Specialist grade 2021 – success stories, challenges and the future

The NHS, which was introduced in 1948, was made up of hospital services, primary care services and community services. The medical workforce of the hospitals in the 1950s comprised consultants and doctors in training. The Platt Report of 1961 acknowledged there was a gap in this workforce model with regard to providing and sustaining delivery of clinical care in the hospital setting. It proposed a ‘medical assistant grade’ but did not define details of career progression avenues, which would be the legitimate aspiration of any section of the workforce.

Between the 1960s and 1980s, workforce demands in the hospital setting led to creation of the associate specialist grade, a senior clinical role within the team led by the consultant. These doctors, typically with several years of experience, delivered high-quality care with well-recognised levels of clinical autonomy and identified areas of specialism. The title of associate specialist was formally introduced in the NHS in 1984. The staff grade was introduced in 1988 in an attempt to address a bottleneck identified in the career progression pathway for medical staff – it was junior to the associate specialist grade, which was already in existence.

The lack of a comprehensive workforce strategy in the NHS resulted in the emergence of a plethora of medical roles and designations in the NHS between the 1960s and the 2010s. These include: clinical assistant, part-time medical/dental officer, hospital practitioner, clinical medical officer, senior clinical medical officer, staff grade, associate specialist pre-2008, associate specialist 2008, specialty doctor 2008, doctors and dentists in training pre-2016, doctors and dentists in training 2016, consultant pre-2003 and consultant 2003.

The British Medical Association (BMA) negotiated the consultant contract in 2003 and, in the wake of this and over the next five years, endeavoured to consolidate the other career medical grades into a ‘standardised’ structure. Unexpectedly, the associate specialist pre-2008 grade (MC01) was closed, and an associate specialist 2008 grade (MC41) was opened for a limited window of 12 months. A new unified grade – referred to as specialty doctor 2008 (MC46) – was created.

In the 2000s, NHS efforts to introduce digitisation by way of the National Programme for Information Technology (NPfIT) represented a major initiative to attempt to quantify the delivery of care. This then enabled data mining programmes, such as Dr Foster’s Healthcare Intelligence Portal, to analyse clinical productivity in the late-2000s. However, these data were skewed because the information was bundled into Finished Consultant Episodes (FCEs), without taking into account independent activity delivered by associate specialists (MC01 and MC41).

The SAS Charter, developed jointly by the BMA, NHS Employers, Health Education England and the Academy of Medical Royal Colleges, was published by the BMA in December 2014. Significantly, it resurrected the concept of the independent functional status of SAS doctors by formulating the ‘autonomous practitioner’ role. Crucially, this had been lost when the associate specialist (MC01 and MC41) grades were closed between 2008 and 2010. Unfortunately, the implement-ation of the SAS Charter was patchy and, in 2019–20, the BMA embarked on yet more rounds of negotiations. Thus emerged the specialist grade 2021 (MC70). This stipulated a minimum of 12 years of postgraduate experience with the requirement of six years in a relevant specialty, which could include experience gained as specialty doctor or in a closed SAS grade.

Experiences

Here we present a snapshot of the experiences of some of our colleagues. They are now specialists save one, who works autonomously and is awaiting a final decision regarding moving to the specialist grade pending workforce and job planning. One of our colleagues was reluctant to relate their experience publicly but admitted privately that their journey had been a struggle. We have kept the responses generalised rather than name the individuals.

Was the passage from specialty doctor to specialist easy or difficult?

For one of our colleagues, the experience was fairly easy. They were employed in a role of locum consultant and, whilst seeking a more permanent role, preferred the transition to specialist with active support from the department.

However, it was not as easy for the other colleagues interviewed. For one, the paperwork required to prove they were ‘autonomous enough’ to be graded as such took about a year to sort out. Another colleague mentioned that senior leadership in their department and their manager provided active support. However, the process was largely held up in 2020/21 by the logistics of reopening the trust-employed associate specialist role, which at the time was closed. They then transitioned to specialist with encouragement from the trust. 

Do you believe the specialist role should be natural career progression for the specialty doctor?

Most colleagues interviewed agreed that if the candidate is adequately qualified to take on the challenges of autonomous practice, then transition should be smooth and structured. It should not be dependent on variable local interpretation, but should be recognised as a natural step for the candidates who demonstrate the required capabilities.

As rightly pointed out by one of our colleagues, there are inconsistencies across the regions, primarily because of limited understanding of the grade, financial constraints, workflow vacancy management and hierarchical mindsets within the organisation. Only a minority of colleagues felt the specialist role, which is akin to the previous ‘associate specialist’ role, should be advertised in NHS Jobs.

What do you think are the benefits of the specialist role?

Everyone agreed that the role was fair recognition for an experienced clinician, which gave them the chance to work autonomously, improved work satisfaction and helped workforce retention. In addition, the specialist grade (MC70) has a higher pay scale, which recognises the autonomous role of the specialist appropriately.

It was rightly pointed out that there were departmental benefits in reducing the dependency on locums for waiting list initiatives and in supporting service continuity and leave cover. Besides, it also meant that there would be a cohort of experienced clinicians who would take on leadership roles, such as in education, supervision and governance, should they choose to. Patients would benefit directly, with experienced clinicians ensuring safety and high-quality care.

What are the hurdles faced at trust and departmental level in transitioning to the specialist role?

Most colleagues felt supported by their department, and agreed that it was necessary to have strong backing from the senior leadership in their department. It was pointed out that this was not always the case and that there were often departmental hurdles reflecting a traditional, hierarchical mindset – SAS doctors were considered to be ‘service providers’ while the role of ‘decision-makers’ was perceived as being restricted to consultants.

It was also mentioned that trust priorities were mostly financial. Sometimes there was a distinct lack of interest in promoting the specialist role because it was perceived as paying more money for the same work already being done by the ‘de-facto’ autonomous clinician.

The future

The specialist grade 2021 (MC70) was a step in the right direction. Some trusts have seized this opportunity to create a continuum of career progression roles from LED (locally employed doctor) at CT level to specialty doctor and then to the specialist grade, thereby forming a ‘notional single-spine’ for an alternative route for career progression, as in the Basingstoke model. Furthermore, provision of recognised autonomous practitioner status, enabling ‘attribution’ of activity through the mechanism of the NHS Commissioning Data Set ver 6.3 (CDS ver 6.3), could mesh in synergistically with parallel avenues facilitated by locally developed arrangements, such as the Bristol Urology Portfolio Pathway Rotation model.