council. Spotlight on SAS doctors and LE doctors: analysis of Barometer survey 2022 results. Working paper 13. London: General Medical Council; 2023 Oct.
General Medical Council. Specialty, associate specialist and locally employed doctors workplace experiences survey: initial findings report [Internet]. London: General Medical Council; 2020 Jan. Available from: https://www.gmc-uk.org/-/media/documents/sas-and-le-doctors-survey-initial-findings-report-060120_pdf-81152021.pdf
British Medical Association (BMA) Scotland. Recognition, support and development: a charter for SAS doctors and dentists in Scotland [Internet]. 2024. Available from: https://www.bma.org.uk/media/fujppn5z/bma-scotland_sas-charter_may2024.pdf
The Society for Cardiothoracic Surgery. SAC & Training Programme [Internet]. Available from: https://scts.org/professionals/education/career_groups/ntn_trainees/sac_training_programme.aspx
The Society for Cardiothoracic Surgery. Hospitals [Internet]. Available from: https://scts.org/patients/hospitals/
The Society for Cardiothoracic Surgery. Find a Consultant [Internet]. Available from: https://scts.org/patients/consultants/
British Medical Association. New Scottish SAS contracts [Internet]. 2024. Available from: https://www.bma.org.uk/pay-and-contracts/contracts/sas-doctor-contract/new-scottish-sas-contracts
The Royal College of Surgeons of Edinburgh. SAS and Locums Committee. [Internet]. Available from: https://www.rcsed.ac.uk/the-college/leadership-steering/our-committees/sas-and-locums-committee
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