The rise of trust doctors

Non standard grade doctors—more commonly called trust doctors—are a relatively new phenomenon in the United Kingdom. They have several different titles, but essentially they have arisen as a means by which hospital trusts can employ additional junior doctors, despite the Department of Health's ceiling on training grade numbers, which exists to prevent a bottleneck at specialist level. Trust doctors are employed by trusts (local hospitals) for service and are therefore not regulated by the royal colleges or the deaneries (departments of postgraduate medical education). There were few posts for trust doctors in the United Kingdom until the introduction of stricter regulations of hours for junior doctors. Trusts most commonly state that they employ trust doctors as a direct result of these changes. However, the big picture regarding trust doctors is only just emerging ¹,²—they are employed mainly in the acute specialties, a significant number work at specialist registrar level, and their numbers are growing fast. Most want to be consultants in the United Kingdom and are in post as a temporary measure. Their work is often indistinguishable from that of the training grades yet few trust doctors have regular appraisals, and trusts report no organisational strategy for their education and supervision.

No one has any idea how many trust doctors there are in the United Kingdom because the annual census from the Department of Health includes them as the equivalent training grade. Both the Yorkshire deanery survey¹ and the study by Dosani et al² in this week's issue, confirm the dramatic rise in the numbers of trust doctors.

The medical establishment has so far adopted an uncoordinated approach to the problems this situation poses. Whereas the BMA junior doctors' committee is opposed to the advertisement of trust doctor posts, in our experience, some colleges encourage them to be incorporated as part of a rotation, so that trusts can increase numbers, and doctors still get the time in the training posts they need. The General Medical Council recently relaxed its rules so that doctors with limited registration can apply for non-training posts. This has made mixed rotations easier, and whereas before trust doctor posts were hard to fill, many trusts now find they can easily fill these posts with overseas graduates if they simply state that the trust doctor post is akin to a training post (http://www.gmc-uk.org/register/).

There is a workforce paradox in the United Kingdom. On the one hand we face a shortage of general practitioners and specialists, yet there are already more junior doctors than posts to progress to. There is no doubt that we need more doctors because of demographic changes and the European Working Time Directive. Many consultant posts go unfilled when advertised.³ The Royal College of Physicians estimates that several hundred extra consultants would be needed to implement the European Working Time Directive just to maintain the current level of service.⁴ The United Kingdom already has fewer doctors per head of population compared with most European countries. The number of emergency admissions is rising each year⁵ and junior doctors perform most of the out of hours work in many specialties. For this we depend on overseas graduates with one third of senior house officers having trained abroad.⁶ We have increased medical school output by 2000 per year, which will be delivered in 2008, but this is nowhere near providing the numbers of medical staff needed to implement the European Working Time Directive. Yet despite not having enough junior doctors to implement acceptable shift patterns in many areas,⁷ the Royal College of Surgeons reports that its specialty still has too many senior house officers for specialist registrar posts,⁸ which are centrally regulated. At the root of all this is a historical lack of adequate workforce planning, with the resulting two tier system we have today.

The current situation poses many questions and few easy answers. If it is in the interest of all doctors to engage in continuing professional development, regular appraisal, and study leave, what is the point of having training and non-training grades? At a junior level, this is an anomaly and should be abolished. While trusts may state that a trust doctor post is akin to a training post, there is no formal assessment of competence and one could argue that this makes a mockery of the idea of limited registration. Acute care is increasingly being delivered by junior doctors who are educationally unsupervised, and this has implications for patient care and for the doctors themselves.

Should we simply accept that many junior doctors would not be able to progress in their chosen hospital career? Should we create a renamed, revamped, and destigmatised staff grade type role for such doctors? Or perhaps more imaginative thinking is required in terms of skill mix. Much has been made of recent initiatives (physician's assistants, extended nurse training, hospital at night schemes), but most of these have only just been set up and will not mature until well after the European Working Time Directive deadline, which requires near universal shiftworking for junior doctors.

Finally, we seem to be creating an underclass of doctors at the same time as we are making attempts to correct the injustices which have been inflicted on another group of mainly overseas doctors—the non-consultant career grades. There is a huge moral question mark over employing large numbers of doctors, mainly from the Indian subcontinent, in posts where their identical service is not recognised for training or examinations, the very reason they come to the United Kingdom.

It is time to tackle the issue of trust doctors, and a good start would be to have centrally collected data, one recognised title (for example, trust senior house officer or trust registrar), and for the relevant parties to sit down together and formulate a coordinated way forward.