Autonomy for SAS doctors and guidance on progression

The NHS has a significant number of permanently employed doctors who are neither consultants nor in formal training programmes. These are collectively known as SAS (Specialty doctors and Specialists; also closed contracts of staff grade and Associate Specialist), and they make up a significant proportion of the permanent anaesthetic workforce. SAS anaesthetists are employed on nationally negotiated terms and conditions, with minimum entry criteria and defined salary scales. The diverse nature of SAS doctors and their roles means that the level of education, training and experience can vary considerably. 

The 2021 reform of the specialty doctor grade has created a framework and expectation of career progression. The introduction of the Specialist grade has allowed for recognition of specialist anaesthetists as autonomously practising doctors, within a locally defined scope of autonomous professional practice.

 What is autonomy?

Autonomy refers to the ability to work independently, make decisions, plan and give care, and carry the associated responsibilities, without supervision from and referral to a consultant, including for complex patients.  Autonomy therefore goes beyond merely running operating lists single-handedly whilst under distant supervision. Autonomy in providing clinical care goes hand in hand with the expected level of professional behaviours expected (see Link 2). 

Autonomy is typically granted to SAS doctors within specific areas of expertise, reflecting the individual doctor’s experience and skills. These areas are defined individually and locally, and should be outlined in the job plan. Where SAS doctors are working autonomously, the scope of their practice must be clearly defined, mutually agreed and understood by both the doctor themselves and other members of the department.

Working autonomously should not stop individual doctors from asking for help or seeking second opinions when felt necessary. All doctors – regardless of grade- are required to recognise and work within the limits of their clinical competence, and to seek help from colleagues or others where this is appropriate.

How can a doctor demonstrate autonomy?

A SAS anaesthetist wishing to demonstrate their autonomy and/or seeking eligibility to be appointed to the specialist grade is expected to build a personal professional portfolio, containing documentary evidence of work undertaken as well as skill development. 

To demonstrate clinical autonomy, the portfolio should contain evidence of senior- level decision making. Examples of such evidence can be logbooks, letters and clinical records, records of senior roles in procedures and educational assessments. Particularly helpful are feedback and references from colleagues commenting on the level of responsibility and decision-making by the individual. If educational assessments are collected it can be helpful to use the RCoA Lifelong learning platform. To show the level of skill and independence, it can be particularly helpful for assessors to comment on the ‘entrustment levels’ as used in formal training paths. 

Table 3 – The levels of supervision

In relation to the scope of clinical practice in which the individual wishes to be recognised as autonomous, the assessor should be able to give an entrustment level 4.

In addition to evidence on clinical practice there should also be evidence for wider contributions within the department or beyond. The required professional values and behaviours should be evidenced. Leadership skills, teamworking and engagement with patient safety and quality improvement must be shown. All senior doctors should be willing to engage in informal and formal training and education.

Who recognises an individual doctor’s autonomy?

Autonomy is typically granted to SAS doctors within specific areas of expertise, defined individually and locally, and should be outlined in the job plan. It is therefore not necessarily transferable into other areas of practice or a different job with a different profile.

To have your autonomy recognised – for all or part of your practice- you should approach your clinical lead/director in the first instance with evidence as described. The evidence can be assessed by them or an experienced educator (for example the college tutor of the department). Your autonomy can then be confirmed in writing, either separately or as part of your job plan. If gaps are identified, they can feed into your professional development plan via the appraisal process.

For further guidance on how to collate evidence against the specialist grade appointment framework please see below.