The CCT cul de sac?

Authors: Helen Jaques 

Publication date:  14 Sep 2011

New research from the Royal College of Physicians has shown that doctors who have recently gained their certificate of completion of training (CCT) are struggling to get consultant posts. Helen Jaques looks at the problem and one of the emerging “solutions”—non-consultant roles for CCT holders

Throughout the five or six years of medical school, the couple of years in foundation training, and the seven plus years in specialty training, most hospital doctors assume they’ll get a consultant job at the end. This outcome is becoming increasingly less certain though, as mounting evidence suggests that there are not going to be enough consultant posts available for the number of trainees currently working their way through the system.

The raw stats on workforce numbers seem to support this claim. Over the past 10 years the number of consultants in the United Kingdom has increased by 4.5% a year to 13 351 in September 2010, but the number of hospital registrars has increased by 11.6% a year to 25 428 over the same period.[1] Only 2528 (24%) of the current batch of consultants are expected to reach retirement age by 2020,[2] with just 204 estimated to hit 65 in 2010-11, yet the General Medical Council granted 6299 certificates of completion of training (CCTs) to newly qualified doctors between April 2010 and March 2011.[3]

Not enough consultant jobs

Now new research by the Royal College of Physicians has provided some hard evidence to back up this suspicion that there simply won’t be enough consultant jobs to go round. The college’s medical workforce unit has shown that the proportion of CCT holders who achieved a substantive consultant post on qualification has dropped from 59.3% in 2009 to 55.7% in 2011 (table ).[4]

The data, collected by three annual electronic surveys to all doctors who obtained a CCT in the preceding 12 months, also showed a decrease in the proportion of doctors obtaining a locum consultant post, from 23.8% to 20.1%, and an increase in the proportion who remained as specialty registrars, either within or beyond their six month “period of grace” after achieving a CCT. Most alarmingly, for the first time the results show unemployment among CCT holders—three (0.7%) of the 419 respondents in 2011 reported being unemployed when asked about their current work situation.

“These figures are hugely concerning,” says Shree Datta, co-chair of the BMA’s Junior Doctors Committee. “What we’re talking about is a lot of financial investment and a lot of time and passion going into training but with doctors having nowhere to go, so effectively you’re talking about a dead end for training.” Without guaranteed jobs at the end of training, newly qualified doctors could be more likely to take their skills abroad or to the private sector, which would not be a good use of NHS resources and public spending, she adds.

Competition for the posts available is also getting tougher, according to the Royal College of Physicians research. In 2011 CCT holders applied for more posts in almost all the specialties than in previous years, but the data show no evidence of a drop in success in gaining interviews nor success in being offered a post. There was no clear pattern as to which specialties were becoming harder for newly qualified doctors to get posts in, but acute medicine and haematology do appear to be getting tougher. A few specialties—cardiology, dermatology, endocrinology, gastroenterology, palliative medicine, and renal medicine—seem to have a persistently high rate of unsuccessful application to substantive posts, however, say the authors.

Study author and director of the Royal College of Physicians medical workforce unit Andrew Goddard describes the causes of this decrease in the proportion of doctors achieving a substantive consultant post as twofold. The first issue is that a lot of extra national training numbers were created in 2004 in anticipation of the service delivery problems that would be created by the European Working Time Directive (EWTD), which has generated a “bulge” in the number of trainees moving through the system.

The second cause is financial: the NHS needs to save £15-20bn over the next few years, and many trusts are facing considerable financial challenges, meaning that organisations are often not filling consultant posts when they become vacant. “We did a separate survey of training programme directors across England and Scotland and we found that several of them were reporting that vacant posts were not being replaced,” says Dr Goddard. “Trusts and hospitals see this as a chance to save money—if there’s a vacant post and they can’t fill it then they’ll withdraw that post.”

A subconsultant grade?

But if CCT holders are not getting consultant posts, where are they going? One answer is that these doctors are heading into post-CCT fellow jobs and their ilk. The Royal College of Physicians research found that the proportion of newly qualified doctors ending up in these posts has increased from zero in 2009 to 2.7% in 2011,[4] an increase the authors describe as “exponential.”

Many view these roles as a last resort for newly qualified doctors who can’t bag one of the few consultant jobs around, not least because the jobs are not generally considered to be good career opportunities. The BMA, for example, sounded the alarm over non-consultant post-CCT jobs at its annual representatives’ meeting earlier this year, with speakers describing these roles as “exploitation” and a “dreadful waste of careers.”[5]

The main reason for this concern is that post-CCT fellow jobs tend to be short term six or 12 month contracts and the terms and conditions are determined on a trust by trust basis, so pay and benefits can vary across the country. They also often don’t have any formal educational or continuing professional development opportunities and don’t have a clear “exit point” where a doctor might expect to progress to a consultant role.

“You are at the mercy of the trust that is employing you, so whether you will then go on to the promise of a consultant job is up to them, whether you get time for SPAs [supporting professional activities] will be up to them, whether you will simply be delivering service or night shifts or out of hours is really up to them,” says Dr Datta. “We’re very clear when it comes to post-CCT fellowships: this is not something that we would be able to recommend as the JDC in terms of career prospects.”

These posts are also seen by trusts as a way of plugging rota gaps and saving money, says Dr Goddard. “If you are a trust and you’ve got a limited budget, if you can get a fully trained doctor to work for you in post-CCT fellow position or whatever they want to call them, you’re going to do that,” he says.

Some argue, however, that non-consultant CCT-holder jobs provide a valuable opportunity for very specialised training in areas where it’s difficult to go into sufficient detail during the main training programme. The Association of Surgeons in Training supports such programmes, which it says provide valuable opportunities for obtaining superspecialty and multidisciplinary skills not easily available within some specialty training programmes or regions. These “peri-CCT fellowships” generally comprise periods of up to 12 months spent abroad or increasingly in the UK at centres of excellence and are completed either before or after receipt of a CCT, but typically before a trainee has started applying for consultant posts.

However, although post-CCT fellow posts have their place in very niche areas and in particular in highly specialised subspecialties, they should not be the norm for conventional or larger subspecialties, argues Ian Wilson, deputy chairman of the BMA’s Central Consultants and Specialists Committee and of the union’s representative body. “For example, gynaecological oncology subspecialty training is included within training programmes, not stuck on the end of a training programme as an extra,” he points out. “Shoving a bit of extra training on at the end in a subspecialty as a way of getting somebody who has a CCT working at virtually consultant level but without the career progression options and on the cheap is taking us back a couple of decades in terms of reforming workforce planning and training.”

If extra training is provided in a post-CCT job it can also mitigate against the reduced time for training as a result of the EWTD. In many specialties, in particular craft based specialties such as surgery and gastroenterology, some trainees struggle to get in enough procedures or enough theatre time within the working hour restrictions imposed by the EWTD. “While that’s fine for some trainees who are very good, for the trainees who need a bit more experience it does render them a little weaker when they get their CCT,” says Dr Goddard. “I think an opportunity to develop those skills in a controlled setting is a good thing, and I think there are lots of specialties that feel that.”

What are the solutions?

The ideal solution to the expected oversupply of CCT holders would be an increase in the number of consultant posts in the country, which would please trainees and would also potentially be the best solution for the health service. The BMA has long pushed for an increase in consultant numbers on the basis of its view that consultant led care is the best service approach for patients and the NHS as a whole.[6]

“I think we need to have a serious discussion about what patients need, but every time we have that discussion about what it is that patients need we actually agree that what patients need is CCT trained doctors,” says Dr Wilson. “The reality is that the consultant grade is a remarkably adaptable, efficient, and effective way of delivering healthcare.” Consultants are more efficient for the health service than doctors in service roles such as post-CCT fellow roles, agrees Dr Datta, and they provide better continuity of care and more dedication than those in short term posts.

This is unlikely given the financial climate, however, so perhaps instead what is needed is a national conversation on the value of post-CCT fellow roles and generation of national job descriptions, terms and conditions, and educational pathways for these jobs, says Dr Goddard.

“If we genuinely feel that these jobs are the right things for the profession and the patient, then we should discuss them openly rather than just create these things by the back door, because all we do then is create more and different lost tribes that we have spent the past 15 years trying to get rid of in pursuit of a more coherent and integrated training system,” agrees Dr Wilson.

Unfortunately it seems that the situation is only going to get worse. “I still think we’re very much at the top of the down slope in job prospects,” says Dr Goddard. “I think the next couple of years are going to be the crucial years where we see major swings, because that’s when the austerity limitations are really going to hit and also that’s when the bulge of trainees are coming through; I think we’re now going to see a whole tranche of trainees coming through and their job prospects are going to be a bit difficult.”

Competing interests: None declared.


  1. NHS Information Centre. NHS staff 2000-2010 (medical and dental). 22 March 2011. [Link] .
  2. Federation of the Royal Colleges of Physicians of the UK. Census of consultant physicians and medical registrars in the UK, 2009: data and commentary. Royal College of Physicians, 2010. [Link] .
  3. General Medical Council. Certification statistics: certificates of completion of training (CCT). 2011. [Link] .
  4. Goddard AF, Newbery N. Survey of medical CCT holders career progression 2009-11. Royal College of Physicians, June 2011. [Link] .
  5. Jaques H. BMA condemns rise in non-consultant CCT posts. BMJ Careers  1 Jul 2011. [Link] .
  6. BMA. Enhancing quality: promoting consultant expansion across the NHS. April 2008. [Link] .

Helen Jaques news reporter BMJ Careers

Cite this as BMJ Careers ; doi: