|
THE DIFFERENT GRADES - UK System
GME
in Pakistan GME in
THE UK GME in THE
USA
Thus the doctors in the NHS
can be broadly groups into the GPs and the Specialists.
However, the categorization
is not that simple. Doctors in the NHS are in “grades” reflecting their position
in the hierarchy of the NHS. As doctors get into higher grades, they get paid
more, assume greater responsibility and, it must be said, attain greater
prestige as well.
The lowest grade is the
Pre-Registration House Officer (PRHO). UK graduates enter this grade
immediately after graduating from medical college. The term “pre-registration”
is applied to this grade because after completing it, the doctors are “fully
registered” in the General Medical Council, or GMC of the UK. They
are, in other words, registered as doctors. This is similar to the Pakistani
system, where an MBBS student is only registered with the PMDC as a Registered
Medical Practitioner (RMP) after completing a one year house job. The PRHO lasts
for one year after which doctors compete for posts (i.e., jobs) in the
Senior House Officer (SHO) grade.
The overwhelming majority of
overseas doctors coming to the UK today compete for the SHO posts. There are
very few PRHO posts for overseas doctors, so not many get them. This is why most
doctors who apply for posts in the UK do so only after they have completed house
jobs in their home countries.
SHO posts last for 6 months
in a certain specialty. Job opportunities for SHO posts are advertised openly
and awarded on a competitive basis. After finishing one SHO posting, doctors
apply for the next, and then the next, and so one until they leave this grade by
attaining their Membership of a Royal College (MRC) - which we will come to
shortly. Doctors remain in this grade until they attain their Membership.
However it is possible (and this in fact has become a big problem for the NHS)
that doctors simply stay in the SHO grade for 8-9 years before getting around to
completing their memberships. Indeed, currently there isn’t a built-in mechanism
within the NHS structure compelling doctors to attain their membership quickly
and leave this grade. Ideally, the doctor should attain his Membership within
3-4 years and move forward, taking on greater responsibilities, and making room
for newer doctors in the SHO grade.
The different SHOships are
not centrally integrated by any educational body. This makes it difficult (at
least to the overseas doctor whose does not have the luxury of rejecting any SHO
post he is given) to ensure that the time spent in the SHO grade will follow a
well-planned, integrated programme. This is in sharp contrast to the US system
where a US resident has a fixed contract with a certain hospital and will
continue to work and train there for several years. If he has chosen go into
Internal Medicine, he will spend a fixed amount of time in the different
subspecialties of Internal Medicine and be transferred from one ward to the next
without any interruption of his training.
The reasoning behind
limiting the SHO posts to 6 months at a time, with no centrally decided
integration between the different SHO posts is to give the doctor the
opportunity to sample different specialties. If for example, he wishes to
experience Nephrology, he can take a 6-month job in it. If he wants, his next
post can be in Psychiatry. By spending 6 months in such posts, he will be able
to decide if he wants to pursue that field as a specialist, and even if he
doesn’t, the exposure and knowledge learned in that field will add to his body
of knowledge and make him a well-rounded doctor.
However this system was
designed and set in place decades ago, when competition for SHO posts was not as
fierce as it is now. So, while the theory of 6-month SHOships seems fine, the
system becomes flawed when the SHOship that a doctor enters is not out of
choice, but out of compulsion - caused by today’s difficult job situation. This
problem hits overseas doctors the hardest, who are considered for SHO posts only
after UK-graduates are accommodated first.
Since there is no link
between the first and second SHO post, it is quite possible for you to be
exposed to very different specialties during your time as an SHO. One post could
be in Cardiology for example and the next in Psychiatry. For the overseas
doctor, its a matter of taking what you can get.
Having said that however, it
must be emphasized that the training imparted during the SHOship is quite good.
A hard working doctor can benefit immensely and learn a lot during his time as
an SHO. Another important clarification to the above is that not all SHO posts
are 6-month contracts. They can be 2-3 year contracts in which planned,
integrated rotations are structured into the training. However it is very
difficult for overseas graduates to obtain such contracts. The vast majority
receive 6-month posts.
During the SHOships, the
doctor will study and train for the Membership exams of one of the Royal
Colleges. There are a number of Royal Colleges for the different generic
specialties (by generic we mean the large specialties, like medicine – not the
subspecialties within them like Nephrology). The Royal College of Physicians,
for example is responsible for Medicine. We also have the Royal College of
Radiology, Royal College of Psychiatry, Royal College of Ophthalmology, Royal
College of Obstetrics and Gynecology and so on.
A doctor becomes a “member”
of a Royal College when he passes that college’s membership exams. For example,
if a doctor wishes to progress as a surgeon, he will have to pass the Membership
exams prepared, administered and assessed by the Royal College of Surgeons. If
he is able to pass the exams, he will be an MRCS (Member of the Royal College of
Surgeons) and eligible to advance to one of the grades above that of an SHO.
These are:
-
Staff Grade
-
Specialist Registrar (SpR)
Type I
-
Specialist Registrar (SpR)
Type II (FTTA)
The staff grade is a post in
which the doctor does not have a chance of progressing career-wise to reach a
consultant grade. The reason for this is that the staff grade is a
non-training post. Training elements incorporated into this post are not
formally recognized by the Specialist Training Authority (STA). Since
becoming a consultant requires its own training program (that has to be approved
by the STA) a staff grade doctor cannot improve on his credentials to become a
consultant. The inability of the SAS doctors to progress towards a consultant
grade has given this group of doctors a lot to complain about.
If a doctor works in a staff
grade for 10 years, he is entitled to an Associate Specialist grade –
which is a more senior grade with a higher pay scale. The Staff
grade and Associate Specialist doctors are
collectively referred to as the SAS Doctors.
Some hospitals have a
tradition of actively teaching and training its staff grade doctors on par with
the SpR doctors (SpR posts are explained below) – even if this training is not
officially recognized by the STA. Therefore, an overseas doctor who is
interested in going to the UK primarily to improve his expertise can still do so
in a good staff grade job. However it is equally likely for a staff grade
doctors to be neglected if the consultants in the hospital don’t make it a
priority to actively train them. Staff grade doctors therefore may or may not
receive active training depending entirely on the senior doctors who they are
working under. The best thing to do for an overseas doctor is to have a CV
strong enough to obtain a staff grade post in a hospital that has a long
standing tradition of actively training its staff grade doctors.
With regards to the staff
grade post, Graham Buckley, the Director of the Scottish Council for
Postgraduate Medical and Dental Education, made the following points:
·
The posts are
not for training. They are non-consultant career posts.[see “Terms not already
covered” below for definition of non-consultant career posts]
·
Traditionally,
the British medical profession has been hostile to the development of
non-consultant career grade staff, expressing this through both the BMA and the
royal colleges. Grades such as the staff grade…have been perceived as a threat
to standards.
·
It should be
clearly understood that the staff grade is not a route to becoming a consultant.
·
…the
implementation of shorter and more structured training for specialist
registrars, has left a service gap which has been filled by staff grade doctors.
·
The content of
the work of staff grade doctors and their working hours is clearly varied. It is
this flexibility in filling awkward gaps in the service that makes these doctors
such a key component in the medical workforce and should lead to their achieving
higher status
·
At present,
the staff grade posts seem to be a lottery, with job satisfaction highly
dependent on the approach taken by the supervising consultants.
In order for a doctor to
attain a Consultant grade (the highest in the NHS) he will have to go
through a formally recognized, well-planned, specialty training program called
Higher Specialist Training (HST) which lasts from 4 to 6 years, depending
on the specialty. A doctor admitted into an HST programme will have the grade of
a Type I Specialist Registrar. After completing the HST programme, he
will be awarded the Certificate of Completion of Specialist Training (CCST),
which entitles him to the Consultant grade.
A doctor in an HST programme
as a Type I SpR will be given a National Training Number (NTN), which
registers him as a doctor on his way towards a consultancy grade. The NTN is
only awarded to those doctors who have permanent resident rights in the UK
(i.e., they are allowed to live and work there just like British citizens).
Overseas doctors without such resident rights are given a Visiting Training
Number (VTN) instead. By awarding VTN/NTNs to aspiring consultants, the NHS
manages to keep track of the number of consultants that will be available to the
NHS a few years down the road when these doctors complete their HST training.
The NHS keeps this careful count of the number of its consultants-to-be in order
to avoid creating more consultants in a specialty than are needed. For example,
if the NHS predicts that it will require 3000 Cardiologists in the year 2008, it
will make sure that the number of VTN/NTNs that it assigns to doctors entering
HST in Cardiology does not cause the target of 3000 Cardiologists to be exceeded
in the year 2008. The reason they pay such careful attention to the number of
consultants in any specialty is because these consultants, being at the top of
the NHS hierarchy must have jobs when they finish. After the huge investment
made training them, the NHS cannot afford to have unemployed consultants.
Consequently, there is fixed
number of VTN/NTNs available to be assigned - the number depending on the needs
of NHS at the given time. Competition to get a Type I SpR post is currently very
fierce even for UK
graduates. This post is, after all, the key to getting to the top of the NHS.
For overseas graduates Type I SpR posts in some specialties (such as cardiology,
neurology, gastroenterology, respiratory medicine, general surgery and
orthopedics) are exceedingly difficult to obtain.
The Type II SpR posts are
more commonly referred to as the Fixed Term Training Appointment (FTTA) posts.
FTTA posts are also SpR posts. They identical to Type I SpR posts in terms of
content, duties, and training components - however they do not lead to an
CCST, which means that they do not lead to a consultant grade. While the
Type I SpR posts are contracts that last for four to six years, the FTTA posts
seldom for more than 2.
These posts exist for two
reasons. Firstly to accommodate overseas doctors who wish to work in an HST
programme in order to gain expertise they would return to their own countries
with – and secondly to fill deficiencies in the number of junior SpR doctors
without creating more consultants than are needed. For the second reason UK
doctors, and not just overseas doctors, are eligible to apply for FTTA posts.
In a few years time, the
number of FTTA posts will be reduced to almost nothing.
Currently, the NHS is facing a consultant-deficiency crisis. It needs more
consultants in the system and as a result the work-force space previously
occupied by the FTTA posts is being taken over by Type I SpR posts. By doing
this, the NHS aims to overcome the consultant-deficiency crisis it is currently
facing in a few years time.
Increasing the number of
Type I SpR posts at the expense of FTTA posts probably does not bode well for
overseas doctors who wish to gain further training in an HST programme. It is
widely believed that
UK doctors are
actively preferred over overseas doctors when it comes to awarding Type I SpR
posts. Therefore overseas doctors who previously stood a chance at obtaining at
least an FTTA post will have this option cut off for them as well.
To illustrate, the following
is an excerpt from the Advice Zone section of a BMJ Careers issue dated June
19th 2004:
Question:
What are the chances of a non-European Union resident getting a type 1 training
number in orthopedics? Is there any chance that I could be a consultant in
orthopedics in the
United Kingdom? (I am
a Pakistani national.)
Answer:
Dr Phil Hammond, the comedian and general practitioner, has recently written a
sitcom about an Asian orthopedic surgeon who struggled to get the top
London
teaching hospital job that he wanted but instead was banished to the
Isle of Wight.
Sadly, this does reflect the prejudice that remains in the 21st century among
the medical community. “Racism blocks the career progression of doctors from
ethnic minorities and from overseas,” a BMA report said (BMJ 2003;326:1418). It
saddens me to quote such a line, but all the evidence is there that it is no
doubt more difficult to get the job you want if you are from overseas.….
Andy Goldberg
Specialist Registrar in
Orthopedics
Whittington Hospital NHS
Trust
Since the year 2000, which
saw a massive increase in the number of overseas doctors coming to the UK (an
increase that still continues), the number of overseas doctors attaining Type I
SpR posts has been declining steadily.
It is worth mentioning here
that a few years back, there were Registrar and Senior
Registrar Grades. If you come across these terms you may ignore them.
These posts no longer exist - they have been replaced by the SpR posts.
Those who do not wish to
train to become consultants or are unable to get a Type I SpR post are compelled
to enter the staff grade (which as already been explained) or Trust Grade
Post.
A “trust” refers to a
small number of hospitals which are collectively responsible for the population
in a certain area (like a county, or a city for example). There are a little
over 300 trusts in the UK.
The NHS is very exact about
giving trusts the precise extent of financial, structural and workforce
resources needed to deliver healthcare to the locality under the trust’s care.
Giving too much money or allotting too many doctors to a trust would be
wasteful. The size of the workforce in each trust is therefore closely monitored
by the NHS.
However, each trust is
allowed some flexibility. When a trust feels that it there is a need for a
doctor in a certain grade, whatever that grade may be (PRHO, SHO, SpR or Staff
grade) the trust will create a post to fill that particular gap in its
workforce. The post created to fill this gap is the “trust post”. The ability
of trusts to create such posts as and when needed is essential to quickly fill
up gaps in the workforce that may prove to be only temporary. If, as time
passes, the trust finds that the gap is permanent, then it will request the
central authority in the NHS to increase the number of doctors allotted to the
trust in the grade which is deficient.
During the period of time
when it is not yet clear to the trust whether this gap will become permanent or
not, the trust post remains a non-permanent grade, and its job contract
is not a “standard” one. The trust grade doctor does not enjoy any of the
privileges that the other “standard” grades provide. Furthermore, since the
trust does not know if the gap being filled by the trust post will become
permanent, the post offered can be terminated when and if it is thought that the
need for the post is not longer there. As a result, the trust grade posts, are
not secure and more importantly, they are not be recognized for training.
It is clear therefore that
trust posts are created for the benefit of the trusts, not the doctors who work
for them in that capacity. This situation has caused much criticism as many
believe that trust posts exploit doctors, especially overseas doctors, who are
forced to these posts simply because they can’t find a standard post elsewhere.
A BMJ Careers article dated
3rd January, 2004 focused on these so called non-standard grade doctors. A panel
of professionals discussed the issue:
Sam Lingam, former
chairman of the British International Doctors Association, told the panel that
his association advised doctors to take such posts if that was all that was
available. "Without trust grade doctors they will have nothing. They will be
homeless and jobless." He continued: "We say to them, `take what's there, for
now.' There are many doctors who have the PLAB [Professional and Linguistic
Assessments Board test] and so are job ready but find it difficult to get jobs.
They have great difficulty even getting a clinical attachment. We advise them to
take what is available."
Steve Field [postgraduate
dean of the West
Midlands
Deanery]…disagreed that doctors should take up such posts out of desperation,
calling this "abusive behavior" and the alternative to working at McDonalds or
something like it. He said, "We are abusing doctors rather than valuing them."
The lesson to be learnt here
regarding trust grade positions is that they can be used by overseas doctors if
they are desperate for a job, however it should also be kept in mind that not
all trust grade posts are necessarily bad. Some trusts take conscientious
responsibility in developing their trust doctor’s expertise during his time
there. However, when circumstances permit, one should leave the trust grade when
they can get a standard grade post.
Locums are temporary posts
in which a doctor fills in for an absent doctor already employed by the NHS. If
a doctor in the NHS is sick, (or in case of a woman, requires maternity leave),
on study leave, or on vacation, then a locum doctor will be appointed to perform
the duties of the doctor on leave. Locums will last for as long as the other
doctor is absent from duty and can be in any of the grades. As such, they can
last from a few days to a few months, but rarely longer than that. Locums can be
in any of the grades, and they have in the past served as a valuable source of
money for otherwise unemployed doctors living in the UK, seeking jobs. A locum
at an SHO grade for a month can earn the doctor up to 2000 Pounds Sterling, and
as such, can greatly relieve his financial difficulties. The job situation and
the monetary considerations of the
UK
option are discussed below.
Getting a locum can not only
provide much needed financial relief, but also valuable UK work experience that
will add to your CV. There are locum agencies in the UK through which most
junior doctors obtain their locums, but as the locum employer is usually a
senior doctor working in the hospital, knowing such a doctor (or someone who can
put in a good word for you on your behalf) can be instrumental in securing a
locum post. | 
