Staff, Associate Specialist and Specialty Doctors (SAS) role.
Written by Dr Anthea Mowat MMEd, MRCA, RCPath(ME), MB ChB, FHEA, MWF Honorary Secretary and former SAS grade Anaesthetist
Within the NHS, there is a large group of doctors who are in neither consultant nor training grade posts. There are mostly in the group of Staff, Associate Specialist and Specialty Doctors, known collectively as SAS grades, and comprising about 20% of the secondary care permanent medical workforce, according to NHS Digital figures from August 2021. The SAS grade staff are on nationally negotiated terms and conditions of service, and are an important group of senior doctors within secondary and community care. There is a high proportion of both female doctors and of international graduates within the SAS grades.
There is also another significant group of Locally Employed doctors (LEDs) on local contracts which do not have national terms and conditions, and which may be of fixed term duration. Names of the LED role may include trust doctor, clinical fellow. The post may be for a specific purpose eg post-CCT fellowship or CT3 equivalent. Employers of longer-term LEDs contract holders should be encouraged to convert these staff onto formal SAS grade roles.
The SAS grades have been in existence in some form since the inception of the NHS, more latterly including the now closed Staff Grade and Associate Specialist Grade. The current SAS grade contracts are Specialty Doctor introduced in 2008, and the new Specialist Doctor Grade introduced in 2021 in England, Wales and Northern Ireland. Negotiations for the SAS Specialist Grade contract in Scotland continue in 2022 though they are likely to closely mirror that in the other nations.
The minimum entry requirements to enter the Specialty Doctor grade are 4 years full time postgraduate experience, with at least 2 years in the relevant specialty or equivalent. It is therefore open to doctors who may be earlier in their career, as well as to more experienced staff.
For the new more senior Specialist Doctor Grade, the doctor should have completed a minimum of 12 years’ experience since qualification, with a minimum of 6 years in a specialty doctor role (or equivalent) within the relevant specialty, and should also meet the generic capabilities framework for the grade, which is highlighted in a template within the Specialist Grade Appointment Guidance as agreed by the British Medical Association (BMA) and NHS Employers.1 The role involves a greater degree of experience and responsibility, and will often involve working independently. It is similar to the now closed associate specialist grade.
Contracts are based on programmed activities (PAs) which are usually in blocks of four hours work, with the majority being clinical, but a minimum of 1 PA being for supporting professional activities designated for job planning, and to meet the requirements for appraisal and revalidation. Terms and conditions of the contracts can be found on the SAS pages of the NHS Employers website Terms and conditions of service for specialty doctors (England) 2021 | NHS Employers and Terms and conditions of service for specialist grade (England) 2021 | NHS Employers.
The purpose of the 2021 contracts is to enable better career progression and job satisfaction within the SAS grade, and to enhance recruitment and retention within the role.
Reasons for choosing SAS grade posts
There are many reasons why doctors may choose to have a SAS grade role. These include
- Flexibility in work-life balance and working hours
- Geographic stability at an earlier stage of career, without having to rotate posts
- Flexibility in work without having to meet the requirements of a formal training programme
- Opportunity to gain experience and skills at a pace which suits the individual
- Opportunity for a portfolio career to fit with interests, and with different roles
- Focus on patient care, and possibly subspecialist work
- More time to study for postgraduate examinations
The GMC undertook a survey of SAS and LED grades in 2020 2 which showed that the main route within the SAS grade is development and progression while remaining in the grade, but with some SAS grades undertaking Certificate of Eligibility for Specialist Registration (CESR) to gain this recognition on the GMC specialist register, and other SAS Grades returning to training grade posts.
Recognition and Development
Historically SAS grade posts were rather neglected with few opportunities for development and progression. However a realisation that it is necessary to provide facilities for a rewarding career in order to recruit and retain these important staff members has led to improvements, and the chance of a more rewarding role.
Royal Colleges and specialist societies have improved their representation of SAS grade staff, with many now supporting both SAS committees and representation on their Councils. Several Colleges/Societies are producing supportive documentation for SAS staff, such as the Association of Anaesthetists which first produced a “SAS Guidance” handbook in 2007, and which is now on its fourth edition since 2020 3.
In 2014, the BMA, the Academy of Medical Royal Colleges (AoMRC), Health Education England (HEE) and NHS Employers produced a “Charter for Staff and Associate Specialist and Specialty Doctors” 4 in England. This document was replicated in the devolved nations. The charter called for proper support and recognition of the role, including minimum conditions which could be expected for contracts, job planning, support, development, and involvement in organisations. While uptake was initially slow, the SAS charters are now accepted in many more places of employment and are being implemented.
Health Education England recognised that there remained a need for SAS career development and set up a working party which, together with NHS Improvement, produced a document in 2019 on “Maximising the Potential: essential measures to support SAS doctors” 5, which highlighted shared commitments by many stakeholder organisations to enable satisfying careers for SAS doctors, in areas such as career development opportunities, involvement in education, facilitated return to training for those who wish to do so, a clear role in workforce planning, and improved access to funding to aid career development.
Alongside this work, in 2020 a paper “SAS doctor development: summary of resources and further work” 6 was produced by AoMRC, HEE, BMA, NHS Employers and British Dental Association. This document gives short guidance on the SAS charters, job planning, continuing professional development, autonomy, CESR, extended roles, management roles etc, uses vignettes, and clarifies the expectations on Health Boards, Medical Directors, SAS clinicians, and medical staffing/human resources.
AoMRC have also produced a document in 2021 called “SAS – a viable career choice” 7, which looks at extended roles for SAS grade staff, recognition and reward, benefits for all stakeholders of making SAS a viable career, and makes recommendations for stakeholders.
All the above shows how the role of SAS doctors has now come to the fore, and been given due recognition of how to ensure it is a rewarding role.
Tips and Strategies
SAS grade posts can enable a rewarding and viable career, but it is useful to consider how to make the most of the grade.
The national SAS contracts include provision for taking study leave of up to 30 days over 3 years. This is usually booked in line with departmental rotas guidelines, but should not be unreasonably withheld. A study in 2014 by Mowat and Schofield looked at the awareness and usage of study leave 8, and showed that 98% of respondents took 16 days or less of the 3 year entitlement. The funding associated with taking study leave is determined locally rather than nationally, and the level provided does vary between employers. In the study, only 77.4% of respondents were aware of having study leave funding available, and it was often not fully utilised. As all doctors are expected to keep up to date with professional development, it is a good strategy for SAS grade staff to utilise as much as possible of the study leave time and funding to which they are entitled.
Health Education England provide SAS development funding to employing Trusts in England, with similar arrangements in the devolved nations. These funds are provided to regions to be utilised via SAS Tutors, associate deans, or a nominated individual looking after SAS staff. There is a formal application process for this, and it is separate from study leave funding. It can be utilised for clinical, managerial or educational development. Examples where SAS staff have used this funding include clinical placements to assist with CESR applications, and for postgraduate qualifications in education, although it is usually not permitted to be used for postgraduate College examination fees. In addition to this recurring SAS development funding, and as part of the 2021 contract implementation, there has been the provision of some extra funding from NHS England and NHS Improvement to employing trusts for SAS staff continuing professional development for the years 2021/22 and 2023/24 only.
There may be opportunities to specialise in a specific area within the post, especially as the postholder becomes more experienced within their department. There are examples of SAS staff being appointed as the clinical lead for subspecialist areas.
Annual appraisal and revalidation is a requirement of employment. The appraisal process can be very useful not only in reviewing achievements over the previous year, but also an opportunity to explore ideas for future professional development. An agreed objective from a realistic post-appraisal development plan is more likely to be supported for award of study leave or development funding, with the added incentive of expectation that it will be undertaken.
As well as the advantages of personal appraisal, SAS staff can also train to become appraisers, which is very rewarding. NHS Employers and the GMC have clarified that SAS staff can not only become appraisers, but that they can appraise all levels of medical staff. There are examples of SAS staff leading the entire appraisal system for Trusts.
Non clinical role:
There are often chances to undertake useful roles outside the clinical arena. This may be within the department such as rota co-ordinator, journal club co-ordinator, multi-disciplinary team meeting organiser, or lead for induction of new staff.
All SAS staff will undertake teaching informally, but there are often opportunities to do more formal teaching in student or in trainee programmes. Additional roles in the education sphere include training to become a clinical or educational supervisor.
Training in leadership and management helps develop useful skills, which can be used in everyday work, or to apply for formal roles within the department or the Trust. There are examples of SAS grade staff who have become clinical directors and associate medical directors.
It can be very rewarding to represent your SAS colleagues. This may be locally such as SAS Tutor, setting up a SAS forum, or sitting on the Trust Local Negotiating Committee (LNC). Several SAS grade staff have become chairs of their LNC. There may be regional or national opportunities to represent colleagues in Colleges, on specialist societies, or within the BMA. Some SAS staff have become examiners for Colleges.
When working in the SAS grade, it is helpful to be aware of what your own personal priorities and drivers are, and how that interacts with your role. When developing your career, consider applying for available roles, and have self-belief. Do not think “why me?” but consider “why not me?”. But also do not be downhearted if not successful at getting one role: instead look for other opportunities that may present themselves.
Unfortunately some departments are not as supportive of SAS grade staff as would be hoped. A survey of SAS grade staff by the BMA showed that approximately 40% of incumbents had experienced or witnessed bullying and harassment. This led to a report from the BMA in 2018, entitled “Bullying and Harassment: how to address it and create a supportive and inclusive culture” 9, which gives strategies on how to deal with this issue. Local policies should be followed to raise any issues, but it is also helpful to utilise the network of Freedom-to-Speak-Up-Guardians within the Trust, as they are happy to listen to any concerns.
Having a career as a SAS grade is a much more rewarding and viable option than used to be the case. The support from Trusts, and from organisations such as GMC, HEE, NHS England (and the equivalents in devolved nations), NHS Improvement, and NHS Employers now means there is more awareness of the importance of the role of SAS grade staff, and of the need to ensure there are ongoing opportunities for developing within the role.
1 NHS Employers: SAS contract reform 2021-Specialist Grade template person specification sas-paper-3-specialist-grade-template-person-specification-2021.pdf (nhsemployers.org) (https://www.nhsemployers.org/sites/default/files/2021-06/sas-paper-3-specialist-grade-template-person-specification-2021.pdf)
2 General Medical Council: Specialty, associate specialist and locally employed doctors workplace experiences survey: initial findings report, 2020. GMC Council 180107 (gmc-uk.org) (https://www.gmc-uk.org/-/media/documents/sas-and-le-doctors-survey-initial-findings-report-060120_pdf-81152021.pdf)
3 Association of Anaesthetists: The SAS Handbook 2020 The_SAS_Handbook_2020.pdf (anaesthetists.org) (https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/The_SAS_Handbook_2020.pdf?ver=2020-01-07-101915-670)
4 NHS Employers: a charter for staff and associate specialist and specialty doctors, 2014. SAS-Charter-for-SAS-Doctors.pdf (nhsemployers.org) (https://www.nhsemployers.org/sites/default/files/2021-06/SAS-Charter-for-SAS-Doctors.pdf)
5 Health Education England: Maximising the Potential: essential measures to support SAS doctors, 2019. SAS_Report_Web.pdf (hee.nhs.uk) (https://www.hee.nhs.uk/sites/default/files/documents/SAS_Report_Web.pdf)
6 Academy of Medical Royal Colleges: SAS doctors development : summary of resources and further work, 2020. SAS_doctor_development_guide_1020.pdf (aomrc.org.uk) (https://www.aomrc.org.uk/wp-content/uploads/2020/10/SAS_doctor_development_guide_1020.pdf)
7 Academy of Medical Royal Colleges: SAS – a viable career choice, 2021. 251121_SAS_A_viable_career_choice.pdf (aomrc.org.uk)
8 Mowat A, Schofield S. Study leave usage by SAS grade staff. Royal College of Anaesthetists: Bulletin 2014; 83: 9-10.
9 British Medical Association: Bullying and Harassment: how to address it and create a supportive and inclusive culture, 2018. bma-bullying-and-harassment-policy-report-oct-2019.pdf (https://www.bma.org.uk/media/1100/bma-bullying-and-harassment-policy-report-oct-2019.pdf)