Staff Grades and Associate Specialists Group (SAS)

Wales Good Practice Guide

Introduction

This Good Practice Guide has been developed by the Welsh SAS Reference Group to promote good practice in the employment of doctors and dentists within the Staff and Associate Specialist group (referred to as ‘SAS doctors’ throughout this document – this includes dentists). 

The Reference Group was set up in 2004 with the following terms of reference:

‘To provide a discussion forum to encourage best practice and where appropriate recommend changes in the working conditions of the Staff and Associate Specialist group of practitioners in Wales. To share ideas about the development of new terms and conditions of service for this group and to feed these into the main negotiating arena.

The forum includes representation from the Welsh Staff and Associate Specialists Committee supported by BMA Cymru Wales and other craft committees; the Welsh Assembly Government and NHS Wales.

It is agreed that the Staff and Associate Specialist group includes Associate Specialists, Staff Grades, Clinical Assistants, CMO’s, SCMO’s, Hospital Practitioners and other non-standard grades.’

This Good Practice Guide (GPG) has thus been jointly agreed by representatives of the Welsh Assembly Government, the profession (via the BMA Wales SAS Committee) and the service in Wales, and is issued by the Welsh Assembly Government.

The GPG will need to be reviewed once current UK negotiations on new terms and conditions of employment for SAS practitioners have been completed.

SAS doctors are vital members of the multi-disciplinary teams delivering healthcare to the people of Wales.  Ensuring good practice in the employment of SAS doctors is a necessary part of ensuring the best possible healthcare provision for patients and the people of Wales.  In particular this GPG has been developed to ensure the best use is made of the current terms and conditions of employment of SAS doctors pending UK negotiations on an amended contract.

A regular theme throughout this guide is the effective use of job planning and appraisals to better channel the contribution of SAS doctors and ensures their effective involvement in decisions about healthcare delivery in a modern and responsive NHS.

Job Plans

All SAS doctors must have an up-to-date Job Plan setting out their clinical (and any non-clinical) commitments and an agreed development plan.  The annual appraisal will inform the Job Plan.

The Job Plan is mandatory and should be agreed between the SAS doctor and the appropriate Clinical Director or Consultant with the support of the appropriate local manager, on at least an annual basis.  It should set out the mutual expectations of the SAS doctor and their employer, be fair to both the SAS doctor and to their employer, and be linked with the wider service objectives of the department, directorate, or organisation.  The personal development plan should include how the agreed Continuing Professional Development needs of the SAS doctor are to be met during the coming year, as well as the contributions of the SAS doctor to the work of the clinical team through activities such as audit, teaching or training, clinical governance, and other roles such as clinical management activities as appropriate and agreed at the appraisal meeting.

There must be an agreed appeals process in place to resolve any conflicts that arise during the job planning exercise.

It is understood that many aspects of CPD and contributions to the work of the clinical team require identifiable and protected time within the job plan. 

The service in Wales recognises and recommends that SAS doctors should have in the order of twenty per cent of their working time (based on a basic full-time commitment) identified for CPD activities and for their contributions to the work of the clinical team. Ideally this is as protected time on a regular weekly basis or if undertaken more flexibly, will need to be discussed and agreed during job planning, dependent on the particular circumstances of the Doctor/job.

A job plan is a detailed description of the duties and responsibilities of an SAS doctor. It includes details of any on-call and emergency work commitment, management responsibilities, and a work programme showing the nature, location and timing of regular commitments.   Changes in the job plan should only be made with agreement of all parties, and should also take into account the work life balance of the individual doctor.  When circumstances change significantly during the year, the job plan should be reviewed and any appropriate changes agreed by all parties. 

Effective job planning forms an important part of local workforce planning, service delivery planning and personal development.

Elements of the Job Plan

The following should be identifiable within the job plan

Direct clinical care commitments
	Adequate time for CPD and contributions to the work of the clinical team
	Recognition of on-call and emergency work in the form of sessions or NHD’s
	Identification of shift or other working patterns
	
Direct clinical care can include the following

	On-call and Emergency duties
	Operating sessions including pre and post-operative care
	Ward rounds
	Outpatient clinics
	Clinical diagnostic work
	Other patient treatment
	Public Health duties
	Multidisciplinary meetings about direct patient care
Administration directly related to patient care (e.g. discharge summaries, referrals, clinical letters, discussion with other colleagues.) 
	Travelling time as in the current Terms and Conditions of Service.
This list is not exhaustive.

CPD and contributions to the work of the clinical team could include the following

	Continuing professional development
	Audit
	Appraisal
	Job planning
	Clinical Management
	Teaching
	Training
Research (e.g. publications, preparation for presentations etc.) 
	Local clinical governance activities
The job plan should reflect other agreed activities, for example; trade union activities, college work and work for the wider NHS. 
This list is not exhaustive

The amount of time identified for CPD and contributions to the work of the clinical team will be variable. It should be recognised that some SAS doctors may have significant teaching or training commitments and this should be reflected in the job plan. There will be in the order of twenty percent of time (based on a basic full-time commitment)  identified in all doctors’ Job Plans for CPD and contributions to work of the clinical team, always accepting that some doctors may require more and this will need to be agreed at the Job Plan.

There will however be a minimum identified in all practitioners Job Plans for CPD and contributions to the work of the clinical team. 
 
Information should be included in the Job Plan about relevant staff and other resources available to support the SAS doctor. This should include:

•	their named consultant(s)/unit
•	other senior staff in the department
•	numbers of junior staff and their rotas
•	other clinical staff such as nursing, technical and secretarial support

•	office accommodation and IT support.

The SAS doctor cannot be expected to contribute effectively in their clinical work, or as an employee, unless they are afforded the necessary resources and environment to achieve this.

An example model Job Plan, which can be adapted locally, is included as Appendix 1.

An example of a scheme used in one Trust for recognising On-Call and Emergency Work is included as Appendix 2. 

Appraisals

It will be a requirement that all medical and dental staff are revalidated by the GMC/GDC.  This together with the development of clinical governance in the NHS has emphasised the need for a comprehensive annual appraisal scheme for all doctors and dentists.  In October 2002, agreement was reached on the introduction of a national appraisal scheme for non-consultant career grade doctors, which was to be implemented in such a way that all these doctors would have been appraised by 31st March 2004. This resulted in Advance Letter (MD) W5/2002 which provides a model appraisal form. All appraisal forms should be completed in accordance with this Advance Letter.

It is essential for employers to comply with this Advance Letter in order for SAS doctors to satisfy future GMC/GDC revalidation requirements.  If appraisal has not been completed in advance of revalidation, individual doctors may have difficulty satisfying the GMC/GDC and could therefore be unable to work as a licensed practitioner.

In order for individuals to obtain the most benefit from appraisal, both the appraiser and the appraisee need to understand the process and set aside sufficient time.  An appropriate amount of preparation time will be required by the appraiser/appraisee before the appraisal meeting.

Advance Letter (MD) W5/2002 introducing appraisal for all non-consultant career grades stated that … ‘Employers must recognise that preparation time, and time for carrying out the appraisal are instead of, rather than additional to, the non-consultant career grade’s existing duties and workload, and therefore should take place during usual working hours.  In order to prepare for appraisals, individuals should be explicitly released from other duties for a specified period of time.  In the first year of the scheme it must be recognised that appraisees will require further time for the work involved in setting up their appraisal folders’.

Therefore, a suitable period of uninterrupted and protected time should be set aside for the appraisal meeting and it is assumed that this would be a minimum of an hour and a half.  Recognising the particular needs of the revalidation timescales, for individuals who have yet to be appraised for the first time, time equivalent to a normal working day should be allocated for preparation for this appraisal.  This should be agreed locally and be identified from within normal working hours.

Training for those conducting and participating in appraisal is essential.  Where this has not already happened Trusts should take urgent steps to ensure that this is in place.  Trusts should also look to identify suitable SAS doctors who can act as appraisers when the need arises.

Following the appraisal the written documentation should be agreed which includes the following:

•	A summary of achievement in the previous year
•	Objectives for the next year
•	Key elements of a personal development plan
•	Actions expected of the Trust
•	A summary of the appraisal discussion
•	A joint declaration that the appraisal has been carried out properly

Involvement & Communications

SAS doctors are important and professional members of the clinical team delivering services to patients.  It is axiomatic that their contribution to determining the most effective and efficient ways of delivering services should be encouraged, and that they should be involved in the employer’s processes for making service delivery decisions, and decisions that affect their working lives and conditions.

All employers are therefore expected to ensure that SAS doctors along with all other staff, are fully involved in the Trust’s arrangements for communicating, consulting and influencing such matters, and that SAS doctors can fully participate in the employer’s formal and informal mechanisms for ensuring staff are kept informed and their views sought on relevant issues.  

It is also important that SAS doctors are appropriately involved in the employer’s service management arrangements at clinical team or directorate (or equivalent) level.  Similarly, it is important that SAS doctors are appropriately involved in the employer’s staff consultative arrangements. This is best achieved by adequate representation on the Trust LNC (or equivalent).

SAS doctors are encouraged to agree with their employer an appropriate forum for discussion of relevant issues and a reliable route for distribution of information with appropriate support from Executive Directors.

Regrading to Associate Specialist 

The process for regrading is laid out in DGM (96)158

It is beneficial to employing authorities to reward and recognise the experience and expertise of high performing doctors. Regrading to Associate Specialists is one such way. Where practitioners are already working at the level of an Associate Specialist Trusts should look to regrade.

Some of the benefits to Trusts could be:

•	Retention of experienced, highly skilled senior clinical staff
•	Maintenance of a high quality service
•	Improved clinical staff morale
•	Continued commitment from SAS doctors to the Trust and the service it provides
•	Improved quality of patient care

It is important to understand how the process works.

The National Assembly for Wales has produced an application form for personal Associate Specialist regrading. There are 2 parts to the application form.

The Clinical Director should complete part 1 of the application form. This includes details of: 
•	The post – speciality, location, present staffing in the department; 
•	The need for the post; 
•	The job plan, which must reflect the full duties of the post; 
•	Time allowed for CME and audit.

The applicant completes part 2 of the form. This includes: 
•	Personal details; 
•	Qualifications; 
•	Confirmation of relevant experience to satisfy the entry criteria to the grade OR signature of Postgraduate Dean or College Regional Adviser confirming your equivalent service is acceptable; 
•	A personal statement by the SAS doctor giving professional and personal reasons for regrading to an Associate Specialist post. Ideally, this shouldinclude:

- How the job is at the level of an associate specialist rather than the current grade;
- The SAS doctor’s achievements in their current and/or previous posts. It is worth listing the achievements using the same or similar headings to those used applying for optional points, eg, clinical expertise, quality of patient care, team working, etc.

SAS doctors should also be encouraged to attach a copy of their CV. 

Action by the Trust

The Trust’s Chief Executive is required to sign the agreed application forms before their submission to the Welsh Assembly Government for consideration.

Trusts should endeavour to deal with regrading applications as expediently as possible and within a maximum of six months.
 
Trusts should ensure good lines of communication so that if delays do occur the practitioner is informed.

Trusts should have procedures, which reflect the above, agreed with the LNC.

Confirmation of the regrading

Once a regraded post has been confirmed the doctor should receive a new contract. 

The starting salary of the regraded doctor is calculated as set out in the terms and conditions of service (relevant paragraphs are 127 and 133) taking into account, where relevant, the different hourly rates for notional half days and sessions. It is recommended that the regrading should be backdated to the date of the application. 

Appeals

Doctors have a right for their application to be considered fairly and without discrimination. In line with good employment practice, all Trusts should have an appeal mechanism to consider the case of any doctor who is dissatisfied with the outcome of his/her application for regrading to Associate Specialist.

Optional/Discretionary Points

Discretionary/Optional points are consolidated payments in addition to the maximum of the salary scale, which may be paid to SAS doctors at the discretion of the employer in the light of professional advice. The importance of these schemes to reward and incentivise SAS doctors has been emphasised by the Doctors and Dentists Review Body in recent reports. All Trusts must have procedures in place to ensure that all eligible doctors may apply for these awards. 

Guidance on the schemes is set out in AL(MD) 7/95 for Associate Specialists and AL (MD) 4/97 for Staff Grades. It is important that the process is seen to be fair, non-discriminatory and as far as possible objective. To aid consistency across Wales the following guidelines should be adopted:

1)	There should be policy agreed with the LNC on the award of Optional and Discretionary Points in every Trust and available to doctors. 

2)	Each Trust policy should identify Decision Making Groups (DMG), which should meet annually to award points.

3)	DMG should include at least one member of the relevant grade (not currently being considered for an award) and preferably selected by the local SAS Committee.

4)	Each eligible doctor should receive a formal invitation to submit a written application each year.

5)	To maximise objectivity the DMG should assess applications against the relevant criteria laid down in Annex D of AL(MD)(W)4/97 and Annex B of AL(MD)(W)7/95. Since individuals may not work closely with the Clinical Director or Consultant the practice of considering references is not recommended. 

6)	Awards are not automatic annual increments or seniority payments but should be made to all doctors who are judged to be making an above average contribution to the service taking into account the circumstances in which they work. Trusts should ensure this process is conducted annually.

7)	The two schemes (Discretionary Points for Associate Specialists and Optional Points for Staff Grades) are separate. Awards made to one group should not affect decisions relating to awards from another. 

8)	Applicants should be informed in writing whether or not they have been successful. The LNC should be given details of the awards allocated annually. Applicants who are unhappy with the decision should have the opportunity to receive feedback on their application. 

9)   All Trusts must have an appeals mechanism in place agreed by the LNC.

Working Time

Job plans should be compliant with the European Working Time Directive (EWTD) regulations. Although these currently include the provision of a voluntary ‘opt out’ for the individual, SAS doctors should not be pressurised by their employer to work beyond the EWTD requirements.

Study Leave

SAS doctors are eligible to be considered for study leave as per paragraph 251 of the terms and conditions of service and employers should ensure that they are not disadvantaged in relation to CME. 

Employers should ensure that SAS doctors are able to apply and participate fully in the continuing medical education programmes organised by medical royal colleges and professional organisations. It is important that doctors in these grades are able to maintain and develop their skills for two main reasons. Firstly, so that they are able to contribute fully to high quality patient care and secondly so that they can, if desired, apply to return to full-time training in order to obtain a CCT. 

Signatories to the GPG

Derek Jones					Dwijendra Baruah
Dr Bruce Ferguson				Jane Fenton-May
Dr Gill Todd					Gareth Jones
Shelagh Lloyd Jones				Jit Lodhi
Keith Jones					Mike Murphy
Angela Rackham				Rajnesh Nirula			
Beryl Jones					Lucy Dawson
S P Rees					Richard Lewis
Sue Haylins					Erica Stamp
Denise Roberts				Rhys Owen
Gwenda Davies				Sarah Miller
Clem Price					A Chadwick
Sue Morgan
Dennis Patrick

Appendix 1

A. Weekly work programme form

This should include all regular direct clinical care activities indicating their nature and location. The hour’s column should indicate the start and finish times of the activity.	  

	AM	Hrs	PM	Hrs	
Mon
					
Tues
					
Wed
					
Thurs
					
Fri
					
Sat
					
Sun

On-Call Commitments

Frequency of on-call (e.g. 1:3)

Level of on call (e.g. second on)

Resident/Non-Resident?

Information should be included in the Job Plan about relevant staff and other resources available to support the SAS doctor. This should include:

•	their named consultant(s)/unit
•	other senior staff in the department
•	numbers of junior staff and their rotas
•	other clinical staff such as nursing, technical and secretarial support

•	office accommodation and IT support.

B. Average number of hours spent each week on NHS duties

Duty type							Average number of hours

Outpatient clinics
Ward work/rounds
Operating sessions
Other patient treatments
Clinical diagnostic work
Patient related administration
Other direct clinical care duties
Travelling time

CME
Clinical audit
Research
Teaching/training
Management duties
Committees (local/national)

Based on this information an average number of sessions/NHD’s per week can be allocated by agreement between the SAS doctor, the clinical director and the HR department

The sessional/NHD assessment should be rounded up to the nearest whole number of sessions/NHD’s

Appendix 2

EXAMPLE FROM ONE TRUST

On-Call and Emergency Work

On-call and emergency work should be rewarded as sessions or NHD’s. 

For out of hours on-call work (i.e. 5pm to 9am Monday to Friday and all weekend) the sessional reward is based upon the approximate % of time spent working while on-call. There are 4 bands.

a)	Up to 25% time spent working. Equates to 1 session/NHD for 8 hours on-call
b)	26% to 49% of time spent working. Equates to 1 session/NHD for 7 hours of on-call
c)	Greater than 49% of time spent working. Equates to 1 session/NHD for 6 hours of on-call
d)	Almost all of the time spent working. Equates to 1 session/NHD for 4 hours of on call.

This obviously requires activity to be recorded over a period of time.

Where a SAS is required to be resident on-call then every hour on-call is an hour worked.
            
Recognition in terms of extra sessions/NHD’s should be given to SAS’s working:

shift patterns such as in A&E,
regular unsocial hours
with significant additional responsibility
with a recognised high work load intensity.