Staff and associate specialist doctors are often said to lack a voice. Could this explain why they were the last group to sign their new contract, or is institutional racism to blame, asks Daloni Carlisle

These days, it is quite hard to work up much sympathy for doctors, what with their bulging pay packets and, in theory, regular working hours. But spare a thought for the staff and associate specialists.

Often described as “the workhorses of the NHS”, these are the 8,000 or so staff and associate specialist doctors who are in non-training jobs and will therefore not go on to become consultants.

The British Medical Association estimates that as many as 80 per cent are non-white, mostly Asian. Among other things, they fill the gaps in anaesthetics, accident and emergency and obstetrics. The NHS would collapse without them.

They have a much lower profile than junior doctors, consultants or GPs. Who among the general public would hear the term “SAS doctor” and think of anything other than a hybrid soldier/medic?

They were the last group to sign a new contract. The juniors got theirs in 2000, the GPs and consultants in 2003. The SAS doctors had to wait until last month.

Unlike the other contracts, this one was scrutinised closely by the government’s public sector pay committee and the Treasury before being agreed. It took more than a year. It was cash limited. And unlike the other contracts, it will see neither massive hikes in income nor big reductions in working hours. Despite SAS doctors voting for it, many are still deeply unhappy.

All of which begs the questions: why did it take so long and what, from the doctors’ perspective, has gone wrong? Ask the people involved and a number of themes emerge, including: the government’s determination to avoid yet another unexpected pay bill on implementation; NHS Employers’ negotiating skill; lack of support from the BMA; and in-fighting among the BMA negotiators.

Another thought hangs over all this. It has not been voiced loudly and never raised officially. The Department of Health and NHS Employers vehemently reject it and it is this: that the treatment received by the SAS doctors may be tinged with institutional racism.

Dr Peter Royle, a consultant anaesthetist and formerly medical director of North Tees and Hartlepool trust, sees several factors involved in the delays. The first was between 2003 - when the government accepted the need for a new contract - and 2005, when talks started; and the second from 2006-08, while the government scrutinised the figures.

“This is traditionally an under-represented group, with no real political clout and no champion,” he says. Until 2002 they lacked their own committee at the BMA and fell under the ambit of consultants, who some believe do not always have their colleagues’ best interests at heart.

Dog’s bodies

“The consultant point of view is that this group does not deserve higher status because they have not done the training,” says Dr Royle. “They don’t want them going round the back door into consultant posts. But the problem is they get trapped in the grade because they are not allowed to do top-up training. Then you end up with contradictory situations where they are not allowed to be consultants but are happily used as locums.

“They have a contract to be a senior hospital specialist but at the same time will be covering a junior doctor’s work and a consultant’s work. They are used as general dog’s bodies and fixers.”

Dr Royle, who championed their cause when he was medical director and standardised contracts across the trust, pushing for bursaries and protected posts that would allow associate specialists to gain the necessary accreditation, sees a racial element to this. “My colleagues are suspicious of anybody coming from outside and I have felt that they have not been very enlightened,” he says.

In public, Dr Ashok Pathak, chair of the BMA’s negotiating team, and Dr Mohib Khan, joint chair of the BMA’s SAS committee, are wary of playing the race card. “It’s very difficult to say openly, but there may be underlying institutional racism in this,” says Dr Pathak. “Some of the doctors have raised this question.”

Dr Khan adds: “I can’t really say it is institutional racism, but the majority of doctors in this group are from Asian backgrounds, so one can perceive there is a racial element to it.”

Dr Pathak blames the government for the delay from 2006. “They could not agree the financial modelling,” he says. “It was agreed with the NHS Employers, but the government pussyfooted around it. In the process, we have lost out on three years of pay rises. Yes, morale remains low.”

Clever hand

“We were the last group they dealt with,” says Dr Abdel Aziz, who represents southern England for the College of Emergency’s Forum for Associate Specialists and Staff Grades in Emergency Medicine.

“They had experience with the consultants’ and GP contract and the negotiations were very hard-going. But the majority of this group is ethnic minority and nobody seems to talk about that very much. It is a sensitive issue.”

The government played a clever hand, says Dr Meng Aw-Yong, chair of the forum. “What’s often forgotten is that the GPs threatened to go on strike,” he says. “Our contract negotiations were pushed back until after the 2005 election.”

He points to divisions within the negotiating team and the BMA. “The team was not very homogenous,” he says. “Mostly they did not want the racial card being played, although certainly at least one senior member of the BMA was pushing for the truth to come out.”

He is in no doubt that the fact the contract was so far behind the others and subject to so much delay was institutionally racist, in that it disproportionately affected a group in which ethnic minorities are over-represented. “But evidentially it is quite hard to prove,” he says.

Dr Khan denies this, saying the team was “strong and coherent”, although others mutter darkly about “rogue elements”.

The BMA rejects the idea that it did not fully support SAS doctors.

A spokesperson says: “SAS doctors had to wait longer than any other group for a modernised contract, largely because of government stalling tactics.

“The wider BMA, including the consultants committee, has been… vocal in its support for SAS doctors, and will continue to fight for them as the new contract is implemented.”

Both NHS Employers and the DH appear to be blind-sided by the argument that there could be any racial element at all in the treatment of SAS doctors. Gill Bellord, NHS Employers’ director of pay, pensions and employment relations, says: “I cannot see the connection with racism. Clearly in the context of the contracts that had gone before, the government would have wanted to ensure this was robustly costed.”

The negotiation stage was relatively tight, compared with, say, Agenda for Change. “We started in April 2005 and finished at the end of October 2006,” she says. “The delay was from submitting the proposals to the DH and them getting approval.”

Likewise the DH, which says it has not been formally approached about this issue. “We do not understand the grounds for this claim,” says a spokesperson.

The delay in considering the contract once it had been agreed was down to the need to carry out rigorous analysis, especially in the light of the National Audit Office report on the consultant contract, the spokesperson added.

Before agreeing it, the government wanted more information on the costs and modelling and ways to avoid overspending. It also “satisfied itself that this contract would deliver benefits to patients, the wider NHS and SAS doctors themselves”.


That is where it seems to be falling apart. Ms Bellord believes it is a “good contract” and currently NHS Employers is running roadshows to help trusts implement it.

Health secretary Alan Johnson has welcomed the new contract, saying SAS doctors will receive “much fairer rewards that recognise their exceptional skills and experience”.

But HSJ was not able to find a single SAS doctor happy with what is on offer. Admittedly, doctors voted for it - by a margin of 60 per cent on 40 per cent of those eligible to vote.

But they are unhappy at the closure of the associate specialty grade, the failure to ring-fence£12m training funds for doctors wishing to progress to consultant status, inadequate compensation for overtime and too low a cap on senior pay levels in the new specialty doctor grade.

Dr Khan speaks for many when he says: “We have been conned by NHS Employers and we have been robbed. SAS doctors are furious. If anything, the stigma attached to the grade has grown.”


2000 Junior doctor contract agreed

2003 Consultant contract agreed

2003 GP contract agreed

January 2004 DH consultation on choice and opportunity accepts case for pay modernisation for SAS doctors

October 2004 NHS Confederation backs case for modernising pay

January 2005 Health minister John Hutton announces£75m to fund new contract for SAS doctors

May 2005 First formal meeting between BMA negotiators and NHS Employers

June 2006 BMA rejects draft contract

November 2006 BMA and NHS Employers agree contract and submit it to DH

January 2007 Contract referred to public sector pay committee

June 2007 Contract referred back to DH

November 2007 Contract approved by prime minister Gordon Brown

March 2008 SAS doctors vote to accept new contract

1 April 2008 Contract implemented locally

Numbers game

The new contract applies to 13,500 non-consultant career-grade doctors, who include 8,000 SAS doctors as well as 5,500 clinical assistants and hospital practitioners.

Of this 13,500, 2007 figures show that 45 per cent were white and 34 per cent Asian or British Asian.

However, of the 8,000 SAS doctors, it is estimated by the BMA that up to four-fifths are non-white, most being Asian.

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