Career Focus

Thinking of taking a staff grade post?

BMJ 1997; 315 doi: (Published 29 November 1997) Cite this as: BMJ 1997;315:S2-7120
  1. Graham Buckley, director
  1. Scottish Council for Postgraduate Medical and Dental Education,12 Queen Street,Edinburgh,EH2 1 JE

    “Don't” is the conventional wisdom. Graham Buckley, director of the Scottish Council for Postgraduate Medical and Dental Education, considers the doctors who have stepped off the career ladder.

    The simple advice that should be given to a young doctor considering taking up a staff grade post is “Don't do it.” The posts are not for training. They are non- consultant career posts. The conservative traditions of medicine continue to regard being a principal in general practice or a consultant in one of the other specialties as the only legitimate end points of postgraduate training.

    Traditional hostility

    Traditionally, the British medical profession has been hostile to the development of non- consultant career grade staff, expressing this through both the BMA and the royal colleges. Grades such as the staff grade, or previously senior hospital medical officers, have been perceived as a threat to standards and a possible means of obtaining medical care on the cheap. It is interesting that clinical assistants and hospital practitioners are not viewed in the same way by the profession, since these doctors together contribute the same number of whole time equivalents to the health service as staff grade doctors.

    It should be clearly understood that the staff grade is not a route to becoming a consultant. Even during the extended transition period for the introduction of the specialist registrar grade and the establishment of the specialist register, this is true. Only in exceptional circumstances is the Specialist Training Authority likely to accept time spent in a staff grade post as counting towards specialist training. Doctors who have occupied substantive or honorary career registrar or senior registrar posts in the past, and who could be considered to be within 12 months of completing a specialist training programme, may be given training numbers and allowed back into training. They will also need to have been in a staff grade post before January 1996. Other non-consultant career grade doctors may be recommended for entry to the specialist register during the transition period if they can show that they have acquired, in the United Kingdom, the full range of knowledge, level of responsibility, skill, and competencies of a fully trained specialist. This potentially applies to a small number of associate specialists, but these criteria are unlikely to be fulfilled by staff grade doctors.

    Career blind alley?

    Given the cul-de-sac of the staff grade, why are over 2500 doctors in the United Kingdom in these posts? The reasons give a fascinating insight into the complex- ities of planning the medical workforce in this country. The number of staff grade doctors would be even higher if recruitment by NHS trusts was not limited by a national agreement with the profession to limit the numbers to 10% of the number of consultants. Initially, the 10% limit was accepted at a local level, but pressures of service and difficulties in recruitment to consultant posts have led to some clinical departments having 25% or more of their career medical staff in the staff grade.

    In spite of reservations by the profession, the introduction of the staff grade was one of the principal recommendations of the consultative document Achieving a Balance, published in 1987.1 The justification was to “find a way of providing essential support to consultants in the acute specialties, without training doctors for non-existent posts.” This basic driver for having a non-consultant career grade remains, but it is not on the agenda in polite conversations about the future shape of the medical workforce. Orthodoxy favours an expansion in the number of consultants, leading to a consultant provided service. Although there has been a steady 3% growth in their numbers over the past decade, consultants have, understandably, generally shown little enthusiasm for radically altering their working patterns. This, and the “New Deal” on junior doctors' working hours and conditions and the implementation of shorter and more structured training for specialist registrars, has left a service gap which has been filled by staff grade doctors. Their numbers grew rapidly from zero in 1988 to over 500 in 1991 and to over 2500 at present.

    Recruitment patterns to the staff grade

    The health circular introducing the grade in 1988 anticipated that applicants would only exceptionally have held a training grade post higher than senior house officer, but the actual recruitment pattern has been different. The pattern has also been different in different parts of the United Kingdom. The annual census of doctors, reports from the Standing Committee on Postgraduate Medical Education,2 and the Scottish Council for Postgraduate Medical and Dental Education3 document these patterns. The two reports also describe the educational and career opportunities and frustrations of doctors in the staff grade.

    In England most doctors in the grade have qualified overseas and are male (60%). In contrast, in Scotland the biggest group are British qualified and female (44%), overseas qualified male doctors forming a third of the total. In spite of the posts coming into being within the past decade, the average age of staff grade doctors is 43, 75% being between 35 and 50 years old. Indicative of the seniority and experience of these doctors is the fact that more than half have at least one full membership of a royal college and more than half have previously held a registrar post. These statistics reflect the era before the specialist registrar post, when a barrier to career progression was the competitive hurdle of becoming a senior registrar. However, in the SCOPME and SCPMDE surveys the inability to obtain a senior registrar or consultant post was cited by only 35% and 19% of respondents respectively as a reason for entry to the staff grade. The desire for a permanent post was a frequently expressed reason for entering the grade. Domestic and family reasons were also major factors in making this career move. Both surveys explored the educational opportunities available to doctors in the grade and their future career aspirations. The lack of formal arrangements for study leave is a concern: most staff grade doctors are not able to apply for study leave, but do participate in educational activities within their clinical units and departments.

    Many staff grades want consultant jobs

    The surveys showed that, in spite of the formidable obstacles in their path, betweena third and a half of the doctors still hoped to become consultants. Only 20% wished to remain as staff grade doctors, but nearly 70% realistically thought that this was their likely career position in the long term, with progression to associate specialist the best that they could achieve. Some of the reasons given for disenchantment with the grade were:

    • End of the road job with little chance of promotion;

    • Used as a pair of hands with little regard for actual competence;

    • Isolated position with little support from senior colleagues.

      All is not doom and gloom, however. Many in the grade, particularly women who had qualified in Britain, gave positive views:

    • It allows those not wanting or able to climb the career ladder to work at a suitable level;

    • It increases the number of experienced middle grade staff, thus improving the service;

    • It has better hours, minimum on call, no obligatory managerial duties, and allows part time working.

      A common complaint from doctors in the grade is that they did not receive career advice before taking up their posts. Of those who had changed their opinions about the grade while in the post, three quarters had become more negative. Some of the most bitter comments reflect badly on the profession:

    • “Viewed with little respect, particularly by doctors in training posts”;

    • “Not taken seriously”;

    • “I am excluded from all discussions about the running of the department”;

    • “I am regarded as a failed consultant.”

    General medicine, cardiol- ogy, geriatric medicine, paediatrics, accident and emergency, general surgery, orthopaedics, anaesthetics, psychiatry, and obstetrics and gynaecology have substantial numbers of staff grade doctors. Information from the surveys reveal that working hours range from two to 13 sessions a week, with 15% of the doctors working 10-13 sessions, and 35% of the women doctors working 5-9 sessions a week. Half the doctors participate in out of hours on call duties.

    The content of the work of staff grade doctors and their working hours is clearly varied. It is this flexibility in filling awkward gaps in the service that makes these doctors such a key component in the medical workforce and should lead to their achieving higher status. While the health service and, I believe, the profession need to have a substantial number of non-consultant career grade staff, this should be achieved in a positive way to create fulfilling and attractive posts. At present, the staff grade posts seem to be a lottery, with job satisfaction highly dependent on the approach taken by the supervising consultants. Any doctors contemplating taking up a staff grade position need to think hard about the long term. Opportu- nities for career development and progression are limited or non-existent. If in doubt, do not enter the grade. There are plenty of other career opportunities in medicine, as Britain continues to be short of doctors.


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