Published: 10/02/2005, Volume II5, No. 5942 Page 36

Despite fulfilling an indispensable role, non-consultant career-grade doctors are often poorly paid and given few career opportunities, reports Colleen Shannon

Doctors in the non-consultant career grades fill one in six medical posts in English hospitals. Many parts of the NHS would collapse without them: one in four doctors working in mental health trusts fall into this category. Yet they have been in a professional twilight zone for years.

They go by different names - associate specialists, staff-grade doctors, trust doctors - and their duties vary hugely, as do their salaries and experience. The job is often seen as a professional cul de sac, with no clear career path.

That could all be about to change. This month, health secretary John Reid promised that a new contract for NCCG doctors will be in place by April 2006. He has pledged£75m to cover costs for the first year.

The British Medical Association and NHS Employers have already had preliminary contacts and both sides agree change is badly needed. 'We believe their contribution has often been undervalued, ' says NHS Employers deputy director Alistair Henderson.

'There is a lot of frustration and anger, ' says BMA staff and associate specialists committee chair Dr Mohib Khan. 'Some have been in the job for a very long time and have acquired a great deal of experience and expertise that is not rewarded by the existing contract.' According to a recent BMA survey, eight in 10 NCCG doctors feel their salaries do not fairly reflect their experience or their contribution to the NHS (see box). Two in three doctors in the survey said they would steer junior colleagues away from this career route.

At present there is huge variation in pay. If discretionary points are included, pay for staff-grade doctors and associate specialists ranges anywhere from£29,845 to£72,882, according to figures from NHS Employers. Factors that complicate the pay equation include:

. Local flexibility Trusts have significant flexibility in fixing the starting salary for a NCCG doctor.

. Discretionary points Doctors in the BMA survey said the points are not awarded fairly to NCCG doctors.

Many would like to see the system scrapped.

. Out-of-hours payments In a preliminary consultation, trusts said they would like the freedom to offer bigger incentives, to make out-of-hours work more attractive to NCCG doctors.

. Wide variations in experience and responsibility The new contract could tidy this up by introducing a tiered grading structure.

For doctors who wish to become consultants, the situation is complicated because entry to the training grades has been treated as a separate policy area under Modernising Medical Careers.

Establishing a set of required competencies is an essential starting point, insists NHS Employers, and this will be another tough negotiating topic.

Both the BMA and NHS Employers agree that NCCG doctors need improved opportunities for training and continuing professional development.

It is not clear which doctors will be covered, beyond the staff-grade doctors and associate specialists. The BMA would like the NCCG contract to apply to trust doctors, and NHS Employers has recommended including all clinical assistants and hospital practitioners not already covered by the general medical services contract.

Many NCCG doctors are looking for more clinical autonomy, but this is likely to be a very thorny question requiring significant involvement from the royal colleges.

One big issue for trusts will be having enough time to make financial plans, assess their workforce needs and set up the mechanics of implementation, says Alastair. If one stage of the negotiation is held up, it would be unfair to expect NHS trusts to make up for lost time by rushing through their part of the work at the end.

Referring to experience with other contracts, he says: 'We have suffered in the past because there has been an immovable end date.'

Out in the cold

'A dumping ground, ' is how some staffgrade doctors have described their jobs.

'Slave labour', 'second class', 'dead end' were other comments, in a BMA survey of 2,596 hospital doctors working outside the consultant and training grades. Some 57 per cent reported low morale.

One reason could be the hours of work.

While doctors in the survey were contracted to work an average of 43.8 hours per week, they actually worked 73 hours per week on average.

Half of respondents found work-related stress to be excessive. Contributory factors included lack of respect, bullying, and inadequate support. And 21 per cent felt they were fulfilling a consultant's duties without recognition.