Journal : vol 34 : Jul/Aug : Recommendations and Standards

Towards an improved career structure for non-consultant career grade doctors

Prepared on behalf of the Royal College of Physicians' Standing Committee for Non-consultant Career Grade Doctors by its chairman Ghislaine Davies MCRP, Associate Specialist in Gastroenterology, High Wycombe J R Coll Physicians Lond 2000;34:355-6

The term 'non-consultant career grade doctor' (NCCG) encompasses a heterogeneous group of doctors working in hospital medicine under the various titles of associate specialist, staff grade, trust doctor and non-GP clinical assistant. They have become the 'lost tribe' of doctors, providing significant service at middle grade and senior levels in the NHS but separated from the main career pathways and opportunities for professional development.

Background

The associate specialist grade was in existence for many years before the staff grade was introduced following publication in 1986 of the White Paper Hospital medical staffing: achieving a balance1. It was a personal regrading for doctors who were committed to a career in hospital medicine but were unable to complete higher medical training or, having completed medical training, were unable to take on a consultant appointment. Posts lapsed with retirement and consultants were often appointed in their place. Associate specialists had their own committee in the BMA with appropriate representation, and jealously guarded their position as senior hospital doctors with a professional contract similar to that of consultants.

However, there were also other grades of doctors who had embarked on a hospital career but were unable to progress. They became stuck as senior house officers (SHOs), long-term locums or clinical assistants with little hope of advancement or professional development.

Unintended consequences of Achieving a balance

The introduction of the staff grade was an attempt to rectify the situation, but it has brought its own problems. Its purpose was to make up for the shortfall of doctors in middle grades following the limitation of the numbers in training, and thereby 'find a way of providing essential support to consultants in the acute specialties without training doctors for non-existent jobs'1. It was also thought that the staff grade would provide a secure job for doctors unable to progress to further training for personal or domestic reasons. The intention was for staff grade doctors to be recruited at a junior level, the minimum requirement for entry being three years' experience as an SHO. In practice, most staff grade doctors were more senior and posts were often taken up by experienced overseas doctors desperate to find employment. Trusts seized the opportunity to create staff grade posts to meet workforce requirements following the restriction of junior doctors' hours. Moreover, once the 10% ceiling was lifted on staff grade posts, the concern that trusts would appoint staff grade doctors to do senior work in preference to creating consultant posts became more acute.

Promotion from staff grade to associate specialist is not a natural progression. The intention was that the doctor would remain in a staff grade post for the rest of his/her working life. There are, therefore, many senior doctors in middle-grade posts with no hope of advancement who are feeling frustrated and undervalued. In retrospect, it was naive to expect doctors to be happy to remain in a middle grade for the whole of their career. Finally, there are no external checks on the competence of these doctors.

The impact of the specialist list

The creation of the specialist list took the lid off the simmering pot of resentment by excluding many NCCG doctors who did not fulfil the necessary criteria. By the time the Royal Colleges created a system of assessment, further training within a limited time was impractical for many NCCG doctors, who were left trapped at a relatively junior level in Britain and are now unable to move elsewhere in Europe. This took place at the same time that junior doctors in training had unprecedented access to and protected time for education, in stark contrast to the lot of NCCG doctors.

Problems with the staff grade

Two previous reports from RCP2,3, the SCOPME report4, and more recently a report from the Centre for Postgraduate and Continuing Medical Education at the University of Nottingham5 have identified the main problems with the staff grade:

  • poor career advice before entry
  • variable work content, sometimes at an inappropriately high or low level
  • variable supervision
  • poor educational opportunities
  • no external checks on competence
  • limited or non-existent career progression and professional development.

Recommendations of the new RCP report on NCCG doctors

A report by the Royal College of Physicians' Standing Committee for NCCG doctors entitled Recommendations for an improved career structure6 was published recently. It incorporates suggestions made in the previous college reports, and in addition recommends ways of implementing them and monitoring progress. The main recommendations are:

  • all NCCG doctors should have good career advice
  • NCCG doctors must be made aware that a move back into training is the exception
  • appointment committees for NCCGs must be properly constituted with college representation
  • there must be a job plan and description before appointment
  • there must be time available for CME and audit
  • the work must be suitable for the grade and on-call commitment must be in keeping with a permanent appointment
  • in each deanery there should be a college officer, usually an NCCG doctor, working with the regional advisor to advise on issues related to NCCG doctors and attend general professional training (GPT) visits to gather information
  • each staff grade doctor should have an education plan and should be assessed regularly. There should also be a mechanism to monitor each doctor's progress
  • incentives to progress need to be created and could be linked to optional points or progress to the associate specialist grade
  • all medical NCCG doctors, whether college members or not, should be associated with the RCP for the purposes of CME, clinical governance and revalidation.

A 'back door' to becoming a consultant?

There are concerns that the recommended changes will encourage doctors to take up NCCG posts as a back door to consultant posts. To become a consultant, a doctor must have accreditation with CCST and the only way to obtain this is through recognised specialist registrar training posts. There is no back door. However, young doctors may need to mark time while waiting for specialist registrar posts to become available and should not be disadvantaged by spending a short time in an NCCG post.

Conclusion

With the current UK manpower situation, NCCG doctors are likely to be here to stay. Like all doctors they need to have career pathways and be integrated into a system of continuing professional development and regular assessment. This can lead only to improved job satisfaction for these doctors and ultimately better patient care.

References

  1. Department of Health and Social Security. Hospital medical staffing: achieving a balance. London: DHSS, 1986.
  2. Royal College of Physicians. Staff grades: towards a better future - a way forward. London: RCP, 1993.
  3. Royal College of Physicians. Review of the impact of the Royal College of Physicians' report on staff grade doctors with further recommendations. London: RCP, 1996.
  4. Standing Committee on Postgraduate Medical and Dental Education. Meeting the educational needs of staff grade doctors and dentists. London: SCOPME, 1994.
  5. Baker M, Williams J, Petchey R, Flett A. Staff grade doctors and the consultant ladder: falling off or stepping off? Hospital Medicine 1999;60:824-8.
  6. Royal College of Physicians. Non-consultant career grade doctors: recommendations for an improved career structure. London: RCP, 2000.

 

This page last updated on October 5, 2000