Position statement in support of reopening the Associate Specialist grade


This position statement sets out the view of the Royal College of Anaesthetists and the Association of Anaesthetists that the grade of Associate Specialist should be reopened to new entrants based on workforce need.

This statement will be:

  • placed on the College and Association websites
  • tabled at the Academy of Medical Royal Colleges November Council
  • used to make representation to the Review Body on Doctors’ and Dentists’ Remuneration (DDRB), who in turn provide independent advice to the Department of Health and Social Care (DHSC), to this effect. The DDRB recommended the reinstatement of the Associate Specialist grade as recently as 2017
  • shared with senior health stakeholders, as appropriate.


Staff and Associate Specialist (SAS) doctors make up nearly one quarter (22%) of the anaesthetic workforce and are vital staff for delivery of patient care in the NHS across the UK.

Though we recognise that this issue is also a contractual matter, we believe that the potential workforce impact on recruitment, retention, morale and welfare of our membership compels the College to develop this position. The College is determined to support all anaesthetists of all grades throughout their career and we are particularly alert to the workforce pressures that are having a detrimental impact on the anaesthetic workforce and as a result, potentially undermine the delivery of patient care. The Royal College of Emergency Medicine published a similar opinion in a statement in September 2018.

The Associate Specialist grade was closed to new entrants a decade ago, following the introduction of the specialty doctor contract in 2008. At the time, the specialty doctor contract was assumed to be attractive enough for both employers and employees to become universally implemented. This is not presently the case. Instead there has been a proliferation of locally employed doctors under a variety of terms and conditions. To assist recruitment and retention many Trusts have recently recruited to “Trust Associate Specialist” posts, mirroring previous Associate Specialist terms and conditions.

Ten years on the current arrangements do not acknowledge the skills, experience and contribution of the SAS cohort due to a range of factors:

  • recognition of autonomous practice: the principle of autonomous practice for suitably experienced and qualified SAS doctors is established and recognised by NHS coding frameworks, but in practice it is often difficult to implement and formalise. Before 2008 the Associate Specialist grade recognised a senior doctor’s expertise and Associate Specialists were understood to be working autonomously at a senior level. Re-grading was not an automatic process, but instead it acknowledged clinical expertise and seniority. It was assumed in 2008 – when the specialty doctor contract replaced the previous arrangements – that a system of credentialing would be established to recognise expertise gained outside formal training programs, but this is not a reality in current practice
  • lack of recognition for senior SAS staff: the College’s 2017 report (SAS anaesthetists – Securing our workforce) showed that many SAS anaesthetists feel they are not recognised for the range of skills and experience they possess. There is no visible promotion for SAS doctors.The job title of “specialty doctor” includes doctors with experience ranging from four years to several decades. Patients and other health care professionals are unable to deduce seniority from the job title
  • lack of career progression: specialty doctors range from four years post qualification to decades of experience, without a change in job title denoting the level of seniority. The evolving character of today’s workforce, including the demand for less than full time working patterns, creates an appetite for alternative career pathways
  • poor pay progression: the 18-year timeline for specialty doctors to progress along their pay scale denies financial recognition of seniority. There is currently no mechanism to reward excellence through pay or job title and there is no system equivalent to Clinical Excellence Awards for SAS doctors. It would take a specialty doctor 22 years minimum, from qualification, to reach the very top of their pay scale and still fall short of the starting salary for a consultant, without any further option to enhance their income.

Recruitment and retention difficulties

The College’s 2015 workforce census demonstrated widespread difficulty recruiting to SAS posts. The most recent (46th) DDRB report states that 77% of NHS providers had experienced some difficulty recruiting to SAS posts and 30% had experienced difficulty with retention.

Potential inequitable distribution of workforce

Against the backdrop of difficulties in recruiting and retaining specialty doctor posts, trusts only have two potential tools to distinguish them favourably when competing for potential recruits:

  • Trusts can offer developmental programmes, in particular those supporting overseas doctors aiming for their Certificate of Eligibility of Specialist Registration (CESR). The target areas for CESR development are the special interest areas for intermediate and higher training (Neuro, Paediatric, Intensive Care, Cardiothoracic, Pain etc). This favours trusts that are tertiary centres and can offer exposure to these areas, leaving district general hospitals, especially those outside urban areas, facing even greater recruitment difficulties than is already the case
  • Foundation Trusts can offer “Trust Associate Specialist” posts, a practice becoming widespread and compounding the recruitment difficulties described above for non-Foundation Trusts.


Therefore, based on the above, the Royal College of Anaesthetists and the Association of Anaesthetists have concluded that reintroduction of the Associate Specialist grade would help to address the above issues and ease the workforce pressures. We understand that this would also be the case in other medical specialities and are keen to work in partnership to reopen the Associate Specialist grade.

Further information:

1. Royal College of Emergency Medicine. Associate Specialist Grade Position Statement. September 2018
2. Review Body on Doctors’ and Dentists’ Remuneration 46th Report: 2018. July 2018
3. Royal College of Anaesthetists. 2015 Census – Final Report 
4. Royal College of Anaesthetists. SAS Anaesthetists – Securing our Workforce. June 2017




14 November 2018