AS you like it SAS doctors have a renewed sense of optimism that the AS (associate specialist) grade – effectively closed 10 years ago – will be reopened. Tim Tonkin finds out what this would mean

Victoria Hewitt has championed her specialty, been a clinical lead, and developed educational resources. Hani Mekhael (pictured above) has introduced new procedures which have given his unit some of the best outcomes in the country.

What is interesting about these two high flyers is they say it’s their grade that has given them the freedom, status and motivation to achieve benefits for their patients.

They are associate specialists, a cherished but latterly endangered position. Effectively closed to new entrants by the Department of Health in 2008, there are now fresh hopes it will be reopened after years of BMA pressure.

‘We’ve never been so close to reopening the AS [associate specialist] grade as we are right now,’ says BMA staff, associate specialist and specialty doctors committee chair Amit Kochhar.

KOCHHAR: ‘It will be an excellent outcome for doctors’

‘This will be a dream come true, we have fought so hard for this for so long, it will be an excellent outcome for doctors and the BMA if we are able to secure what we want.’

Dr Kochhar has been encouraged by supportive statements about SAS doctors by the Review Body on Doctors’ and Dentists’ Remuneration (one of the very few reasons to cheer that report) and an agreement in principle from health and social care secretary Matt Hancock in September to reopen the grade to ‘extend career development for this important group of doctors’.


Negotiations on reinstating the role are due to begin later this year. If they are successful, it will restore to SAS doctors a licence to lead and innovate which many feel they otherwise lack. Associate specialists and those who aspire to the position often say the specialty doctor grade, which replaced it, does not provide the same opportunities, career progression or status that comes with being a senior hospital doctor.

‘Putting me on the AS grade made me feel valued by my employer,’ Dr Mekhael, an associate specialist in obstetrics and gynaecology says. ‘You cannot expect doctors to develop if you do not invest in them.’

Egyptian-born Dr Mekhael first came to the UK in 1994 and began working at the South West Centre for Reproductive Medicine in Plymouth in 2002.

‘You cannot expect doctors to develop if you do not invest in them’

During his time there, Dr Mekhael was responsible for most of the assisted conception work, and put a huge amount of effort into developing the service. He introduced the technique of the dummy run for transferring embryos, which greatly increased rates of clinical pregnancy. His initiative saw the unit propelled into the national top 10 for clinical pregnancy rates per embryo transfer.

‘If I’d been employed as a consultant I would have had to follow a different job plan which wouldn’t have given me the chance to focus on this particular area, and excel in IVF and assisted conception,’ he says.

‘I think being an associate specialist at that unit with all my time and effort dedicated to assisted conception services facilitated all the success.’

HEWITT: ‘You’re allowed to bring that wealth of experience that you’ve got’

You might think that Dr Mekhael is at least one of the doctors who ‘made it’ as an associate specialist before the drawbridge was pulled up 10 years ago. But it’s not that simple.

For when he came to move from Derriford Hospital in Plymouth to North Devon District Hospital, he could not automatically assume there would be a job of the same grade waiting for him. Instead he needed to negotiate with his new employer to draw up a local contract, the first to do so. Others have been less successful.

This is why Dr Mekhael says the current piecemeal access to the grade is discriminatory, not only because it prevents those wishing to become associate specialists from doing so, but because it limits the options of those who already are.

By ensuring that all trusts reopen the grade, existing associate specialists would not have to fear ‘sacrificing’ their grade if they wanted or needed to change their jobs, he says.

Leadership roles

With SAS doctors reporting among the highest rates of bullying and harassment in the workplace, Dr Mekhael warns that the reduced mobility resulting from the inconsistent transferability of the associate specialist grade, makes these doctors potentially more vulnerable to such issues.

For Dr Hewitt, like Dr Mekhael, holding an AS post has enabled her to bring great benefits to her patients. A palliative care doctor in Newcastle, she is a prime example of how the grade can be a springboard for service innovation and leadership.

Initially a GP, she decided she wanted to focus on palliative care. In 2006, she became clinical lead of the Northern Cancer Network, which sought to gain greater acknowledgement of the role of palliative care beyond its use within oncology.

‘I think there is an inherent bias and assumption that if you’re a specialty doctor you’re not as experienced’

She now has an educational role at Newcastle University, which has included developing a free online course for health professionals focusing on safe prescribing of opioid medication in cancer patients.

She says being an associate specialist was key.

‘It has definitely been an advantage because you’re allowed to bring that wealth of experience that you’ve got and to be seen as an equal.

‘If I think back to the opportunities I had, would I have had them if I had not been an associate specialist? Probably not. I think there is an inherent bias and assumption that if you’re a specialty doctor you’re not as experienced.’

One by one

It’s important to stress that the efforts to reopen the associate specialist grade are not about diminishing specialty doctors – many of whom have led and innovated within their hospitals.

Gareth Clark has recently become an associate specialist in emergency medicine in Swindon. He is a beneficiary of a painstaking trust-by-trust approach taken by the BMA to reopen the grade locally – to which 29 have so far agreed in principle – while at the same time lobbying for a new national deal.

Dr Clark says reopening the AS grade would not diminish the appeal or standing of the specialty doctor role, but rather complement it.

‘People are more likely to apply for the specialty doctor or clinical fellow posts if they can see that there is career progression up to the most senior non-career grade post,’ he says.

Dr Clark believes it would give more stability to the workforce, and the opportunities that come with independent practice.

He says: ‘Specialty grade doctors have a broad set of opportunities for things they can do, particularly outside of hospital medicine, that trainees don’t. But people get put off applying for these posts because they know they cannot reach the echelons on a par with consultancy.

‘Reopening the associate specialist grade gives them somewhere to go, as they can be on a par with the consultant team and be part of the senior management in the trust.’

The BMA is urging members who would like to become part of a future negotiations team to put themselves forward. It is not yet clear which parts of the UK the negotiations will cover.

It is also seeking the views and input of SAS doctors ahead of negotiations through a survey which will seek to gain a better insight into respondents’ working arrangements.

‘Reopening the associate specialist grade gives them somewhere to go, as they can be on a par with the consultant team’

The survey will also be a chance for doctors to highlight the issues they would like to see prioritised across categories such as pay and entitlements, career development, job plan and role, safeguards and workload.

‘The recommendations of the DDRB and the commitment displayed by the health secretary demonstrated that the needs and concerns of SAS doctors are finally beginning to receive the recognition they have long deserved,’ says Dr Kochhar, himself an associate specialist.

‘With these negotiations we have an opportunity to make a significant and lasting difference to the career-progression opportunities of SAS doctors, and to enhance the recognition of the important work we do and contributions we make to patients and the NHS.’

APPRECIATION: Some of the thank you cards received by Dr Mekhael’s unit


Emma Brown

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