Non-training grades in the NHS workforce: the lost tribe?

Once upon a time, hospital doctors were predominantly either substantive consultants or trainees. Staff Grade, Associate Specialist (SAS) doctors and locums were a rarity.^1,2 However, over the past two decades, this dynamic has shifted dramatically: non-training roles now constitute a fundamental component of secondary care.^1–3 SAS doctors and locally employed doctors (LEDs), composed of Trust doctors, clinical fellows and senior fellows, have now become integral to the National Health Service (NHS) workforce.^1,2,4

In this paper, we argue that SAS and LEDs are a particularly vulnerable group, at risk of exploitation and abuse by NHS Trusts, anxious to plug gaps and paper over cracks in the medical workforce. Moreover, as these roles increasingly replace consultants, the overall status and leadership role of doctors in the NHS becomes diminished. This has a profound impact, both on doctors and potentially on the quality of patient care.

By 2023, non-training doctors held over 50% of secondary care doctors’ posts, comprising 64,000 SAS doctors and 25,000 LEDs. ⁵ Within a 5-year period, there was a 40% increase in licensed SAS doctors, accounting for nearly 30% of the United Kingdom’s medical workforce. Approximately 10% of new registrants were International Medical Graduates (IMGs), and they helped bolster the SAS positions and wider medical workforce. ⁵ However, many encountered considerable challenges adapting to UK clinical practice and culture, which impeded their integration and progression.^6,7

National organisations – including the Academy of Medical Royal Colleges, the British Medical Association (BMA), Health Education England (HEE) and NHS Employers – have become increasingly involved in advocating for and supporting SAS doctors. Initiatives and guidelines such as the ‘SAS Charter’, the ‘SAS Development Guide’ and ‘Maximising the Potential: Essential Measures to Improve Support and Development Opportunities for SAS Doctors and Dentists’, along with the introduction of SAS Advocates, aim to improve SAS support and development opportunities, promote recognition, reward, fairness and excellence, ensuring best practices. However, implementation by Trusts has been lamentable, with only a third of SAS doctors reporting that their Trusts have adopted such initiatives. ⁸ This, consequently, inspired NHS Employers to better respond by providing institutions with materials to help evaluate their progress. Notwithstanding these efforts, professional development support and revalidation remain patchy across NHS Trusts. ⁶

SAS doctors continue to struggle to establish and assert professional identity, access structured career development pathways and secure institutional support.^2,6,9 Many feel invisible despite substantial clinical expertise and experience. All this contributes to poor retention, burnout and suboptimal care.^6,8,9

Organisational culture, focusing on inclusion, autonomy and belonging, is a stronger predictor of retention than workforce size.^3,6,9,10 SAS doctors, primarily in deprived areas, often feel undervalued, although their role is increasingly recognised in policy.^2,6,9,11

The landscape of the NHS workforce is evolving and diversifying rapidly: GMC data highlight that in 2023, 68% of new doctors (compared with 47% in 2017) were international graduates (IMGs), with proportionately more ethnic minority doctors. This makes robust induction and smooth cultural integration key to facilitate seamless transitions into the NHS. ⁵ In 2023, women outnumbered men in the workforce.^12,13 These trends underline the NHS’s increasing reliance on IMGs and affirm the salience of equitable opportunities, regardless of background, across all roles, including leadership, educational and teaching roles.^5,14,15

This rising prominence of SAS and non-training doctors presents both opportunities and challenges.^2,6,9 There is an urgent need for evidence-informed policy reforms to strengthen workplace conditions, professional development, mentoring and leadership roles essential to empower IMGs to thrive and contribute to building a fair, resilient and sustainable workforce.^14,15

Non-training grade doctors have become pivotal to effective service delivery of the NHS.^1,6 The 2021 design of the Specialist grade pathway introduced a feasible avenue of progression beyond the Specialty Doctor level.^1,6,16 As of 2023, 64,000 SAS doctors accounted for nearly 30% of the UK medical workforce, a 40% increase over 5 years. ⁵ SAS and LEDs also play an indispensable role in maintaining the continuity of healthcare services and addressing shortages of consultants and trainees throughout NHS Trusts.^1,6,7

Many pursue SAS roles for stability and better work – life balance. Nonetheless, these positions frequently lack the contractual protections and developmental opportunities enjoyed by consultants and trainees.^1,5,6,7,17 The induction, supervision and appraisal practices across numerous Trusts remain inadequate.^1,18

The Royal College of Physicians recommended a more streamlined Certificate of Eligibility for the Portfolio (formerly CESR) pathway to the Certificate of Completion of Specialist Training (CCST), as well as the establishment of sound national frameworks to better support SAS doctors^1,5,6,16; yet, many still feel undervalued and marginalised.^19–21

A recent survey of 40% of Specialty Doctors revealed continuing challenges in accessing study leave or funded Continuing Professional Development (CPD).^1,5,6,20 The 2021 SAS contractual reforms introduced Specialist grade roles and Supporting Professional Activities (SPA) time; however, implementation has been inconsistent, and numerous Trusts have yet to appoint SAS Advocates.^1,5,6,21

A 2023 government-BMA agreement focused on improving SAS retention; though, financial measures alone cannot remedy the deeper cultural and structural issues.^1,6,8,9,21 NHS organisations must enshrine a holistic workforce planning approach, align SAS pay accordingly, fully implement the 2021 contract, expand Specialist grade roles, streamline CESR pathways promote access to effective developmental opportunities, CPD, mentoring, supervision, reflective practice, mental health and psychosocial support. Combating inconsistency and undervaluation is crucial for SAS retention and advancing the sustainability and effectiveness of the NHS.^{1,2,5,6,19–22}

SAS and LEDs – constituting over 25% of the NHS workforce – have conveyed experiencing marginalisation, deficient induction, restricted career development and discrimination in their practices, particularly among international and ethnic minority doctors. Based on King’s Fund data, 18% of SAS medics identified as having disabilities in contrast to just 4.7% of all GMC-registered doctors, signifying the existence of structural barriers within healthcare systems. ²³

Moreover, a substantial proportion of internationally trained SAS doctors reported encountering discrimination that adversely impacts their appraisals, development and career prospects. Cultural and educational disparities are often associated with this. ²⁴ Gradism – bias against lower professional grades – remains pervasive, hindering careers, excluding SAS doctors from leadership positions, undermining morale and consequently damaging service quality.^22,25

The BMA has played an instrumental part in championing transformative reforms, including enhancing workplace culture, safeguarding equitable career progression and pay equity, incorporating standardised monitoring systems and endorsing better SAS representation in leadership posts.^22,25,26 At the 2025 BMA Annual Meeting, SAS doctors underscored their continued underrepresentation across various positions, including holding just 0.1% of medical director posts, 0.2% of clinical governance lead roles and 4.5% of educational supervisor positions. This reinforces the significance of transparent, competency-based promotion and formal recognition of their substantive contributions. ²⁶

The 2025 NHS England People Promise pilot expanded to 116 Trusts (initially started with 23), successfully retaining 4500 staff and attaining a 12% turnover reduction. This outcome signifies how flexible working arrangements, e-rostering and effective engagement all contribute to enhanced retention. ²⁷

Discussion

Medical training remains key for complex care and leadership. However, medical careers within the NHS face a crisis as doctors’ authority and leadership are increasingly eroded. Medicine is facing a hostile pincer movement: on the one hand, expanding roles of non-medical Healthcare professionals such as Physician Associates (PAs) and Advanced Nurse Practitioners, that challenge both the role and professional identity of the Medical Profession, and on the other, the shifting workforce balance in medicine towards non-training grades and a reliance on locum medical staff creating a medical workforce more easily manipulated and subjugated by management, further marginalising the profession.

Poor morale in the medical profession is not just about pay. Without reforms that enable fair progression and better conditions and treatment for non-training grades, staff will continue to quit the NHS, and the profession will become further diminished. Most importantly, a full and frank discussion needs to take place between the medical profession, NHS leaders and politicians to agree on the role of Doctors in the NHS. At present, the shifting workforce landscape is relegating the Medical Profession, by stealth, to the status of technicians, and we as a profession have been guilty of complacency in allowing this to happen. Doctors are better trained, more experienced, and as intelligent as any, and most importantly, are hard-wired to protect the interests of patients. Decision-makers should be careful about what they wish for.