BMJ  2003;327:961-964 (25 October), doi:10.1136/bmj.327.7421.961

Paper

Recruitment of doctors to non-standard grades in the NHS: analysis of job advertisements and survey of advertisers

¹ BMJ, London WC1H 9JR

Abstract

Objectives To estimate the proportion of advertised non-consultant hospital posts that do not conform to nationally recognised terms and conditions of service and to investigate why these posts exist, who fills them, and what the doctors in such jobs do.

Design Analysis of job advertisements and a cross sectional survey of advertisers.

Setting Job advertisements in one of the leading UK publications listing hospital doctor vacancies (BMJ Careers).

Results Nearly a quarter of non-consultant posts advertised in the two study periods (23% and 21%) were for non-standard grade posts. A questionnaire was sent to the medical staffing officer for each post. Of 430 questionnaires sent out 192 (45%) were returned. 98 trusts said they advertised non-standard grades because there was no more funding from the deanery for approved posts and 75 because service needs could not be met by doctors in training grades. In 132 posts (69%) the post holder would be required to do on-call work, and 50 advertisers (26%) required on-call duty for 1 in 5 or more frequently, which would conflict with the European Working Time Directive. 131 advertisers (68%) expected the posts to be filled by doctors from outside the European Economic Area.

Conclusions Non-standard grade posts are mostly being created to meet service requirements when there is no more funding for standard training posts and are expected to be filled by doctors from overseas. Doctors in such posts can be more easily exploited and their careers hindered. The Department of Health's annual census should include non-standard grade doctors.

Introduction

The number of doctors in the United Kingdom who are appointed to hospital posts that don't conform to the standard NHS grades is rising, as trusts try to comply with restrictions on working hours in the NHS's "new deal" for doctors in training and the European Working Time Directive.^1-3 We define non-standard grade posts as non-consultant jobs that do not conform to the recognised hospital grades (box 1). Doctors appointed to non-standard grades—which tend to be described as though they are training grades—are usually called trust doctors, because they are employed on terms and conditions set by individual trusts. However, a variety of other job titles are used, such as hospital specialist, assistant surgeon, and clinical fellow registrar grade. Terms of employment and education are not standardised.

The actual number of doctors holding non-standard grade posts is not known, as the Department of Health does not include them in its annual census.¹ However, an unsubstantiated statement in a recent health department report said that "separate analysis shows that there are around 5000 doctors on local contracts, for whom the national grade is unclear."⁵

The problem with non-standard grade posts is that they can be confusing and may exploit doctors unfamiliar with the UK system. For example, time spent in non-standard posts cannot be counted towards basic specialist training.⁶ Some doctors may not realise that posts are not recognised training grade posts. Many of the job titles do not clearly convey the type of job the doctors will be doing. Also, applicants need to know where they will fit into the medical hierarchy; doctors holding such posts are seen as "lacking in status and recognition," and there is a "feeling that they are overlooked in terms of professional development, study leave and discretionary points."⁵

We investigated the proportion of advertisements for non-standard grade posts in BMJ Careers, the BMJ supplement that advertises almost all hospital posts in the United Kingdom. We also looked at the reasons why these posts exist, who fills them, and what the appointed doctors do.

Methods

To investigate the proportion of non-standard grade posts placed in BMJ Careers and the range of job titles advertised we took a random sample of eight issues published in the 12 months to 9 September 2002. We took two issues from each quarter, as the type of posts advertised may vary across the year. We compared all non-consultant job advertisements with the standard grades (box 1) and recorded the job titles for all the posts whose details did not meet the standard definitions (box 2).

Box 1: Standard NHS hospital grades for non-consultant doctors Training grades House officer Senior house officer Specialist registrar Senior registrar (entry to this grade is now closed) Career grades Staff grade doctor Associate specialist Clinical assistant Hospital practitioner The health department's Guide to Specialist Registrar Training requests that advertisements for approved standard posts contain the words "The postgraduate dean has confirmed that this programme has the required educational and staffing approval."4 The BMA also advises every week in BMJ Careers that junior doctor hospital posts should contain this statement prominently.

Box 2: Job titles advertised in BMJ Careers that are not recognised by the BMA Admissions ward officer Anaesthetic fellow Assistant surgeon ASTO fellowship Bone marrow transplant coordinator Breast screening physician Clinical fellow registrar grade Clinical fellow SHO level Clinical fellow Clinical lecturer Clinical liaison assistant Clinical research fellow Clinical research associate Clinical specialist Clinical trust fellow Clinical tutor Combined clinical and research fellow Coronary care officer Dialysis fellowship Doctor for service ECMO clinical fellows ECMO fellow post SpR training equivalent Emergency medical officer Examination preparation trust fellow Fellow Foundation fellow Foundation officer Hand fellow Hepatobiliary fellow Hospice doctor Hospice physician Hospital fellow Hospital specialist Intermediate SHO Joint trust grade Junior clinical fellow Junior clinical fellow SHO equivalent Junior clinical medical officer Junior clinical surgery fellow Junior doctor Junior medical officer Junior physician Junior research fellow Junior surgeon Junior trust doctor Locum trust house officer Locum trust SHO Medical casualty officer Medical clinical fellow Medical officer Medical practitioner Middle grade SHO Night trust doctor Non heart beating kidney donor transplantation fellow Orthopaedic fellow Paediatric fellow PICU fellowship Post fellowship post Resident medical officer Resident paediatric officer Senior clinical fellow

We then surveyed advertisers to investigate why they were advertising non-standard posts, who they expected to fill these posts, and what they expected the post holders to do. For each new advertisement for a non-standard grade post published in the four issues of BMJ Careers from 11 January to 1 February 2003 we sent a questionnaire (see bmj.com) to the medical staffing officer responsible for the post. Most advertisers were contacted by post. We telephoned non-responders up to three times, and if they still didn't respond we sent the questionnaire again. Finally, the BMJ's editor and the director of BMJ Careers sent a letter to the chief executives of non-responding trusts requesting their help in ensuring that questionnaires were completed.

Results

Of the 4949 non-consultant jobs advertised in the random sample of eight issues of BMJ Careers published in 2001-2, 1150 (23%) did not conform to the standard NHS grades. In the four issues between 11 January and 1 February 2003, 430 (21%) of the 2073 non-consultant jobs advertised were for non-standard grades. We received 192 completed questionnaires (45%) from these advertisers.

Factors preventing recruitment to standard training grades—The most frequently reported reasons that respondents gave for their not being able to recruit to a standard grade were that there was no more funding from the deanery for approved posts (98 respondents (51%)) and that service needs could not be met by doctors in standard training grades (75 (39%)). Nineteen respondents (10%) said that the posts could be filled only by doctors with limited GMC registration.

Type of post—Of the 192 advertisements 161 (84%) were for substantive (non-locum) posts. Eighty five posts (44%) had been newly created. Twenty nine posts (15%) were advertised because the previous post holder had moved to a senior job, 16 (8%) because the previous post holder had moved to a junior job, and 57 (30%) because the previous post holder had left for other reasons. Fifty four (64%) of these new posts were created to fill gaps in service when doctors in training were unavailable.

On-call commitments—Of the respondents 132 (69%) said the post holder would be expected to take part in regular on-call duty, and 50 of these respondents said the on-call duty would be at least 1 in 5 (being on call for 24 hours every five days and one in five weekends).

Working level—Respondents expected that the non-standard grade doctors would work at the level of various standard grades: 41 (21%) said the post holder would share an on-call rota with consultants, 73 (38%) with specialist registrars, 80 (42%) with senior house officers, 30 (16%) with staff grade doctors, and eight (4%) with associate specialists.

Teaching commitments—Sixty three respondents (33%) expected their post holders to teach medical students, 38 (20%) to teach house officers, 26 (14%) to teach senior house officers, and three (2%) to teach specialist registrars. No teaching commitment was expected by 106 respondents (55%).

Educational needs—One hundred and sixty five respondents (86%) said a session would be allocated to the educational needs of the post holder, though 19 of these said they expected that the post holder would miss teaching time because of clinical commitments.

Recruitment from overseas—One hundred and thirty one respondents (68%) said they were expecting to recruit someone from a country outside the European Economic Area. Most respondents said they expected it was likely or very likely that the posts would be filled by doctors trained outside the United Kingdom (166 (86%)), by doctors coming to the United Kingdom for training (129 (67%)), or by doctors who had failed to find training posts (152 (79%)).

Discussion

Just under a quarter of non-consultant posts advertised in two different study periods were for non-standard grade posts. Half of such posts are created to meet service requirements when there is no more deanery funding for recognised training posts. More than two thirds of the doctors filling these posts are required to do on-call work, and a quarter are on call for 24 hours every five days and one in five weekends, or more frequently, breaching the European Working Time Directive. Most advertisers expect the posts to be filled by doctors from outside the European Economic Area.

Strengths and limitations of the study
The response rate to the survey was low, even though we used recognised techniques to improve completion rates, such as reply envelopes, follow up reminders, and personal letters to trusts' chief executives.^{7 8} The low response rate may be due to the sensitive nature of the questions. Furthermore, because we sent one questionnaire for each non-standard post advertised, some medical staffing officers received several questionnaires.

Medical staffing officers may not have known all the information asked for in the survey. Ideally, we should have sent questionnaires to the person responsible for creating the post, but the limited information given in the advertisements made it difficult to identify who this person was.

BMJ Careers advertises most but not all hospital posts in the United Kingdom. Also, our survey was conducted at the start of the year, and it is possible that jobs advertised at this time differ from those advertised at other times of the year. However, the proportion of non-standard grade jobs in our four week survey in January 2003 (21%) was similar to the proportion of these posts advertised in the random sample of eight issues published in the 12 months to September 2002 (23%).

Implications for policy makers
The NHS's new deal for doctors in training recommends that "trusts should not use job titles that may mislead applicants because of their apparent similarity to recognised NHS training posts."² Our study shows that misleading job titles are widely used by trusts. Most respondents to our survey expected that these posts would be filled by graduates from non-European Economic Area countries looking for training posts. Overseas graduates may not appreciate the difference between standard and non-standard training grade posts, especially when titles such as "junior clinical fellow SHO equivalent" are used. Thus they may be unaware that, unlike their training grade colleagues, they are not entitled to educational supervision.

What is already known on this topic Hospital doctors in the United Kingdom are being recruited to posts that do not conform to NHS standard grades, but the number of these posts is not known Little is known about why non-standard posts exist, who fills them, what the post holders do, and whether the post holders are being exploited What this study adds Nearly a quarter of advertisements for non-consultant jobs in the United Kingdom are for non-standard grade posts These posts are created to keep the service going when there is no more funding for recognised training posts Trusts advertising the posts expect them to be filled by doctors from outside the European Economic Area Working conditions for a quarter of non-standard grade posts conflict with the European Working Time Directive

It may be that non-standard grade doctors are being exploited. A quarter of post holders were expected to participate in on-call duty for 1 in 5 or more. These doctors are protected under the European Working Time Directive and should not be working more than an average of 48 hours each week. Posts that entail an on-call rota of 1 in 5 or more cannot fulfil the directive's requirements.

Conclusions
Doctors in non-standard grade posts should be included in the Department of Health's annual census to show employment trends. Cohort studies following the career paths of trust grade doctors would show whether these doctors are being sidelined.

---

See special issue of Career Focus and Editorial by Cooper and Burr

The questionnaire that was sent to advertisers appears on bmj.com

We thank all the medical staffing officers who participated, Helen Barratt for data entry, and Gaby Shockley for administrative help.

Contributors: RM and JC initiated the study, SD and SS designed the study, SD conducted the study, and SS and SD analysed the data and interpreted the results. All authors helped to write the paper. SD is guarantor for the paper.

Funding: The BMJ Publishing Group's research budget.

Competing interests: Advertisements in BMJ Careers are a major source of funding for the BMJ Publishing Group. Because the study was carried out by members of BMJ staff, the paper was assessed and peer reviewed entirely by external advisers. Members of the BMJ editorial staff were involved in the final decision on whether to publish the paper.

Ethical approval: The BMJ's ethics committee.

References

1. Cooper N, Burr B. Are trust doctors the new lost tribe? BMJ 2002;325: 491.[Free Full Text]
2. Department of Health. Junior doctors: the new deal. London: HMSO, 1991.
3. Council Directive 93/104/EC. Official Journal of the European Community 1993;L307:18-24. (http://europa.eu.int/eur-lex/en/consleg/pdf/1993/en_1993L0104_do_001.pdf).
4. Department of Health. A guide to specialist registrar training. London: DoH, 1996.
5. Department of Health. Choice and opportunity: modernising medical careers for non-consultant career grade doctors. London: DoH, 2003.
6. Norcliffe G, Finlan C. Non-standard grade posts. BMJ 2001; 323(suppl): S2.
7. Dillman DA. Mail and telephone surveys: the total design method. New York: Wiley, 1978.
8. Edwards P, Roberts I, Clarke M, DiGuiseppi C, Pratrap S, Wentz R, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002;324: 1183.[Abstract/Free Full Text]

(Accepted September 25, 2003)

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