An overview of autonomous working
SAS doctors may be capable of taking decisions and carrying responsibility without direct supervision. This is known as autonomous working. This guidance will consider how the principle of autonomy applies to specialist, associate specialist and specialty doctors.
Working autonomously as a specialist
The specialist grade, introduced in 2021, was the result of negotiations between the BMA, the Department for Health and Social Care (DHSC), and NHS Employers. The role was created to recognise and utilise doctors’ experience, skills and knowledge, while giving them an opportunity for career progression within the SAS cohort.
Specialists are autonomous workers, able to work to a level of defined competencies, as agreed within local clinical governance frameworks. This principle has been agreed with NHS Employers and the Academy of Medical Royal Colleges.
If you are a specialist, you should be engaged in a clearly defined autonomous practice, and this work should be recognised (see below section on what working autonomously should look like).
Working autonomously as an associate specialist
While the national associate specialist grade closed in 2008, there are still doctors on both national and local associate specialist contracts.
While the associate specialist terms and conditions do not specifically reference autonomous working, many associate specialists have a wealth of experience and expertise, and a longstanding autonomous practice in defined areas.
If you are an associate specialist engaging in autonomous practice, this should be agreed and represented in your job plan and appraisal process.
Working autonomously as a specialty doctor
The specialty doctor cohort is made up of doctors with a wide range of experience – from those who have worked in medicine for decades, to those who have only four years’ post-graduate training. Unlike with specialists, there is not a blanket assumption all specialty doctors should work autonomously.
Specialty doctors work under supervision, however, they can also work autonomously in all or part of their practice. Some doctors seek this additional responsibility.
The principle that experienced specialty doctors may work autonomously predates the creation of the specialist role. As part of their negotiations for the 2008 SAS contract, NHS Employers agreed that:
At the top of the grade, SAS doctors will have acquired a high level of specialist knowledge and expertise and have the capacity and opportunity to work independently within agreed lines of responsibility and will also take a broader role in the Organisation through other activities such as teaching and audit.
NB: This was specified in the 2006 Summary Agreement, which formed the basis of the 2008 terms and conditions (see our previous guidance for reference), and is also outlined in the UK job planning guidance for SAS Doctors published by NHS Employers in November 2012.
It is also worth noting that the specialty doctor terms and condition (Schedule 13, Paragraph 8 of the 2021 TCS and Schedule 15, paragraph 7 of the 2008 TCS) states that, to achieve pay progression through to the higher threshold, a doctor must meet several criteria including being able to “demonstrate an increasing ability to take decisions and carry responsibility without direct supervision”.
Specialty doctors who think they can do so may, accordingly, request to work autonomously. Such agreements are local arrangements related to the local practice.
We believe that only those doctors/dentists who have been identified as having the appropriate levels of competence and skill should manage patients independently. Like consultant colleagues, SAS doctors may still be able to discuss their clinical decisions with other senior doctors when working autonomously. It must, however, be acknowledged that this needs to happen within a framework of clinical governance that provides assurances of competence and maintains patient safety.
The benefits of such an approach to the organisation, patient and individual are:
- Recognition of the high level of clinical skills and professionalism in the SAS doctor/dentist grade
- Provision of personal and professional development opportunity for SAS doctors/dentists within the Trust/organisation.
- Opportunity to have greater medical engagement of SAS grades
- Support recruitment and retention of highly skilled clinicians
- Improved Governance and Accountability
NB: Autonomous working is not to be confused with acting up (as either a specialist or consultant).
SAS doctors may act up as a more senior grade (for example, to provide cover for an absent doctor). Such arrangements should be formalised, and the rates of payment are stipulated in SAS doctors' TCS (Schedule 19 in the 2021 TCS). For more information on acting up, see our guidance.
Becoming and autonomous worker
Requesting to work autonomously
Taking on an autonomous role is a significant undertaking and should be considered carefully but, if you are confident and experienced in a particular area, it is worth exploring.
When considering whether to make this request, you may wish to consider the following:
- Are there any practical job planning issues to consider which will need to be addressed?
- How would autonomously working impact your workload, and what support might you need for this? How could autonomously working work on a day-to-day basis?
- How would you make sure you are still receiving adequate oversight for your work? You may wish to agree a review mechanism that could be implemented and have regular catch-ups with the relevant consultant.
- How can you demonstrate that you are carrying out work to a high standard already? What evidence do you need to prepare to support this?
- Would your colleagues support your request? You may wish to speak to them about your work and abilities to get an idea of their view.
- Do you wish to work autonomously for all or part of your work plan?
Note it is possible that the consultant and other colleagues will not agree that you are ready to work autonomously.
Trusts may have their own autonomous working policies. You should check to see if there is one currently being implemented in your workplace, and follow the process described within it so that any autonomous working can be formally recognised and evidenced.
In the absence of such a policy, you should raise your aspirations with your line manager/clinical lead, for further consideration during your appraisal discussion. 2015 autonomous working guidance suggests the following process:
- Doctor submits a written request to the clinical lead outlining the proposal for autonomous practice
- The lead discusses this request, addressing areas for consideration
- The lead discusses the request with the divisional chair and CEO or a person delegated by them
- The lead provides a written response to the doctor
- The lead will ensure appropriate coding of activity to facilitate appropriate data on workload, activity and outcomes, henceforth becomes available
- The doctor sends the agreements of the lead and divisional chair to the medical director to obtain his/her sign off
You may wish to refer to 2015 guidance , though please note that this was published before the introduction of the specialist role (and accordingly makes no reference to it). If you require support during this process, and you are a BMA member, you can speak to your local BMA Local Negotiating Committee representatives or contact us for advice.
Being asked to work autonomously
It is possible that a non-specialist SAS doctor could be asked to work autonomously, without initially raising the subject.
If a doctor wishes to agree to do this, there should be a clear agreement in place, outlining the scope of autonomous work, etc. Ideally the process for this would be outlined in the Trust’s autonomous working policy.
If the doctor does not wish to do this, or feels uncomfortable working without supervision, they must not be pressured into acting outside of their competency.
Autonomous working vs inadequate supervision
There is a difference between autonomous practice, and doctors receiving inadequate supervision.
An experienced doctor seeking to work autonomously should do so under a formalised agreement (see above).
Your employer should be assisting you to develop and to meet the criteria to progress to higher thresholds but a SAS doctor should not be forced, through a lack of supervision, to act outside of their competencies.
Inadequate supervision is a cause of concern. If you believe you are struggling with this, and not receiving appropriate support from your employer, please speak to your local BMA Local Negotiating Committee representatives or contact the BMA.
Autonomous working as a SAS doctor vs acting up
It is important to note this guidance looks at autonomous working within a doctor’s substantive SAS grade. This is not to be confused with the provisions for SAS doctors acting up to a more senior grade (either as a specialist or a consultant).
When acting up, a doctor should be provided with a temporary job plan describing their responsibilities, and paid in accordance with their temporary grade. For more information, see our page on acting up.
What should autonomous working look like?
Recognition of autonomous working
It is important that a SAS doctors’ autonomous working can be evidenced, so they can demonstrate their ability to act independently, and be appropriately recognised for it. This could impact their career progression and remuneration for extra-contractual work.
There are several ways to record a SAS doctors’ autonomous work:
- Job plan – independent work must be fully accounted for in an individual’s job plan
- Appraisal process – independent work must also be fully accounted for in an individual’s appraisal process
- Coding of clinical activity
The proper coding of clinical activity produces a more accurate record of patient care, provides evidence of an individual doctors’ experience (which can enable them to progress their career), and provides data on the actual working practices of SAS doctors. Accurate coding should be done with the support of the Trust and department.
The Health and Social Care Information Centre has confirmed that for local recording, organisations can record patient care under a SAS doctor using local codes. However, these will need to map back to national codes for reporting purposes.
It is important to note, however, that all patient care should be more accurately coded, so all SAS input to a patient’s clinical pathway should be recorded, even when not a direct referral. The NHS requires input of accurate data to reflect clinical activity and trusts now have a financial incentive to ensure that coding is accurate, comprehensive and timely.
All SAS doctors with BMA membership are able to use Dr Diary as a key part of their job planning process as it allows you to accurately track and evidence your time and activities, including autonomous work.
Not a member? Join today to access Dr Diary.
Don't have the app? BMA members can download Dr Diary on iOS or Android.
Managing direct referrals as an autonomous worker
Autonomous working specialty doctors should be able to accept direct referrals if this is agreed to in their job plan.
If you are successful in your request to work autonomously, you will need to discuss the ability to take direct referrals in your job plan review. Job plans should be agreed on an annual basis as a minimum, but SAS doctors or their clinical managers may call for an interim review at any time.
Your existing job plan remains in contractual force until change is agreed in a job plan review or until after the conclusion of the appeals process if necessary.
Removal of autonomous worker status
Although unlikely, there may be exceptional circumstances where your line manager will suggest you should no longer be working autonomously, for example, following a process where capability performance issues have been identified. If this happens, the change of practice should be discussed in a job plan review, where you would be able to challenge this through the job plan mediation and appeals process. As mentioned above, these should be agreed on an annual basis at a minimum, but SAS doctors or their clinical managers may call for an interim review at any time.
Autonomous practice and extra-contractual work
While there are currently no nationally agreed rates, it is understood that autonomous doctors are usually compensated at a higher rate for extra-contractual work than non-autonomous doctors.
The BMA believes that this principle should apply to all doctors, irrespective of grade, though we have been made aware of incidences where SAS doctors’ autonomy is not recognised outside of their normal working day.
Such practice must be challenged. If you are working autonomously during your contracted hours, this should be recognised in your extra-contractual work.
If you are struggling to get this recognition and require support, speak to your BMA Local Negotiating Committee SAS rep or contact the BMA.
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