Intended for healthcare professionals


Different but equal: equivalence routes to the medical register

BMJ 2012; 344 doi: (Published 24 April 2012) Cite this as: BMJ 2012;344:e2867
  1. Helen Jaques, news reporter
  1. 1BMJ Careers
  1. hjaques{at}


The GMC’s recent review of equivalence routes to the medical register found disparate views on the value of CESR and CEGPR in comparison with CCT. Helen Jaques looks at how to increase confidence in the equivalence routes

There are two routes to the medical register for a doctor who wishes to practise as a hospital consultant or a general practitioner in the United Kingdom. Most doctors complete a training programme approved by the General Medical Council (GMC) and are awarded a certificate of completion of training (CCT) at the end. Doctors who have not followed an approved training programme in the UK can join the medical register by getting hold of a certificate of eligibility for specialist registration (CESR) or a certificate of eligibility for general practice registration (CEGPR).

The application process for a CESR or CEGPR—known as the equivalence routes to the medical register—requires candidates to show that their skills, knowledge, and experience are equivalent to those of doctors who have completed an approved training programme and been awarded a CCT. This involves providing documentary evidence of training, qualifications, and experience, which is then assessed by the relevant royal college and subsequently the GMC. Most people applying to the equivalence routes are staff, associate specialist, and specialty (SAS) doctors who have trained overseas or have struggled with the UK’s specialty training programme, either with the pace or with getting into specialty training in the first place.

As part of its review of equivalence routes the GMC recently commissioned research to investigate perceptions of the CESR and the CEGPR among employers and doctors.12 Its findings indicate that neither doctors nor employers are entirely convinced that the application process assures the equivalence of CESR and CEGPR holders to CCT holders, and doctors with a CESR or CEGPR may experience discrimination and poor employment prospects as a result.

What doctors think

The GMC’s researchers asked 648 doctors who held a CCT, CESR, or CEGPR (“certificate holders”); 535 doctors in training; and 187 SAS doctors for their views on the CCT and the CESR or CEGPR routes to the medical register.

Just half of the certificate holders (56%), SAS doctors (52%), and trainees (43%) surveyed regarded CESR and CEGPR as robust assurance of a doctor’s competence to practise independently. Conversely, more than three quarters of respondents (85% of trainees, 79% of certificate holders, and 75% of SAS doctors) believed that the CCT was robust, and 56% overall personally preferred the CCT route to certification.

“Not everyone who comes to the medical register through the CESR route is looked on with suspicion; there are many excellent doctors who take the equivalence route,” says Mark Porter, chairman of the BMA’s Consultants Committee. However, some consultants believe that the quality assurance is better with the CCT given the amount of time trainees spend in specialty training and the difficulty and regularity of the assessments and exams they have to complete, he says.

Some doctors’ lack of confidence in the equivalence routes is based on their concern as to exactly why CESR and CEGPR holders didn’t follow the standard specialty training route in the first place. “There is a perception that the equivalence routes act as a back door to the specialty register for people who might not have got in through the normal pathway through specialty training,” says Nicholas Grant, head of the Joint Royal Colleges of Physicians Training Board at the Royal College of Physicians.

Many doctors who apply for a CESR or CEGPR, however, would happily follow the CCT route if only they could get a place in specialty training, says Radnakrishna Shanbhag, chairman of the BMA’s SAS committee. “If the front door was open, why would doctors want to go through the back door?” he says. “Many applicants have been denied the opportunity to get through specialty training—the training pyramid has a narrow top, and someone has to be stopped from getting on to the specialty register.”

The negative perceptions of the CESR and CEGPR can’t be pinned just on people’s confidence in the application process, though—these doctors do experience real discrimination, adds Shanbhag. “Traditionally the CESR route has been used by overseas doctors, and there is an ingrained prejudice against this group of doctors,” he says. There’s also an element of the doctors who follow the structured CCT training programme and the royal colleges that promote it defending their approach.

What employers think

Among the 52 medical directors and human resources directors surveyed by the GMC, only a quarter (24%) agreed or strongly agreed that a CESR or CEGPR is a robust qualification for application to consultant or GP post (55% neither agreed nor disagreed). More than three quarters (78%) stated either a preference or a strong preference towards CCT holders over doctors with a CESR or CEGPR. This is borne out by reports received by the GMC of advertisements for substantive consultant posts that have specified possession of a CCT as a prerequisite for employment.

For employers to distinguish between applicants with a CESR and those with a CCT would not be good practice and would verge on unlawful discrimination, says Porter. However, people with a CESR or CEGPR believe with some justification that they are not appointed to jobs for which they feel equivalently qualified. “That reflects the confidence in the ‘product’ offered by the CESR.” The GMC’s research backs this up: employers said that CCT holders are more likely to operate to a uniform standard, whereas CESR and CEGPR holders operate to variable standards as a result of their disparate training and experience.

New CCT holders, however, have merely followed a process that has prepared them to be consultants, whereas CESR holders have demonstrated that they have the competence to practise at that level, says Shanbhag. “Individuals who come out from the CCT route are good in theory but may not be able to deliver on the floor,” he says.

As a rule NHS employers are happy that the routes to the register that are available to doctors are accredited and effective—whether CCT, CEGPR, or CESR—says Bill McMillan, head of medical pay and workforce at NHS Employers. On the other hand, appointments to a consultant or GP post are based on more than just the fact that a candidate is on the specialty or GP register. “Employers agree that they can all indicate that a doctor is sufficiently qualified, but employers must also satisfy themselves that every doctor has the experience, knowledge, and skills to perform the role they are being recruited to,” he says.

“To get a CESR doesn’t mean that somebody will be a consultant the next day, it simply means they are eligible to apply for a post,” agrees Grant. “If they apply for a post and are considered suitable for it, that’s another level of quality assurance to the process.”

Establishing equivalence

One of the key issues among doctors and employers surveyed by the GMC is their lack of confidence in the current process for establishing equivalence, which leads them to doubt the knowledge and competence of CESR and CEGPR holders. However, the GMC has stated that there is no evidence that the current arrangements for awarding a CESR or CEGPR have led to patients being harmed as a result of applicants being inappropriately included on the medical registers, and CESR and CEGPR holders are not disproportionately represented in the GMC’s fitness to practise proceedings.

The GMC is now consulting on proposals to make the process for evaluating equivalence more robust, consistent, and efficient. The revamped process could potentially comprise four elements: a six month period of acclimatisation to the NHS for those doctors not already working in the UK; a formal test of specialty knowledge; workplace evaluation of performance in practice; and documentary evidence of experience, although less than is required at present.34

The GMC hopes that this new approach will enhance the robustness and credibility of the equivalence routes in the eyes of doctors and employers. The regulator is also planning a “comprehensive” communications programme to promote visibility and understanding of the CESR and CEGPR routes, to tackle negative perceptions.

The GMC should be careful, however, that asking employers rather than the royal colleges to assess the competence of CESR and CEGPR applicants does not introduce variation through a different route, says Grant. “There needs to be some kind of overall quality assurance that the curricula are being properly applied to these applicants and that there is consistency across the way that their evaluations are conducted locally,” he says. “Taking the colleges out of the loop is something we are concerned about for those reasons.”

Another risk is that the new approach could end up being practically identical to the process that CCT holders have to go through but not as demanding, says Porter. “It actually almost makes it easier to get on to the register through a CESR than through a CCT because it starts to look like a CCT programme but without seven years of training,” he says. “It’s absolutely not the case that we need to make it easier to access the specialist register; we don’t have a shortage of candidates.”

In particular, the possible introduction of an examination is strikingly similar to what CCT holders have to do, which is not appropriate given that the equivalence routes are supposed to be an alternative, says Shanbhag. “By saying that equivalence route applicants should be doing an exam to demonstrate their knowledge is not actually about ‘equivalence’—you’re saying, ‘You have to do exactly what a specialty trainee is doing,’” he says. “If I’m doing exactly what a trainee is doing, then why would you call it an equivalence route?” Another problem is that the current exams are designed for doctors who have strictly and recently followed the relevant specialty curriculum, he says, not doctors who have been on the “shop floor” for years and acquired much of their knowledge through experience.

Is “equivalence” the answer?

This leads us to the issue of whether an alternative route to the medical register really can or should be strictly “equivalent” to the CCT route. The GMC is keen to move on from the concept of equivalence between the two routes because the current nomenclature reinforces perceptions that the CCT provides the gold standard that other routes need to match. The council would prefer that the standard for entry to the specialist and GP register should become the important element, instead of the route taken.

“What employers are looking for, the end point, is for people to be on the specialist register. How you got there is not important,” says Dr Shanbhag. “So I say that rather than give a CCT or a CESR, why don’t you just identify the end point: specialty registration? Because by identifying the route you are perpetuating this prejudice; you are promoting it.”


  • Competing interests: None declared.