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Undermined and overlooked: SAS doctors respond to survey

The Doctor magazine
16 x 9

February 2020, Issue 18
MACRAE: 'Bullying can be subtle'

SAS doctors often feel bullied and sidelined, according to new GMC research. But changing attitudes and some enlightened employers give cause for hope. Tim Tonkin reports

‘No offence, but we need a proper gynaecologist to do this.’

‘It wouldn’t look good if your department had an SAS doctor as clinical director.’

These are just two of the comments received by one senior staff, associate specialist and specialty doctor and tutor from a clinical director and appraiser respectively.

They will be familiar to very many SAS doctors, and those who are locally employed, who have long reported bullying and discrimination.



Doctors from foundation and post-foundation level can be classed as locally employed and fall under no single nationally defined contract but rather are employed on fixed-term arrangements with employers.

The latest, and one of the most significant, surveys to support this was published last month by the GMC. It was the first the regulator had carried out of SAS and LE (locally employed) doctors’ workplace experiences.

Of the more than 6,000 doctors taking part in the survey, 30 per cent of SAS doctors and 23 per cent of LE doctors say they had experienced bullying, harassment or being undermined by a colleague in the previous 12 months.

For SAS staff, the most common forms of harassment included belittling and humiliation (26 per cent), rudeness and incivility (27 per cent) and threatening or insulting comments or behaviour (16 per cent), with these categories being respectively reported by 27 per cent, 30 per cent and 15 per cent of LE doctors.



Added to the findings relating to bullying is the 61 per cent of SAS doctors who either disagreed or strongly disagreed when asked whether they felt the role of an SAS doctor was viewed as a positive career choice in the medical workforce.

‘I think what this report has shown is the problem is greater than we thought it was,’ says Fiona MacRae (pictured), an associate specialist in anaesthetics based in the north west of England and chair of the Mersey SAS committee.

‘Bullying isn’t always in-your-face style nastiness, it can be more subtle such as sidelining, ignoring or otherwise treating someone differently.

‘It’s the sense of powerlessness and lack of autonomy.’


Few reports

Of the 30 per cent of SAS doctors who experienced incidents of bullying or harassment, only 9 per cent reported the incident. For LE doctors this figure came to just 6 per cent.

For those who stayed silent, 34 per cent of SAS doctors and 33 per cent of LE doctors told the GMC they had done so out of fear of adverse consequences, while 40 per cent and 35 per cent respectively said they didn’t think reporting an incident would make a difference.

Dr MacRae says she has on more than one occasion been told by colleagues to fetch someone ‘more senior’, despite being one of the most experienced staff members in her department.

‘I work fully independently but I feel I’m often kept at arm’s length, sidelined and passed over for opportunities,’ she says.



‘It’s never a level playing field. All I’ve asked for is to be treated fairly and with respect and this often doesn’t happen.’

Dr MacRae supports the idea of an independently appointed anti-bullying champion being employed at every trust who would be able to listen to and rule on complaints brought to them.

She feels confusion or even ignorance of SAS job titles means the seniority and experience of members of the grade is not clear and underestimated as a result.

‘Trainees can be “pigeonholed” at different levels by their specialty training level, so you can know how close to consultant level they are. We don’t have those sorts of labels for SAS doctors and I think that confuses people,’ she says.



Yet the picture painted by the survey’s findings is far from clear cut.

72 per cent of SAS doctors and 75 per cent of LE doctors either agreed or strongly agreed they felt they were valued members of the teams they worked in.

52 per cent of SAS and 62 per cent of LE doctors also responded this way when asked whether they felt they had the opportunity to participate in workplace decision making.

Precisely the same proportion said they felt a senior colleague would be open to their opinion in the event of a disagreement.


Leave the room

BMA Northern Ireland SAS committee chair Carole Cairns (pictured below) acknowledges the GMC’s survey is a mixed bag, with sources of positivity alongside causes of concern. 

‘Personally, I have had a great career and always felt fully accepted as part of the team,’ she says.

NISASC chair Carole Cairns
BMA Northern Ireland

‘However, I’ve come across [other SAS doctors] who have not even been allowed to remain in the room while the consultants are discussing something.’

Dr Cairns says poor understanding of SAS job titles in relation to expertise and experience, as well as lack of awareness of the role played by SAS doctors in the workplace, needs to be addressed.


Career paths

She adds that more should be done to promote the SAS career path to younger doctors to dispel the idea that the grade is merely a ‘stop-gap’ role for those unsure as to what direction to take their careers.

‘We should be talking about three cohorts of permanent doctors: consultants, GPs and SAS,’ says Dr Cairns.

‘A lot of employers and trust management have no concept of what an SAS doctor is. They need to have an understanding of the definition and we need to make sure this goes right to the top.

‘Additionally, quite a lot of SAS doctors do not receive induction. If we made this compulsory this would help put them firmly into the mind of employers as a distinct group of doctors.’



Greater recognition, be it of clinical experience or contributions in the workplace, has been another long-standing cause for frontline doctors and the BMA staff, associate specialist and specialty doctors committee.

This desire was overwhelmingly reflected in the survey, with 70 per cent agreeing that recognition of SAS doctors on the GMC’s online register would help to support the career development of members of the grade.

Associate specialist in child and adolescent mental health Victoria Thomas says she opted to return to the SAS grades after completing her CESR (certificate of eligibility for specialist registration) and becoming a consultant, because of the flexibility afforded by the AS role.

Dr Thomas, who works for Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, says there are signs SAS doctors are starting to get the recognition and consideration that had traditionally been insufficient or absent, at local and national levels.

‘Our trust is incredibly supportive of SAS doctors,’ she says.

‘There have been a lot of initiatives around things such as supporting people doing CESR, having an active SAS forum and a full commitment to the SAS charter. There does now seem to be greater recognition [of SAS doctors] not just at my trust but nationally.’



Dr Thomas’s optimism is backed up by some of the report’s more encouraging findings.

These include a majority of SAS doctors (57 per cent) reporting having access to SAS tutors or advisers in their workplaces, and 83 per cent stating they received one or more SPA (supporting professional activity) session per week.

For LE doctors, 54 per cent reported having one or more SPA a week while 74 per cent have a named person in their departments to support them with CPD (continuing professional development).

74 per cent of SAS doctors and 49 per cent of LE doctors said they trained others as part of their jobs. However, when asked to rate the level of support received from their trusts or boards in this capacity, the picture is mixed.


Lack of support

While 38 per cent of SAS doctors describe support as either good or very good, 54 per cent label it as indifferent to poor. This contrasts to 51 per cent and 44 per cent respectively for LE doctors.

Commenting on the report’s findings, BMA SASC co-chair Amit Kochhar (pictured below) expresses his regret that many members of his grade continue to feel marginalised and overlooked in their careers and workplaces.

He says: ‘Specialty and associate specialist and locally employed doctors are vital to our NHS, which is why it’s crucial that they, like any other member of staff, feel supported and valued as they carry out their life-saving work.

Amit Kochhar BMA council comittee member 2014

‘These doctors have long felt overlooked, so it’s disappointing to see this theme re-emerge in this latest survey – particularly that more than a quarter of SAS colleagues disagreed or strongly disagreed their working environment is a fully supportive one.

‘While many employers recognise the [SAS] charter and the needs of this important part of the workforce, today’s survey has made clear that more needs to be done to ensure all SAS and LE doctors are properly listened to, appreciated, and above all, valued – regardless of where they work.’


GMC survey: exhausted and burnt out

  • 41 per cent of SAS doctors in the UK either agree or strongly agree that patients they are responsible for are correctly coded to them. However, 44 per cent disagree or strongly disagree with this
  • While 30 per cent of SAS doctors in the UK work completely autonomously, 58 per cent work under some degree of supervision and 12 per cent do not work autonomously at all
  • 66 per cent of SAS doctors say they had access to an e-portfolio to track CPD progress. However, 30 per cent of this total had to pay for access rather than having it provided for free by their employers
  • 43 per cent of SAS doctors and 41 per cent of LE doctors describe their work as emotionally exhausting to a high or very high degree with 56 per cent of SAS doctors and 46 per cent of LE doctors saying they feel burnt out by their work either somewhat or to a high degree
  • 61 per cent of SAS doctors say they see themselves continuing in their roles in a year’s time compared with just 22 per cent of LE doctors, while 30 per cent say they will consider joining a formal training programme in the future compared with 71 per cent of LE doctors.

Read the report

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