Intended for healthcare professionals


SAS doctors’ perceptions of their role in the NHS

BMJ 2012; 344 doi: (Published 26 April 2012) Cite this as: BMJ 2012;344:e2819
  1. Gillian Phazey, project manager1,
  2. Steven Agius, senior research fellow in medical education1,
  3. Jacky Hayden, dean of postgraduate medical studies1
  1. 1North Western Deanery, Manchester, UK
  1. g.phazey{at}


Gillian Phazey and colleagues interview the “hidden heroes” of the NHS

In 2006, in a publication entitled The Hidden Heroes of the NHS, the BMA’s chairman of council stated that “despite their often Herculean contribution to patient services, staff grade and associate specialist (SAS) doctors are frequently marginalised and denied the plaudits they deserve. They were the last group of NHS workers to see their pay and working practices reviewed, and there still is insufficient recognition for their achievements—both within the NHS and outside.”1

SAS doctors have been described as the dependable backbone of the NHS medical workforce,2 occupying well supported and well remunerated positions that were established to provide an attractive career option for qualified medical staff.3 In the past 20 years considerable expansion of these grades has occurred. In 1991 there were 490 staff grade doctors in England, but by 1999 there were 3640.4 Workforce census statistics published in 2009 showed that the total number of SAS and other non-training trust grade posts in all specialties was about 12 800.5 The increase in the number of SAS doctors across all medical specialties has paralleled and enabled the reform of the training grades as part of Modernising Medical Careers and compliance with the Working Time Regulations.6

Although empirical evidence concerning SAS doctors’ working conditions is limited, a recurring theme in the literature is the difficulties faced by these doctors in terms of career progression and advice,7 access to educational and development opportunities,8 professional support,3 and continuing professional development activity such as appraisal.9 For reasons such as these SAS doctors have often been described as the “forgotten tribe.”8

In the past three years, with the introduction of the new specialty doctor contract and a £12m injection of funding aimed at tackling their continuing professional development needs, the situation for SAS doctors has started to change. The new funding has led to localised development opportunities that were previously often unavailable to SAS doctors. These developments have raised the profile of SAS doctors, casting light on their role in the NHS.

In the North Western Deanery we investigated SAS doctors’ perceptions of their historical employment conditions and sought to identify areas that SAS doctors see as lacking in terms of supporting their career progression and professional development. We did this not only to understand the experiences of SAS doctors but also to help inform local developments and use of nationally allocated funding.

The deanery’s approach

In 2009 telephone interviews were carried out with 10 SAS doctors in the North Western Deanery region. The interviews were transcribed and analysed for any recurring themes.

Interview questions were informed by a preliminary literature review and explored the following areas:

  • Details of their current post, including who the participant works with and in what capacity

  • Opportunities currently available to the SAS doctor in terms of professional development

  • Relations with the wider organisation and the immediate team, and

  • Support available for SAS doctors in their role.

What we found

A total of 10 SAS doctors (three staff grade doctors, six associate specialists, and one clinical assistant) were interviewed. The participants spanned a number of specialties, including general adult psychiatry; ear, nose, and throat surgery; cardiothoracic surgery; ophthalmology; haematology; cardiology; and gastroenterology. Two were women and eight were men. The table summarises the recurring themes in the participants’ transcripts.

Recurring themes from interviews with 10 SAS doctors

View this table:

Professional and career development

The SAS doctors reported a lack of training and development opportunities and of structure in career progression and in access to basic careers advice and guidance. The doctors referred to the service focus of their role and the effect that this had on access to development opportunities.

The role of the immediate supporting consultant was cited as a key factor in determining the provision of careers advice and guidance. One participant said:

“I know that I am quite lucky with the consultant I have at the moment, in terms of the degree of support that I get . . . If I had a less supportive consultant, like some of the consultants I had earlier, then I would not be feeling anything like as comfortable as I do.” (Participant 001)

The SAS doctors commented on the difficulties faced in career progression both within and outside the SAS role. External factors affecting current career progression, such as the process for obtaining a certificate of eligibility to the specialist register (CESR), were raised as an influence more often than factors from within the trust.

“I’m looking at getting a CESR to give me more options because an associate specialist at the minute is a dead end position . . . The highest priority for me is getting top-up training . . . There isn’t any mechanism around for that at the moment.” (005)

The doctors reported finding it hard to access training and development opportunities owing to the “non-training” aspect of the SAS role.

“The trust and my seniors’ focus was towards more and more service out of somebody in a grade like me, giving less and less opportunity to develop himself . . . In fact I was pushed to the wall to even use my skills that I already had attained.” (002)

Doctors also referred to other factors influencing the trust and the NHS in general that contributed to the difficulties in accessing development opportunities, such as the historical lack of funding for SAS development activities and the trusts’ own agendas. Access to continuing professional development activities has been a longstanding issue for many doctors, particularly those in SAS posts. Research has shown that SAS doctors in emergency medicine have found it increasingly difficult to access educational opportunities and activities.3 This finding was mirrored in the national survey of SAS doctors’ training needs published by the BMA in 2008, which reported that 35% of SAS doctors surveyed had not been able to take their full study leave entitlement during their past three years in employment.10

Fairness and equity

This theme relates to perceived fairness and equity in recruitment processes and important professional development related activities such as formative appraisal. The doctors interviewed had a common view of the difficulties encountered in applying for training posts in open competition with those already in training.

Several comments concerned the difficulty in finding time with the supervising consultant to undertake formal appraisal. Consultants often lacked time to carry this out, and other commitments often prevented appraisal taking place.

“I did have one appraisal. That was with my previous consultant, who left the trust, and I would say for the first time I felt that I was getting more opportunities to develop myself, and after that appraisal there were changes in management and there were changes in consultant level, so that was lost . . . Things have deteriorated since then.” (002)

Some of the limited empirical research about SAS doctors and their employment relationships has explored the presence of professional development activities, with similar outcomes to this study. For example, in a survey of SAS psychiatrists in the south west of England only 50% of the 90 respondents had a professional development plan, and 41% reported having had an appraisal.8 Another study investigated the working conditions and educational opportunities of SAS doctors in genitourinary medicine in the UK: of 244 respondents, only a third had received an appraisal and one third had a job plan.9

Several references were made to perceived issues concerning fairness in selection. Mostly this was in relation to applying for re-entry into training posts through national recruitment systems, but there were also comments about fairness in the regrading process or in trying to gain recognition for regular additional work.

“I’m conscious that I competed openly against some of my peers that I trained with, who . . . have attained an ST4 [specialty training year 4] post, but their overall level of experience is much less than mine in terms of service and the things that I’ve done . . . It grates a little bit.” (007)

“I do have one objective, and that is to be regraded . . . I run the anticoagulant clinic at [the trust], but I was told that I didn’t do any more than the nurses and I didn’t deserve the regrading.” (004)

These findings may relate to a lack of funding and a lack of formal policies or of advice being in place to assist these processes. In the medical profession in general few opportunities exist for formal upgrading or promotion. Although this has been perceived as a difficulty for SAS doctors in this study, many other parts of the medical workforce do not have this opportunity in their roles.

Recognition and value

We found instances throughout the interviews of a perceived lack of recognition for the contribution that SAS doctors made to their teams and for the service they provided. The comments related to both the immediate supporting consultant and the trust more widely. In addition, participants implied that their role and their work were undervalued by their employers. Examples of this were highlighted both explicitly and implicitly by the SAS doctors interviewed.

“I’m here on the consultant rota. I do everything independently, but when you are doing a clinic you are doing it in somebody else’s name. You can’t do it in your own name.” (006)

The doctors commented on a lack of recognition, not only in relation to their own employment situation but in relation to the SAS group as a whole.

“I think one of the biggest problems is trying to get people’s thinking to change, that associate specialists and staff grades are in fact important and valuable people. At the moment, because you’re not a consultant you’re considered almost like a second class doctor . . . There’s got to be a big change in people’s thinking and perceptions.” (009)

Closely linked to a lack of recognition for the SAS role was the participants’ individual views on their identity and role. In particular, the participants suggested that there was little clarity about where the SAS doctors’ role fits in relation to colleagues and in the post-Modernising Medical Careers structure. This was described from a personal perspective and in relation to how other colleagues viewed the SAS role.

“Where we fit into that, I don’t really know . . . I sort of fall below everybody’s radar really.” (004)

“I am working in this grade and I know the difficulties we face . . . It’s a kind of job which is in between, so it is not a training post and it’s not a senior role.” (010)

Previous research with SAS psychiatrists has reported similar findings. SAS doctors felt some confusion and a lack of clarity in expectations of them and their responsibilities, as they had high level responsibilities but also completed tasks done by more junior doctors.8 Other research has commented on the importance of a strong sense of personal and professional identity in being able to identify with a professional group.11 The authors highlighted the importance of continuing professional development in maintaining professional identity, given that professional bodies have outlined what is necessary for that particular role. The views reflected in our study imply that the absence of a strong identity for SAS doctors is also affected by a lack of opportunities for continuing professional development.

Implications of our findings

Although our findings are based on a small scale, qualitative investigation of SAS doctors’ perceptions of their employment conditions, they add to the growing evidence that some SAS doctors may face a number of challenges in their employment relationships. In particular, development, training, appraisal, selection, recognition, and value were reported as potential issues within the SAS role. Although we questioned our sample of SAS doctors about their immediate employment relationships, it is interesting to note that much wider influences or agents were cited in their perceptions of the factors affecting their general working conditions. We identified bodies and organisations (such as the Department of Health and the General Medical Council) that, owing to their formal connection with the profession of medicine or the NHS, were seen as having a major impact on the SAS doctors’ employment relationships.


Although our study indicates some of the potential problems in SAS employment relationships, since our data were collected important changes relating to SAS doctors’ careers and professional development may have improved the situation for some. Additional funding for SAS continuing professional development has been issued by the Department of Health and channelled through postgraduate deaneries to trusts, with some retained at a regional level to support a range of initiatives, such as provision of generic skills courses and careers management programmes and the establishment of trust SAS tutor networks and academic bursary schemes.12 Nationally, a number of organisations such as the royal colleges and the National Association of Clinical Tutors have established groups and hosted conferences to share good practice and guidance aimed at supporting SAS doctors.

Recently, the Conference of Postgraduate Medical Deans group for SAS doctors’ development (with associate dean representation from each deanery) has been revived and is looking into developing a strategic vision for agreed priorities for SAS doctors’ development. This will, we hope, start to pave the way for stronger national guidance on supporting SAS doctors’ professional development. A new standardised national employment contract has also been introduced, creating a new grade of “specialty doctor” and a new contract for those in the associate specialist grade. This has provided the opportunity for better career progression and has formalised the requirement to undertake and record professional development activities.

Such developments over the past three years have raised the profile of the SAS grades and the importance of improving these doctors’ development opportunities. In the North Western Deanery we are now planning follow-up work to explore the effects of this investment in the SAS grade. However, with the UK coalition government’s planned structural reforms to the NHS and ongoing economic difficulties across the public sector, it is imperative that the momentum to improve the working lives of this vital section of the medical profession is not lost.


  • Competing interests: None declared.