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SAS doctors – the solution to the GP workforce crisis?

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan

Another week, another NHS workforce report.  This time, we look to the annual GMC ‘State of medical education and practice in the UK’ study which analyses workforce trends across the GMC register.  The main messages from this year’s report focus on specialty and association specialist (SAS) and locally employed (LE) doctors, a workforce that has increased by more than 40% over the last five years.1  The report contrasts growth in this sector with that of the GP workforce, which is only growing at 7%, a rate almost six times less than the SAS workforce.  The growing SAS workforce, and the stalling growth of the GP workforce, combined with warnings of a mass exodus from the profession, has clearly got people thinking.  The GMC report suggests that there is a solution here – and it involves shifting the SAS workforce into general practice.

SAS doctors have historically been able to work in hospital, but not in general practice.

It’s worth reminding ourselves who these doctors are.  SAS doctors are sometimes referred to as the backbone of hospital services and comprise 22% of the licensed GMC workforce.1   SAS doctors are not in training and do not appear on GP or specialist registers, and are usually locally employed by a trust on a short or fixed-term contract.  They encompass a diverse group of medics.  The majority of SAS doctors complete their primary medical qualification overseas.  Previously referred to sometimes as ‘staff grades’, all doctors now appointed into SAS roles join as specialty or specialist doctors.  Speciality doctors have at least four years post-graduate training, with two in a specialty training programme, while specialist doctors are highly experienced medics with at least 12 years post-graduate training.2  So, while some might be fairly junior, and may need closer supervision, others have considerable experience, expertise and can work more autonomously based on the scope of their previous clinical practice.

SAS doctors have historically been able to work in hospital, but not in general practice.  Currently, to train and work as a GP in the UK you need to be on the primary medical performers list.  Performers list regulations are legislated through UK government statute, which states that ‘a medical practitioner may not perform any primary medical services unless that medical practitioner is a general medical practitioner and is included in the medical performers list.’3  As SAS doctors are not recognised specialists and are not involved in a training scheme, they are currently not able to join the Performers List and therefore cannot currently practice autonomously in general practice.

The GMC is billing the Performers List as a bit of ‘red tape’: in a recent interview the Chief Executive of the GMC, Charlie Massey, says that ‘we’ve got a massively increasing number of doctors who are prevented by red tape by being able to work there [in general practice].  So let’s remove that red tape, and then work out who and how many and in what way and how quickly we’re able to move people into primary care.’4  In other words, seeing an opportunity to tap into this growing workforce, the GMC  is suggesting a change in the Performers List criteria that prevents SAS doctors from working in general practice.  Alongside changes to the Performers List, the GMC report suggests the creation of an SAS grade in primary care to allow this group of doctors to work alongside GPs in ‘complementary primary care roles’.

Chief Executive of the GMC, Charlie Massey, says that ‘we’ve got a massively increasing number of doctors who are prevented by red tape by being able to work there [in general practice]…

There are existing pathways to allow experienced doctors to join the general practice workforce in a safe and supported way, for instance, by completing a shortened GP training programme.  Doctors with experience from other specialty training programmes or overseas experience can transfer their capabilities to reduce the three-year GP training programme by up to twelve months.  Overseas qualified GPs can join the International Induction Programme (IIP) which provides a supported six-month pathway for overseas qualified GPs to join the medical performers list.  These programmes recognise the experience and training needs of each doctor and provide individualised training pathways towards working as a GP.

The GMC proposal, however, isn’t suggesting that SAS doctors should become fully qualified GPs.  Indeed, some SAS doctors who value the flexibility of their role might not want to be part of a training programme. Developing innovative roles in general practice has been a keystone of recent general practice workforce planning, partially because the government has repeatedly failed to meet targets to increase the number of GPs.  Staffing in general practice is already being bolstered by additional health professionals such as physician associates, clinical pharmacists and others involved in the Additional Roles Reimbursement Scheme (ARRS).  Proposing the creation of another complementary primary care role needs a fair bit of thinking through in terms of induction, training, revalidation, role definition and supervision.  It is currently unclear how the capabilities and training needs of an SAS grade doctor in primary care would be met, especially in such a diverse workforce where one proposal will not fit all.

Time will tell if the government accepts the GMC proposal and considers legislative change to allow SAS doctors to join Performers Lists.  Any changes to the law are not going to be quick, and as Martin Marshall has highlighted, ‘we would need to see more detailed proposals from the GMC about how SAS grade doctors could work in general practice and integrate with existing teams.’5  Existing pathways to GP registration need expanding to allow more experienced doctors to join general practice in a supported and safe way.  It is tempting to see the growing SAS workforce as a lifeline to the general practice workforce crisis, but it would be naïve to see this as a quick, or easy fix.

References

  1. The state of medical education and practice: The workforce report London: General Medical Council; 2022.
  2. Staff, associate specialist and specialty (SAS) doctors: Royal College of Physicians; 2015 [Available from: https://www.rcplondon.ac.uk/education-practice/advice/staff-associate-specialist-and-specialty-sas-doctors.
  3. The National Health Service (Performers Lists) (England) Regulations 2013,Stat. No 335 (2013).
  4. Kaffash J. GMC plans to enable ’10,000 or more’ SAS doctors to enter general practice: Pulse; 2022 [Available from: https://www.pulsetoday.co.uk/news/regulation/gmc-plans-to-enable-10000-or-more-sas-doctors-to-enter-general-practice/.
  5. Iacobucci G. Can SAS doctors help tackle the GP workforce crisis? BMJ. 2022;379:o2531.

Featured Photo by Filip Andrejevic on Unsplash

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Thanks for an excellent article, BUT you refer to the GMC report as saying “….. over the last five years. The report contrasts growth in this sector with that of the GP workforce, which is only growing at 7% ….”

But the GMC report only gives total headcount figures. A search in the report for “whole time equivalent” or “WTE” gives zero results. Indeed the report explicitly states that “While the data we collect do not include the hours doctors work, since 2012 the health systems across the UK have consistently reported headcount to full-time equivalent ratios in secondary care of over 0.9 … and around 0.8 for primary care. In primary care in England there’s been slight downward trend from 0.83 in 2015 to 0.79 in 2021, which is a 5% decrease.”

The suggestion that there has been an increase of 7% in the whole time GP workforce is not consistent with other figures available, and I fear may be incorrect?

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