Intended for healthcare professionals


A subconsultant grade

BMJ 2008; 336 doi: (Published 15 March 2008) Cite this as: BMJ 2008;336:s96
  1. Laurence Wood, lead obstetrician and erstwhile national facilitator, SHO review implementation
  1. 1University Hospitals Coventry and Warwickshire, Coventry CV2 2DX
  1. laurence.wood{at}


Not everyone who goes into hospital medicine can expect to be a consultant. A lower tier may be the answer, argues Laurence Wood

The Tooke report takes a major sideswipe at the execution of Modernising Medical Careers,1 but, ironically, firmly beds its hidden agenda—the creation of a labour market between obtaining a certificate of completion of training (CCT) and the consultant grade. Tooke labels it “specialist,” the very term favoured in the old regime, and dodges the issue in a recent interview.2 Is this a cynical means of creating a cheap substitute for consultants? In my view, yes. But is this a good thing? In my view, it is not only good, but essential.

Experience and skills

The most obvious argument in favour of the need for specialists is that when they were called senior registrars they were still accumulating training, while providing high volumes of experienced and skilled care. The grade was done away with in the Calman reforms of the 1990s. An old-style senior registrar would serve perhaps 10 years in the specialty, at say 4000 hours a year. Following the introduction of the European Working Time Directive, a CCT holder will have done seven years of 2500 hours a year—about half the amount, though admittedly with better training and assessment and less time in bed (though also less apprenticeship, and that might be an important loss).

Trainees are now reaching CCT feeling daunted by the challenge of unsupervised on-call. Having the opportunity to take on a temporary post in close working relationship with an experienced “master” might provide the opportunity to fine tune skills and understanding.

Trainee to consultant proportion

An equally compelling reason for the creation of the specialist grade is to help those who otherwise would be unemployed—or employed in Dickensian contracts. The bare fact is that there will never be enough consultant posts to go round. The maths just does not work: seven years to cover all the emergencies on site 24/7, then 35 years to cover the elective work.

Post-European Working Time Directive, the emergencies will be covered by cells of trainees on 1 in 10 rotas. Two such tiers of trainees on a seven year contract would mean that three CCT holders would emerge each year. In steady state, to sustain this number of juniors would need a unit of 50 consultants. Of course, you could get round this by making one of your tiers consultant based. But if older consultants later move to a higher tier, then we still end up with a two tier consultant grade. So if we do not create a specialist grade, it will happen by default, as wave after wave of CCT holder hits what will become for many an almost impenetrable wall.

Deficiency in emergency cover

The European Working Time Directive also creates another problem: we will have to reduce hours to 48. This demands expansion of the emergency tiers by up to 25%. But we have no pool from which to recruit trainees. In Modernising Medical Careers, one of the mistakes made was to downgrade the old fixed term training appointment, to be recruited from inexperienced rather than experienced trainees. Many of those in the grade in 2007 who did not make specialist trainee had to leave the specialty or the United Kingdom.

So employers will look for a quick fix, using unemployed CCT holders. The job advertisement section of the BMJ shows that this is already happening. Will we just let this be uncontrolled?

Capacitance, influx, and efflux

This highlights another benefit of a specialist grade. It creates “capacitance”: the ability to respond to workforce need without long term planning. Experienced people can come to the UK into useful and responsible posts. This is a win-win: those coming in are given an opportunity they otherwise would not have, and the service gets their experience. The best are selected to stay on as consultants. Others move on and are better trained for the experience. Also, CCT holders can spend time abroad without compromising their career. Workforce planning moves towards sustainability.

Setting the consultant hurdle high

Thus such a grade is not only useful, less expensive, better balanced, and important in preventing misuse of trainees, but it also helps set the consultant hurdle higher. A typical annual review of a trainee, the record of in-training assessment, is now almost a paper exercise in which the decision making concerns achievement of minimum performance. Typically, it does not even pretend to make any distinction between shades of excellence.

The creation of the specialist grade will mean competition for consultant posts, which, if well managed, would set the hurdle high in all those aspects of doctoring which we value. This would have repercussions right down the system, as some trainees look ahead from the start to decide how they would like to develop their talents and demonstrate their qualities. The result will be that consultant appointments might well demand training and performance in management, education, communication, safety, quality improvement, and other aspects of service delivery which really matter. Of course, if those standards were reached, it should be entirely acceptable for the most able to move directly from training to a consultant post.

Therefore the specialist grade could become the locus in which realistic workplace based assessment occurs. This would not simply entail checking to see that a doctor could manage a certain case in controlled circumstances, but having a long view of the training, aptitudes, and attributes of trainees in the real life setting. It would provide real discernment between mediocrity and excellence, an unleashing of doctors to excel. An hour long interview, added to a list of (minimum) competences and experiences, is no substitute for a full portfolio of proper workplace based assessment when appointing someone for 35 years.

Training post?

This does not make the specialist grade a training post—we are all committed to lifelong learning—and it is entirely appropriate that even as consultants we should continue to accrue evidence of our abilities and performance. If not a training post, does that mean that specialists can take final accountability for their patients? Yes of course they can. That is what CCT should mean. And in circumstances where they feel out of their depth, they call for help, as we all should continue to do for our entire career.

Everyday work: high volume, low risk, pleasant setting

Perhaps not all specialists will make it to consultant. But then not all will want to.3 The NHS and the public do not need everyone to be able to perform the most difficult and challenging aspects of care; indeed the creation of a cadre of masters would be compromised by the spreading of experience among trainees who might never need to benefit from it. For the everyday consultant level work of the NHS, we need good selection of patients into a stream of accessible, prompt, safe, efficient, effective, comfortable service delivery.

This may sound like New Labour rant, but the logic is inescapable—many activities still occur in a highly pressurised hospital, which could happen more cheaply, comfortably, and safely elsewhere. Some doctors may choose this type of service as being all they want from their career—no pressure to manage the service, write papers, research, be on committees, run the education, supervise the risk management, and so on. Just do the job. No stress, more spare time, less money. Of course, providing realistic financial and managerial support for this model of NHS is a different matter, but creating the grade is a start.


Many good ideas in the NHS cost money. This one is cheaper. So are there any downsides? Of course trainees might want to reach consultant level as soon as they can, and they have come to take for granted the expectation that only two interviews will take them from specialist trainee entry to retirement. The minority who would have got consultant posts directly will be disappointed then by the creation of the specialist grade. It will delay them by a couple of years (. . . the same time they would have spent as a senior registrar before Calman and Modernising Medical Careers).

For the rest of the trainees, they will benefit from having a structured grade to hold them and develop them while looking for the right post. The NHS will benefit from having a pool of experienced workforce to cover straightforward elective and emergency care. Those delivering the complex care, the management, the education, and the research will be of the highest calibre, and will be rewarded appropriately.

BMA in denial

This grade is going to happen—indeed it is already happening. So it is unhelpful to trainees approaching CCT for the BMA to cocoon themselves within long held principles. In the absence of the BMA fighting their corner, trainees need to unite to determine what might be regarded as reasonable minimum terms and conditions of such posts (for example, being on the consultant rota, opportunities for career development, mentorship, workload).

The salary should be reasonable yet realistic—these are highly talented people at the end of perhaps 14 years of intensive training and assessment, who are doing skilled and stressful work, with lives at stake. At the same time, some will go on to earn high salaries as consultants, and we should remember that the 90th centile salary in the UK is £46 000 a year.


The government has cleverly manipulated the Calman and Modernising Medical Careers training reforms to create the specialist grade. Doctors in training never wanted this. The sober reality, however, is that it is a good thing, but it must be managed.


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