Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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The exploitation of non-standard grades - a victim's perspective.
- Arvindan Veiraiah (24 October 2003)
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An old problem:a new solution
- Anthony Morgan (24 October 2003)
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Where to next?
- David P O'Hagan (25 October 2003)
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The terminology never mentioned - racism!
- Tapas Goswami (26 October 2003)
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Warning signs were there
- Faiyaz Mohammed (27 October 2003)
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Reality
- Jaspreet Singh SOMAL (27 October 2003)
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Time to act
- V R Alladi (27 October 2003)
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Demand and Supply
- Kamal Kumar Mahawar (28 October 2003)
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Trust Grades - A Positive Experience
- Alistair R Ramsden (28 October 2003)
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Who is in charge of our NHS?
- Umesh Prabhu (28 October 2003)
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Recognising the place of non-standard grade posts in the NHS
- Annielle Hung (28 October 2003)
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Re: Reality
- Arvindan Veiraiah (28 October 2003)
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One Lonely Voice - The fall of standards
- Klaus Lander (29 October 2003)
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Bridging the gap between SHO and SpR
- Jonathan C Epstein, Kajendran Balasubramaniam, (same appointment) (30 October 2003)
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Re: One Lonely Voice - The fall of standards
- Arvindan Veiraiah (30 October 2003)
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All are equal but some are more equal !Equal pay for equal work-not for doctors?
- A.J Shyam Kumar (30 October 2003)
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The problems of Trust Grade Doctors
- Darell Tupper-Carey (10 November 2003)
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The Unknown/Forgotten Martyrs
- Dr Bakhtawar S. Khattak (3 January 2004)
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Arvindan Veiraiah, Research Registrar in Cardiology Royal Sussex County Hospital, Brighton BN2 1ES
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Dear Sir/Madam, I have been a Registrar in Cardiology in non-training posts for 2&1/2 years now. These included 4 LAS posts and one Trust Registrar post in the first year. Even the last-mentioned Trust Registrar post was merely assumed to be so - I was not even given a contract. I am currently employed in a post wherein the employers themselves are not sure about whether they need to ensure training. I have had troubles with a virtual absence of training in two LAS posts, excellent training coupled with extreme exploitation as well one act of quite bad bullying (as stated to me by the Medical Director of that Trust)in another post, and poor work structure and impossible expectations in a third post. Despite these difficulties, I cannot convince myself that the people who manage these posts set out to exploit either myself or other unfortunates from South Asia. I have discussed, argued and fought for improvements for myself and others like me. I belong to the Black & Minority Ethnic Network in the place where I am currently employed. Even after discussing these issues in such fora, I am not convinced that employers or the British public want to exploit us just so that they can save a few pounds or to save themselves a few hassles. In my opinion, the problem is one of a lack of vision; and a lack of belief that anything can be done by individual initiative. The beaurocratic nature of the NHS also means that managers at the Trust level are still waiting for all decisions to be taken at the national level. I believe that the main problems are as follow: 1. A lot of junior doctor posts in the UK are short-term. This is a great tool for exploitation as employees who question unfair practices can be ignored at the time of extension and references can be unflattering - thereby destroying the employee's career without any active intervention on the part of the employers. Also, the short term of contact makes it difficult for employers to recognise the strengths and weaknesses of employees and makes it impossible to empower them. Another fallout of this illogical preference for short-term posts is that employing trusts are kept busy with a massive workload in dealing with recruitment, particularly as they also get a large number of applications due to the lack of permanence for most junior doctors. 2. The selection system is strongly biased towards references. This is particularly disadvantageous once a candidate enters a short-term post. Also, this is inherently disadvantageous to all minority groups. Even when not racist, referees react negatively to their cultural and linguistic differences with employees, even though these differences may not impact on patient care in most cases. The old boy networks are very strong in the UK mainly for this reason. 3. Excessive faith in the relatively new Calman training scheme despite its own deficiencies. Any training outside this system is looked down upon, even though training in specific topics may be just as good elsewhere. This issue is very complex and needs a lot of work to improve matters. I have the following suggestions: 1. All employers should be encouraged to employ 90% of their staff in posts lasting at least 18 months. 2. All junior doctors should have a recognised mentor/supervisor. 3. The new appraisal system should be welcomed by all junior doctors. 4. The deficiencies in the Calman system should be discussed more openly. 5. Appraisal should also involve evaluation of posts and supervisors by employees. 6. Trusts and employers should try and provide more just systems in their own workplaces without waiting for Government initiatives. The benefit of these changes will not be just fairness for all. Even if the system were unfair, let it be at least empowering. Let those who have skills, knowledge and a burning desire to succeed despite all difficulties be given a chance to use their abilities in the interest of patients and the NHS. Competing interests: The author has undergone exploitation in several non-training posts and reforms to this system could directly benefit him. |
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Anthony Morgan, Consultant Thoracic Surgeon Bristol Royal Infirmary BS2 8HW
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When I was a surgeon in training,there was a huge imbalance between posts needed for training and posts required to replace existing consultants.More were trained than needed and it was everyman for himself (apologies to the fairer sex who were not represented at that time). Today with the European Working Time Directive, more doctors are needed for the service component than ever before.In our unit we have nine consultants and at the moment one SpR with a NTN.There is one type two training post and that is it.The rest of the service posts are the imaginatively called clinical fellow variety which although they receive a full training from me and my colleagues,not one minute is recognised by the authorities. My solution would be to regrade these posts as training posts,recognised for the final Specialty Fellowship examination but not leading to a CCST.This would make it possible for specialists to train here and to take home a worthwhile final specialty examination which the intermediate surgical examinations are not.In this way,people could be trained with a specific goal in mind without flooding the system with specialists who cannot be employed. Competing interests: None declared |
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David P O'Hagan, GP registrar Birkenhead
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This article, the related editorial, the careers section all contribute to the confusion surrounding all hospital medical posts which are not consultant or training posts.The suggestion that none of these doctors wanted to comment is a continuation of the patronising prejudice demonstrated in the articles. There are many hospital doctors who are not in training and are not consultants who have a great deal to say about these issues. That a freelance journalist was unable to find them tells us more about him and his commisioning editor than about those doctors. All hospital doctors who are not in permanent consultant appointments, all doctors who are not in specific training Spr,SHO, or PRHO jobs; all these are represented by the Staff Grade and Associate Specialist committee of the BMA. This is a full committee representing their interests. Where are the comments from them? The two other main commitees JDC and CCSC are represented . The problem is not that people are unwilling to talk it is that there are too many people unwilling to listen. One significant problem in employing standard staff grades or associate specialists is that the pay-scale lags so far behind that of SHOs particularly since banding. This prevents a simple conversion of all the titles to standard ones. Despite the DOH representatives comments suggesting they were doing all they can, this is a situation they have been made aware of by the BMA, the Doctors and Dentists Pay Review Body, and an expensive Price-Waterhouse survey. Their reply was 'we will think about it'; not one year but two, and the patience of many NCCG doctors in standard grades has run out. The market has also moved on creating even more non-standard non-training non-consultant grades. Whether in historical posts, such as CMOs or in neologistically titled trust grade posts these doctors are not exempt from the EWTD and are thus limited to 48hrs unless this right is waived by the individual. To respond to Rhona MacDonald's 'should we start a campaign to ban all non-standard posts?' I thought that this was a BMA policy of some years standing which had fallen down due to the continuing advertising of these posts in the BMJ. William Burr feels that proposals for competency based training would somehow exclude trust grades whilst including standard NCCG doctors. The only way that is possible is by writing down the prejudices held nebulously at present. Appraisal and revalidation do not exclude any doctors. That all doctors go through these is a requirement of continued practice. Competence must be demonstrated in these processes; to ignore it to fail to reward demonstrated ability is to fail the individual doctor and to fail the system. This is the crime that is prejudice. A positive approach to this situation requires a radical review of the medical career pathway for hospital doctors in a similar way to that of Calman. This time it needs to take account of the service needs of a National Health Service, as well as those of training, and to provide solutions for those doctors who are not interested in or able to progress through Royal College defined hoops. The PMETB is perhaps the governments attempt to circumvent the old established order, maybe they are on the right lines. Competing interests: None declared |
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Tapas Goswami, Locum Associate Specialist, ENT St. Bartholomew's Hospital. WC1N
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Well, doesn't this article make it clear the known fact that these posts are created to exploit the non-UK originated doctors?It only demonstrates the "institutional racism" deeply ingrained in the National Health Service. I wish we get a BBC documentary on the racism prevalent in the National Health Service, like the "Secret Policeman". Competing interests: The author worked for five years as a Trust Registrar, not recognised for training. |
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Faiyaz Mohammed, Specialist Registrar -Gastroenterology Trafford General Hospital, Moorside Road, Davyhulme, Manchester, M41 5SL.
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The BMJ has dedicated several articles in this week’s issue to the problems of trust doctors and non-training posts. My only concern is that these problems should have been tackled at least two years ago as warning signs had been present even before then. Norcliffe and Finlan (1) highlighted several negative points and disadvantages about these posts in November 2001 and I also mentioned the negative impact these jobs were having on training in a rapid response letter (2) in December 2001. Who knows – if more attention had been paid to our concerns back then maybe we would not be facing the crisis we see today. 1. Norcliffe G, Finlan C. Non-standard grade posts. BMJ 2001; 323: S 2-3 (24 Nov) 2. Mohammed F. How the working time directive is affecting training. http://bmj.com/cgi/eletters/323/7324/1266 #18114, 17 Dec 2001 Competing interests: None declared |
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Jaspreet Singh SOMAL, none B24 9AA
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Rise in number of trust grade posts in last few years is not a coincedence or a result of increase in patients coming to hospital. The reason is actually "bitter truth". Obviously trust grade doctor is appointed only because he is willing to work as trust doctor and does understand the conditions and shortcomings of post. Still he signs a contract. Why? Today if I go to 10 consultants in NHS and ask them about their views regarding trust level SHO posts, 9 out of 10 say that it's not a good option but just an alternative to unemployment. Story starts like this: An overseas doctor comes to UK, passes some exams and desperately searches for a job. But job process is an open market competition and he falls short of money, wastes lot of time, suffers many setbacks and becomes frustrated. Now if he sees any post he starts applying for that and forgets about minuteness of "trust grade". He finally accepts the post although it's not approved by deanery and royal colleges. Personally I don't feel that it's a bad thing or an option as arguments in favour of trust grade post can be given. For example it is a post created for benefit of doctor who is finding it hard to secure a training post and it provides nice pay and NHS stamp on the CV. Hence Trust grade posts are not an unfair affair but a genuine move as long as doctors working on these posts are not forced to work out of way. Success of this move lies in joint efforts of trusts, consultants and junior doctors. Competing interests: None declared |
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V R Alladi, anaesthetist Tameside General Hospital OL6 9RW
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Dear Sir I read all the articles on trust-grade ( non-standard grade ) doctors in BMJ 25th October 2003 in the Career focus section. The term ‘non’ seems cropping up as if they are a non-entity or an insignificant group of doctors. The big picture regarding trust doctors is just emerging, the editorial mentions. Trust doctors have been pleading authorities for years and every hospital doctor is aware of the problem. It also mentioned that we are creating an underclass of doctors out of trust grade doctors. No doctor is underclass and it is the system that is trying to make them underclass. What ignorance and what a discrimination? I was shocked and dismayed to see that everybody except a non- standard doctor took part in the discussion and I was even more shocked and dismayed that your journalist Peter Cross could not get any trust doctor to take part in the discussion. What kind of journalistic world is he living in? Where did he look for these doctors?! So much has been said about SAS doctors over the years and especially recently and yet nothing constructive is being done. As far back as I can remember, which is more than twenty eight years, these doctors existed in NHS and so much could have been done for them. There has been shortage in the number of applicants for consultant posts since expansion of consultants was contemplated. Is it not common sense that first thing to do is to increase or provide enough places for higher professional training. Otherwise where do consultants come from? It does not make any sense economically or in man-power terms. There was never a proportionate expansion of places for higher professional training to match consultant expansion. Besides, there have always been doctors in non-standard grades working in NHS who were committed to their respective specialities and had necessary qualifications from the Royal Colleges and some with necessary experience. These doctors have been willing to improve their careers and skills and serve as specialists in NHS hospitals if only opportunities were there. Nobody took any interest in them. After twenty five years we are still discussing what to do! What would these doctors do if there were no opportunities for further training and still wish to continue in hospital practice? Become a non career grade or SAS or non-standard doctor. Or change the speciality or even enter general practice. What else can or could they do? A large proportion of doctors of this grade come from the Indian sub- continent. Many of them are already experienced and have post-graduate qualifications. Indeed they come for further training and eventually go back home. It is but natural for any doctor to continue to work where one can utilise skills and knowledge to the best and lead a good quality life. However all these years, these doctors were only used and abused to maintain service in hospitals. They were made to cover trainees and consultants at the same time irrespective of their experience, knowledge and age. They have been working resident on call at nights to fulfil their contractual terms even after fifty years of age. What infuriates and frustrates me is that the authors of the articles seem to have realised only recently that trust grade doctors are exploited, and were given non- standard contracts and that the working conditions have been unfair. The majority of SAS doctors were from overseas and could not for obvious reasons raise their voices nor express their opinions freely. It was jealousy and superiority complex on the part of consultants to keep their status that prevented them from progressing. Now, many British doctors are opting for these jobs for different reasons. It gives them flexibility without the full responsibility. It helps those who fail to get or are not interested in getting post-graduate qualifications and still wish to continue in hospital practice. This has made a difference to the strength of the argument and now these doctors are able to raise their voices with added vigour. There has been such reluctance on the part of colleges, department of health and trusts to deal with this problem all these years. One of the main principles of any manpower organisation is to improve conditions for existing staff and make best use of resources available. So far, possible solutions to the manpower shortage among doctors have been unbelievably unreasonable. Trusts are prepared to pay high rates to locum staff to fill gaps in the service and hire specialists from abroad that are totally unfamiliar with workings of NHS. It makes sound economic sense to provide appropriate in-house training to these trust doctors to fulfil all the requirements to be accredited. Department of Health has not got an account of number of doctors appointed to this grade. Who controls staffing in NHS? Mind boggles. Majority of trust grade doctors only need one or two years of top up training to get accredited. This will improve quality of service to patients and the lives and careers of these doctors. This can easily be done on the basis of flexible training, day release courses and in-house training. These doctors are already carrying out duties of a consultant in district general hospitals independently day in and day out. It will not be difficult to upgrade their skills. It will make sound economic sense. It is lot cheaper than spending money to pay agency locums. Now some of the new consultant appointees who probably had four to five years of specialist registrars’ training are finding difficult to cope with demands of work, especially in surgical specialities, as they do not have quite the confidence to operate only because of shortage of experience. They will also face same problems of in future as they may not have chance or enough time to develop new skills or refresh their knowledge. It is extremely difficult to do whilst working full time. Colleges are trying to introduce appraisals and competency – based assessments and even exit exams for the trust grade doctors to allow re- entry into specialist register. Working full time and resident, how can they get time to better their skills or undergo training. How many consultants over the age-group of forty would like to take exams and undergo competency based assessments, I wonder. It is unfair and unrealistic. There should be formal but tailor-made assessments taking into consideration skills and experience of these doctors individually. One could assess work done by them day in and day out for a start. It was originally discrimination and jealousy on the part of consultants that prevented these doctors from progressing. They were and are being used and abused to cover trainees and consultants at the same time without providing any opportunities to improve skills. But now, there is a need and there are resources in the form of trust doctors who are eager and enthusiastic to better themselves. What else people want? What is everybody waiting for? There is so much talk and no action. Competing interests: None declared |
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Kamal Kumar Mahawar, Trust grade Research/MSc SHO, Department of Surgery, Arrowe Park Hospital, Wirral CH49 5PE
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Dear Sir/Madam, Authors of this study have raised several very valid arguments. There are certain fundamental issues which however need to be understood. First and the foremost of which is that we cant have every junior doctor ultimately progressing to consultant level. Second issue is that with the new working time directives, trusts are going to have to rely more and more on trust doctors to meet the shortfall. I think the simple rule of demand and supply can be applied to this context too. There simply is too much demand for a very few consultant posts. With the present severe shortage of consultants, one cant emphasize enough upon the need for more training numbers. But even a huge increase in training numbers can not absorb all the junior doctors that there are and hence the need to create other options and make them more attractive. For example, though I am on a trust doctor job at the moment, I share only as much responsibility as the training grades and get as much oppurtunity as the training doctors to further my career. In fact the trust I work for has sponsored me to pursue a MSc in the speciality of my choice and they also give me all the time required to pursue it. I have quite consciously accepted the tag of a trust doctor in bargain and am not convinced that I have got a wrong deal. There thus is an urgent need to make non- consultant options more desirable and attractive by such financial and career incentives. Efforts should also be made to reduce the requirement of junior doctors(which in any case cant be met at the present levels) by recruiting more and more people into health related services at various levels.I dont see why a trained nurse cant share a significant amount of work that I do as a senior house officer. Competing interests: None declared |
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Alistair R Ramsden, Clinical Research Associate Midwest Urology Research Foundation, 4646 N Marine Drive, Suite A5500, Chicago, IL, 60610, USA
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It comes as no surprise that doctors trained in foreign healthcare systems are mislead by the questionable wording of advertisements for non- training grade posts. Linguistic subtlety and a naivety of our training structure leave foreign applicants vulnerable to abuse. For the canny trainee, however, a trust grade post can provide a positive experience. Bottlenecks do exist between SHO and SPR and, with the dearth of non-rotational training-approved SHO jobs available (particularly in the surgical specialties), a trust grade can do more than simply provide financial sustenance until one's number comes up. Approved or not, these posts do provide opportunities in training and education; the difference is that as a trust grade these opportunities must be sought. It is a difficult stage of one's career to find the motivation to do this. Many junior doctors have taken these posts by default and may be well on their way to abandoning all hope of a career in their chosen specialty. They should remember though, that Trust Grade posts are poorly defined and not well understood. Rather than perpetuate the image of the Trust Grade as a sidelined, disillusioned SHO heading for career obscurity, redefine it as an opportunity to grow in skill and knowledge whilst chomping at the heels of the SPRs. I applied for a trust grade post about eighteen months ago. I have a reasonably strong CV so my interviewer looked a little bemused and asked why I was applying for the post. "I just want to get a bit more experience before I start applying for SPR jobs" [Translation - I haven't got a snowball's chance in Hell of getting an SPR job and I need to keep a roof over my head while I'm trying.] When he gave me the job he was almost apologetic but he gave me the following advice, “Make of this job what you will. If you want to sit on your arse in the mess for the next six months, no-one’s going to care. But if you’re prepared to make the effort, go to clinics, learn to operate and push yourself forward, then there are lessons to be learnt.” And that was the most important lesson of all. Competing interests: None declared |
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Umesh Prabhu, Consultant Paediatrician/NCAA adviser and Clinical Director for NHS Professional Pennine Acute Hospitals Trust. BL9 7TA
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Congratulations to the authors for raising the profile of this thorny issue. Let me share my own experience regarding Trust grade doctors. I hate these posts as a doctor but love them as a Medical Director of our NHS. Let me explain why this double standard. In 1999, I was the Medical Director of an acute hospital and we had a visit from the task force who told me that our juniors in surgical department were working hard and I had to reduce their working hours by changing them to partial shift system. I agreed and asked for two more junior doctors. Guess what their reply was. "It is not up to us, ask the post graduate Dean". I wrote to the PG Dean who wrote me back saying "I am sorry, there is an embargo on number of SHOs so I can't help you but you may consider advertising two Trust grade doctors. It took another 4 weeks to convince the Board and find the money and we advertised. Guess what, I get a letter from the BMA junior doctors’ committee chairman saying that he is disappointed to see Trust grade posts advertised by our Trust and I shouldn't be doing it and I should advertise standard Staff Grade posts. I told him that we were looking for doctors to do 1st or 2nd year SHO work and why would a doctor with 3 years experience (required for staff grade) would apply and do the job? He didn't have the answer. I then wrote a job description and then came one more bureaucracy the great College. They rejected my job description saying that it was not the right job for staff grade as we were looking for 1st or 2nd year SHO jobs. That day I wondered who actually runs our NHS, who is the "Person in charge" of our NHS and at last I got the answer "Lord Jesus Christ" the Chief Executive of our National Health Service. The fundamental problem in our NHS is too many people or too many organisations with Authority but very few with responsibility and fewer still with accountability. I was the poor Medical Director trying to please all these masters and run the hospital and struggling to provide a good quality of care for poor patients of our NHS. Time has for us to create as NHS where there are less people with authority but more with responsibility and accountability. Competing interests: Various senior clinical management position |
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Annielle Hung, Consultant Haematologist Wishaw General Hospital, 50 Netherton Street,, Wishaw, Lanarkshire ML2 ODP
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A number of us would have faced periods of vulnerability during training with no post to move to at the end of a short-term contract. At such times, one becomes pragmatic and willing to consider any viable options, and if possible, with minimal disturbance to one's personal life. In such situations, locum work or non-standard training posts available locally become attractive alternatives. While those posts should not be used to replace consultant or training grade numbers, they can have a place in providing a period of stability at times of career uncertainty, offering experience in some specialities when training structure is becoming more rigid, and last, but not least, giving overseas doctors an opportunity to gain insight in the NHS. Such posts should therefore not be considered as career dead-end, but perhaps an opening for some. It is important that they are short- to medium-term contracts with clear description of duties, training, regular appraisal and continuing professional development included in the terms and conditions of service. This can only be achieved if the number is monitored and limited by the DOH with guidance from local postgraduate medical boards. Doctors, who take up such posts, do so for various reasons, often to suit their circumstances. It is perhaps not surprising that they are unwilling to participate in this debate, led by the BMA who appears to have definite condemning views while being detached from the real world. Competing interests: None declared |
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Arvindan Veiraiah, Cardiology Research Registrar Royal Sussex County Hospital, Brighton BN2 1ES
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Dear Sir/Madam, The author has described some of the pressures that force doctors to enter "trust grade" posts. However, I do not agree that "job process is an open market" as he states. The system is highly discriminatory and certainly not "open". In his description of the "trust grade story", the author is quite belittling when he states "passes some exams" as though the exam were not a rigorous test for the candidate's ability and then "wastes a lot of time" as if this were not a matter of choice and not dictated by the biased selection processes and the illogical demands of Hospital Trusts, Deaneries and the Home Office. He also echoes the sentiments of a lot of other doctors who feel that those of us who have come to the UK for work should feel grateful for any job offered "as an alternative to unemployment". This is what it all boils down to: everybody in the NHS and the country is doing us a favour when we are alowed to work here as doctors, even though the need exists because Britain cannot find enough doctors amongst her own citizens! It is considered right for rich Western countries to force poor countries to "open their markets" and buy their produce - there is something ennobling about Westernising the rest of the world. As Kipling said, "The civilization of other races is the white man's burden". But woe betide those of other races (for this problem does not affect Occidentals) who want to compete equally in the job market - even in jobs that no one wants! People of all origins should guard against this illogical expectation of gratitude for jobs offered. No South Asian is likely to get any job unless he is the best available candidate for the post; and there is no need for either the employer or the employee to put up with all kinds of unfair and discriminatory practices out of a sense of gratitude. Granting employment is not and should not be a favour - especially in a life-saving industry. In the same way, improvement in working lives is not merely a charitable exercise - it is necessary for the improvement of productivity and service quality. Such considerations apply to all employees - whatever the colour of their skin and whatever their origin. Reform of these non- standard posts is necessary for the better performance of the NHS as much as it is needed in the interest of justice and fair play. Competing interests: None declared |
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Klaus Lander, - Oldham
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Editor – I was intrigued to read the piece by Cooper et al. discussing the rise of the trust doctor and the alleged development of an underclass. These arguments remind me of the much-vilified German debate relating to the Gastarbeiters. Neither issue is debated with much rationality; both are heavily tinged with Kierkegaard’s passion. In debating this issue, we need to be mindful of discouraging xenophobia, avoid lapsing (or being morally pressured) into an apologist liberal Leitkultur - especially in light of the weight of injustices perpetrated in the past, but also strive to be fair to both our physician colleagues (trust and non-trust) and ultimately to our patients. The Gastarbeiters (mainly Turkish immigrants but also Yugoslavian, Greek, Italian and Vietnamese) were invited to Germany in the post-war manpower void, to help realise industrial rehabilitation. The terms of their employment were unequivocal; employment was intended to be temporary (<3 years) and to cover the undesirable vacancies (janitors, porter, miners and cleaners) that Germans did not want to perform. The rationale behind not giving them status nor making them permanent was their generally comparatively low technical skill level, their lack of cultural compatibility and the potential for social disruption/unrest – they were therefore not enrolled in complex training or accreditation programmes. Just as the more recent aspirations of the German government and the Berlin legislature to integrate the 2.8 million remaining Turks has embarrassingly and publicly failed, so will any wholesale attempts to accredit the ill-defined heterogeneous body of trust doctors. We have to face a harsh reality. Although training number acquisition is tinged with anxiety and received with stressful jubilation, in our own quaint British manner, we exercise some ad hoc form of quality control. We tend to recruit doctors who have had some experience with our indigenous population and who culturally understand their needs. Furthermore, the draconian tick-boxes and training post requirements ensure that trainees/consultants are familiar with how the British system operates. On the other hand, trust grades vary in their quality. Some are excellent, but some are truly terrible. The combination of poor linguistic skills, cultural incomprehension and limited technical abilities prove to be a lethal cocktail. While a training post does not in any way guarantee excellence, in most hospitals, trust grades are inevitably expected to perform routine and only purportedly supervised functions. Although it is true that some trust grades posts are British trained (often those that for a variety of reasons can’t get another job – hardly the cream of our graduates!), the majority are occupied by those with no or worse still, a with a poor local track record. Moreover, when error or poor management is encountered, it is often brushed under the carpet sotte voce and with nervous smiles, uncomfortably comfortable in the knowledge that there was someone overnight that held the fort while the rest of our staff slept. Due to a perception of futility or fear of causing offence/upset, often little attempt is made to point out these errors. Perhaps we too perceive that these posts are temporary and hence our hospital guests will leave with minimal trace of their often less than perfect care. Incidentally, it is naïve and disingenuous to state that because trust grades work side-by- side conventional grades and do a similar job, the quality of their work is the same. An attempt to foster better tolerance in Germany by teaching Germans Turkish and a reticence about strongly enforcing German learning among 2nd generation Turks has generated resentment and poor assimilation respectively. One universal lesson to be derived from all relevant models is that nothing devalues the skills of a group of people and generates resentment more than affirmative action. There should be reward for merit not for job description! The need to increase the number and quality of our doctors in light of new time directives is incontrovertible. However rather than becoming a second rate health care system, where our once internationally renowned membership exam has been reduced to tick-boxes of basic clinical questions and our trainees have seen less and done less than their predecessors across the board, perhaps we should re-evaluate our health care system in order to re-attract people away from the attractive financial institutions, back to our noble profession and train them properly. The unpalatable truth is that we must either accept a healthcare system that provides often inferior trust-doctor cover (with no commitment to education and progress) alongside conventional treatment in order to fill a workforce deficit, we or train everyone (logistically impossible) or finally we lose the emotive and unpalatable term underclass. Instead we recognise that as in all professions there are different skill mixes – surely although both are surgeons, a minor ops surgeon and a cardiac surgeon do not have the same skill/responsibility and should not be treated equally (with respect to status or salary). While both these groups have certain basic employment right, the existence of trust grades will prove a useful adjunct. We should certainly not simply accredit anyone who has been helpful enough to plod through a bunch of anti-social on-calls and charge them with the care of our loved-ones, but instead have the will to create homogenous posts that are universally competed for and achieved by equally meritorious individuals, irrespective of other characteristics. After all, the only way to avoid the tainted stigmatism of the Gastarbeiter is to allow their offspring to determine their own position is a social hierarchy through personal merit. A truly moral and ultimately successful society (medical or otherwise), shouldn’t apologise for limiting the resources of the less meritorious nor fail to reward the merit of the hardworking and skilled. These two importers are certainly not the same. Competing interests: None declared |
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Jonathan C Epstein, Clinical Fellow in Critical Care Christie Hospital NHS Trust, Manchester, Kajendran Balasubramaniam, (same appointment)
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We have recently started clinical fellow positions having passed the MRCS. Our posts come with funded study leave, dedicated time for research and access to the same teaching sessions as ICU registrars at the nearest local unit. The clinical experience in critical care should prove valuable in future surgical careers. No one could argue that employing doctors trained overseas to cover nightshifts with no training is a reasonable way to run a service but to regard all trust grade posts in this light may be overly simplistic. Many junior doctors are confronted with a bottleneck between SHO and SpR training and well designed trust grade positions could be at least as useful in career progression as yet another "standard" SHO job. Competing interests: None declared |
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Arvindan Veiraiah, Cardiology Research Registrar Royal Sussex County Hospital, Brighton BN2 1ES
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Dear Editor - Mr/Dr Lander's letter provides good evidence for the problem in using surrogate yardsticks for measurement of capability. Sweeping generalizations have always been part of the process of exclusion - and are not different from the thoughts of many consciously and unconsciously biased and prejudiced individuals. Take the example of the reasons given for the exclusion of the Gastarbeiters: "The rationale behind not giving them status nor making them permanent was their generally comparatively low technical skill level, their lack of cultural compatibility and the potential for social disruption/unrest – they were therefore not enrolled in complex training or accreditation programmes." Lack of cultural compatibility has been offered as a reason for excluding the weak minority. This argument could be extended to every type of jingoism - exclusion of catholics, protestants, jews, muslims, hindus, blacks, Turks, Germans, etc. It is necessary for the servers and the served to adjust to such differences. In fact, such differences can contribute to a healthy and vibrant society, once one can distinguish between true problems due to cultural differences and potential for misunderstandings. Even more prejudiced is the comment on "the potential for social disruption/unrest". In this particular case, we are discussing the small scale difficulties caused by a minority community in the midst of a majority community which was party to the worst human destruction and debasement ever seen. I do not feel that it is right to blame the Germans (and citizens of other Imperial powers) for the suffering caused by their past actions, but I also feel that dominant Caucasian groups have to rethink their prejudices after a better assessment of character flaws that can be surmised from generalized reviews of their own collective actions. Each individual, Gastarbeiter or German, had a right to be judged on his or her own actions and potential, not on the basis of scornful generalizations. Even where problems exist, national and local services would suffer less by empowering such disadvantaged, but enterprising workers (for it always requires enterprise and courage to willingly move to a place where you can expect racial prejudice and unfairness). Another example of generalization is the comparison between the Gastarbeiters, who provoked such a negative and lowly image in the mind of the powers-that-were, with the Trust grades. Such a comparison is extremely dangerous - it associates the employment of doctors from South Asia with employing underskilled, socially incompetent and disruptive doctors! The PLAB exam certainly tests us for our social skills - an exercise that frequently seems necessary for many doctors and other staff of other origins. The author goes on to say: "in our own quaint British manner, we exercise some ad hoc form of quality control. We tend to recruit doctors who have had some experience with our indigenous population and who culturally understand their needs". This "ad hoc form of quality control" is sometimes just overt racism, as demonstrated by studies that showed that the same candidate was more likely to be called for an interview if he gave a false Caucasian name rather than his/her true name. But more often it involves sweeping generalisations about non-majority candidates based upon untested selection yardsticks. This excludes not only the South Asians, but also women, sensitive surgeons, medical registrars who cannot gossip about other staff or talk about golf, caviar and rugby, etc. Let us be honest, the selection process here is greatly biased by the ability to be "one of the boys". Referees always mark up a candidate and even call the selecting authorities if you have the potential to propagate their style - but their style and manner may even be detrimental to patient care! Later, the author says: "the draconian tick-boxes and training post requirements ensure that trainees/consultants are familiar with how the British system operates." These requirements ensure fairness in pay and conditions for those who do get into training posts. But I am not sure that the selection process is fair. Everything depends on who you know and where you are. Once you are out of the loop, or if you have the misfortune of starting outside the loop, it is a monumental task to then get to the right place and get to know the right people - which is more critical for career development than performance per se. Even performance can only be demonstrated in an environment of support, encouragement and opportunity; something that is often not offered to doctors in non-standard posts. So how can selectors be sure that such candidates will not be able to deliver a high quality of service if and when such an environment is made available? Despite my disagreement with the views of some of the authors who have responded to Cooper and Burr's article, I am thankful that we have had a chance to discuss and argue this very important topic. So far, I feel that we have been able to get a well-rounded set of responses from completely different stand points. As a South Asian, I have had a chance to argue for our cause, a chance that is unavailable in our normal working environments, or while applying for jobs. I wish there were a way to argue these complex issues in a wider and more open forum. Competing interests: None declared |
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A.J Shyam Kumar, Clinical fellow(Trust grade registrar) in Orthopaedics City hospital, Birmingham
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The current issue of the BMJ careers made very interesting reading to people like me.I am currently working as a clinical fellow(Trust grade registrar) in Orthopaedics.These jobs are generally seen in surgical specialities like Orthopaedics as transitional posts before getting a training number or as a warming up post prior to taking up staff grade jobs.The advantage is that it gives the necessary operating experience required at the level of a first year specialist registrar . -My saga started almost one year back when I took up a trust grade registrar post in one of the biggest trauma centres in Birmingham.The nature of duties was exactly the same as that of specialist registrars but the contract said that the payment would be at the level of an SHO.I had no other option but to keep quiet as it was my first chance to work at registrar level in the U.K. At the end of my contract,I got a similar job in another Birmingham hospital.I was specifically told in the interview that there would be absolutely no difference between my grade and a training grade apart from the lack of a training number.I was also given an appointment letter in which my pay was fixed up at the eligible equivalent of a training grade. -Everything went on smoothly till I found that my first month's pay-slip hadn't arrived. I waited for 2 weeks and then on my enquiries with the medical personnel department, I was told that my payscale has been rejected by the finance department. After negotiations with the personnel department, I was finally informed that the amount written in the appointment letter was a mistake and the maximum they could do was to continue the same payment which I had received from my previous employer pending negotiations by the BMA.I had no other option but to agree at that point as I was only a month into the job.I felt really let down and I considered it as a violation of my human rights as I was made to do all the duties equivalent to that of a specialist registrar and when it came to pay , I was given less.I wrote to the local BMA representative regarding this and the concerned official was kind enough to offer help to approach the trust on my behalf.I left the matter at that stage feeling frustrated and helpless as I had more things to worry about in my career.I had almost forgotten about the whole episode till I saw this explosive topic staring at my face when I opened the BMJ this week. -My story pales into insignificance when I heard another colleague's experience while I met him at an interview.This particular doctor was working as a trust grade doctor sharing the same rota as specialist registrars and the banding of the registrar rota was 3(according to the intensity of the work).Although the Specialist registrars were paid band 3 , the trust grade registrars were paid only band 1A which is very much less in spite of doing the same heavy work.We cannot call this anything else apart from apartheid in the NHS. -The author is pretty sure that there are many doctors who still suffer in silence and Peter Cross has aptly titled his article as the Wall of silence. I sincerely hope that this BMJ edition will open the eyes of the BMA officials to negotiate for an equal pay for equal work right for doctors. Competing interests: The author is currently working as a trust grade doctor and any improvement in the working lives of this grade will directly benefit the author. |
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Darell Tupper-Carey, Consultant Anaesthetist James Paget Hospital NHS Trust
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Having read your series of articles concerning the problems of Trust Grade Doctors it seems that some fundamental questions have to be addressed if solutions are to be found to the manpower mess the medical profession is currently in. The first question is whether the NHS should be a consultant based provider of healthcare or whether consultants should continue to delegate to junior doctors a large proportion of (particularly emergency) patient care.Without a clear statement of how the NHS is to deliver patient care in terms of its medical workforce it seems that we cannot begin to tackle this problem as we cannot predict the numbers of consultants required in the future. The second question is should the hierachical and pyramidal structure of the hospital career ladder continue. Whist we have a large excess in the number of trainees compared to the number of consultants there will always be trainees who cannot progress further up the career ladder and this group comprises of a large proportion of overseas trained doctors. The UK attracts a considerable number of overseas doctors who wish to undertake post-graduate training in the UK yet many of these Trust Grade posts do not offer the equivalent training opportunities as recognised SHO or SpR posts. It is clear to me that the NHS is relying heavily on these Trust Grade posts to perform a considerable proportion of medical patient care and yet is not adequately recognising their contribution to the NHS.Should the number of training posts match the number of consultant vacancies or should we be content that some doctors fall off the career ladder after somtimes up to 10 years of working in a particular hospital speciality? The rise in the number of Trust Grade medical posts has partly been due to meeting the European Working Hours directive for trainees. Many more doctors will be required to staff the hospital at night unless a radical change in working practices occurs.Calculating how to change the medical workforce particularly at night-time in response to this directive cannot be done unless we have a clear statement from the NHS as to how healthcare should be delivered by consultants in the future. Competing interests: None declared |
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Dr Bakhtawar S. Khattak, Locum Consultant Chest Physician Gloucester Royal Hospital, Gloucester, GL1 3NN.
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“Full many a gem of purest ray serene The dark unfathomed caves of ocean bear Full many a flower is born to blush unseen And waste its sweetness on the desert air” These days, there is a lot of talk about the use of the local consultants and the SAS doctors to be utilized for filling the gap. The rules are going to be changed very soon regarding the SAS doctors to have a chance to get onto the specialist register of the GMC but, unfortunately, nobody talks about those consultants who have not been put on the specialist register. They have been used for so many years as locum consultants because they cannot apply for a substantive post unless their names are put on the specialist register. Is it not the most unkindest cut of all? Is it not the worst and scandalous type of slavery?? I have been working as a consultant chest physician in NHS hospitals for the last 3 years, on top of my thirteen years service in Tehran Medical University as a Consultant Physician and Associate Professor with my Multinational Qualifications, International Publications and Research Presentations. My present job is a consultant physician in general and chest medicine and this locum post is for 2 years. My previous locum post was also for 2 years as a consultant physician in general and chest medicine which I left because I chose this one. Now the clear cut question is that one can look into my overseas qualifications, overseas training, overseas research presentations and overseas publications on the basis of which I am quite successful in having locum consultant physician posts in the NHS even of long duration of more than 1 year, but the denounced STA denied to give me the recognition to be put on the specialist register making the excuse that my overseas training is not recognized here. If overseas Training and experience is good enough for long term locum post of more than one year then how on earth it is not good enough for a post of , say, five years or ten years.? Either a Physician is capable of looking after his patients or he is not capable of it. Do we have Consultant Physicians in NHS who are hermaphrodite in their capability to treat their patients? According to the new regulations, the overseas training, qualifications and experience will be counted, but, unfortunately, the new application form of the JCHMT is almost exactly the same as it was about 5 years ago. I don’t think the changes have actually materialized. So we come back to the same point as mentioned by so many doctors on various forums that why people like us who have been well tested as locum consultant physicians over a long period of time in the NHS in this country are not put on the specialist register to enable us to take a substantive consultant post, while rather unknown and untested people are brought from overseas( EU) and given the recognition and put on the specialist register straightaway. Is there anyone who can come up with a decent and plausible explanation about this odd situation ? Can anybody tell after how many years of Locum Consultant Physician work such physicians will I be eligible to apply for a substantive post.? Or Are they doomed to die as a Locum Consultant Physician and never be able to apply for a substantive post. ?? No private Insurance Company is ready to get its patients treated by a consultant Physician who is not on the Specialist Register.!! But NHS has no objection on its patients treated by Consultant Physicians independently who are denied of entry to the Specialist Register.!!! This double standard of treatment of Private viz NHS patients is shameful discrepancy and both Locum Consultants and the NHS patients are the victims of this disgusting hypocrisy. For how long this will be and should be tolerated.? Why BMA is silent about it.?? In this country everybody talks of equal opportunities, justice and fair dealing. Some one has to give it a sincere thinking to explain why a person is fit for a post of Consultant Physician for two years but not for three or four or more years.?? Dr B.S.Khattak FACP,FCCP.FRS Locum Consultant Chest Physician Gloucester Royal Hospital. Gloucester. Competing interests: None declared |
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