Doctor Grades in the NHS – A Simple Guide

Doctor career ladder NHS

Doctor career progression in the NHS is rarely a straight line. There are several grades of doctor in the NHS, and some international doctors we speak to find plotting their NHS career trajectory a little tricky at first glance. So, we’ve created this no-nonsense guide to NHS doctor grades, from Foundation Year 1 through to locum and substantive consultant level, including the many grades in-between. 

If you’re an international doctor or IMG planning your NHS career in the UK, here’s everything you need to know about the different grades you can work at throughout your career – from your first position after medical school through to retirement.

Junior Doctor Titles

The following doctor grades are generally considered to be part of the Junior Doctor category. They represent doctors who have graduated from medical school up to Consultants. 

Junior doctors are qualified doctors who are undertaking clinical training. Common titles for Junior doctors include FY1, FY2, ST (Specialty Trainee), SpR (Specialty Registrar), GPST (Specialty Registrar in General Practice), and SHO (Senior House Officer). Junior doctors can have up to 9 years of experience before becoming a specialty doctor in some specialties – or they may choose to remain at Junior Doctor level for longer, or even their whole career.

Foundation Year 1/FY1 Doctors (Internship)

FY1 doctors are in their first year of training after medical school. FY1 doctors work in NHS teaching hospitals more often than not, and work toward a structured curriculum with regular assessment. The goal for FY1 doctors is full registration with the GMC (General Medical Council). Upon completion of their FY1 year, these doctors move on to FY2. 

Foundation Year 2

FY2 doctors have completed their first year at an NHS teaching hospital and are fully registered with the GMC. Doctors of this grade were formerly known as senior house offices (SHO). FY2 posts remain at NHS teaching hospitals by and large, and upon successful completion doctors in the NHS must then choose to enter specialty training or continue along the core training path. Upon finishing FY2, doctors receive a Foundation Programme Certificate of Completion (FPCC). Once they have their FPCC they can either enter a specialism or continue on to become a General Practitioner (GP), or stay at Junior Doctor level.

Alternate routes for International Doctors: CCT – ST Run Through and CESR

If clinicians wish to change specialty after completing CCT for one specialty, they may have a junior heading after their title – though they are not a junior doctor. For example, a Specialist in Acute Medicine who wished to branch into Emergency Medicine may have ST1 emergency medicine next to their name on paper (in addition to their existing titles), but they would not be a junior doctor.

Run-through training programs typically take 3-7 years, and doctors are hired at the beginning of the program for the full duration of speciality training. CT/core training normally lasts for 2-3 years, but this can vary.

CCT and CESR (as well as CESR-CP) are alternative routes that exist specifically for international and overseas doctors. They are certificates issued by the GMC for international doctors who have proven experience in their specialism, with the intention of continuing their career progression with the NHS as part of a run-through program.

CCT stands for Certificate of Completion of Training. This is a route for doctors who have completed a GMC-approved training programme associated with their chosen specialty. These are accessed via the relevant Royal College, for example, the Royal College of Pathology for Haematology or Microbiology CCTs, whereas a Women’s Health doctor would seek theirs from the Royal College of Obstetrics and Gynaecologists.

CESR, or the Certificate of Eligibility for Specialist Registration, is a little more complex. It’s for doctors whose experience doesn’t include GMC-approved specialty training from a Royal College, and who have trained outside of the UK, Switzerland, or the EEA. CESRs are obtained via direct application to the GMC. CESR certification requires proof that your relevant knowledge and experience equate to a CCT. The CESR route can be complex, so we’ve put together a dedicated CESR guide for international doctors.

Specialty Registrar

Specialty Registrar (StR) is the working title held by doctors in their ST training programme. Not to be confused with SAS doctors and specialty doctors (we cover SAS doctors and specialists a little later on in this article).

ST1/CT1 (Specialty Training/Core Training)

Once they’ve completed their FY2, NHS doctors can choose to enter a speciality or continue on with a core/general practice training and development program. ST1 represents the first year on the run-through training program for a given specialty, for example, ST1 Obstetrics and Gynaecology. CT1 refers to doctors in their first year of uncoupled core training programs.


As above, but for the second year of the run-through program. So an ST2 Radiologist would be in the second year of the Radiology run-through program, whereas a CT2 doctor is in the second year of an uncoupled core training program. Despite the few years of experience between ST2 and FY2, doctors until ST3 grade would still operate under the SHO title in previous decades.

Junior Doctor to Senior Doctor Levels

The following grades are junior doctor positions. They represent the latter years of ST run-through programs, as well as specialisms and unique positions such as being a Clinical Fellow. Here’s everything you need to know about junior doctor grades in the NHS.

Trust Grade Doctors

A term you may have seen used is Trust Grade Doctor. An NHS Trust Grade Doctor is simply a doctor that has been hired directly by an NHS Trust instead of Health Education England. It’s a broader term with different contractual elements for each doctor. For example, some can maintain a portfolio per other doctor training programmes, whereas others may not. Trust Grade Doctor positions provide individual NHS trusts with greater hiring flexibility to match changing needs of the communities they serve. From the perspective of the doctors that take them, it’s a great way for International Doctors to gain NHS experience, and for those already within the NHS to broaden their horizons without signing onto a new training program.

ST3, ST4, ST5 and ST6 NHS Doctor Grades

Just like ST1 and ST2, NHS doctor grades ST3-ST6 denote doctors taking part in specialty training, with the numeric value increasing for every year of the program successfully completed as per guidelines for their specialism. For example, a doctor at grade ST5 Psychiatry will be five years into their Psychiatry training but have worked as a doctor for 7 years minimum, after medical school.

Senior Clinical Fellow

Clinical Fellows play a special part in the NHS doctor grades hierarchy. Senior Clinical Fellows have the responsibilities of a regular doctor, however, they also have assigned research from a Consultant or unit lead. They take on some clinical duties, but their time is equally spent advancing their given specialism by carrying out academic and research-based tasks.

Specialty Doctors, Specialists, and SAS Doctor Grades in the NHS

Once ST training is complete and a doctor is working as a specialist, job titles and NHS doctor grades become less generic. Each specialism will have its own unique position within its own discipline.

SAS (Specialist and Associate Specialist) doctors are specialty and specialist grade doctors that have a minimum of four years of post-graduate training. Two of these need to be in their relevant specialty. Specialty doctors are experienced specialists and previously were known as Specialty and Associated Grade (SASG) doctors. They have fewer administrative duties than consultants, though their experience levels are comparable. For doctors who prefer a more hands-on role that focuses on providing clinical care instead of other senior duties like training, a role as Specialty Doctor is ideal.

At Remedium, we support doctors from all over the world to make the move to the NHS and we have found that SAS and specialist grade roles are often attractive to international doctors who wish to begin the path to becoming NHS consultants. Some international doctors will choose to stay at this grade, opting to focus the remainder of their career on directly providing medical care to patients, as opposed to the more administrative tasks that can be associated with consultant grade roles. However, more often than not, international doctors will work at this level while undertaking CESR, with the view to obtaining specialist registration and therefore becoming eligible to work as a consultant in the UK.  

Locum and Substantive Consultant Doctor Grades in the NHS

Consultant is a broad term even within healthcare, and it’s not exclusively linked to medicine either. As far as NHS doctor grades are concerned, a consultant is a senior doctor that has completed their full medical training in a chosen specialism.

It takes around 6-8 years to reach consultant level. Even though it’s considered a senior grade, there’s a huge variety of experience within this grade. Some senior consultants and clinical directors have decades of experience and are at the end of their career, whereas others might be a lead consultant on their ward with fewer years as a qualified doctor under their belt.  

An important distinction to be aware of is between locum consultants and substantive consultants. Substantive consultants are specialists on a permanent contract. Substantive consultants are appointed via an interview and assessment process led by an Advisory Appointment Committee (AAC) panel. Successful doctors are employed on a permanent contract on a job plan approved by the respective colleague of their specialty. Therefore, in order to be employed as a substantive consultant, a doctor must be on the specialist register having received their CCT.

The locum consultant contract is used for senior doctors, who for a multitude reasons; be it coming from overseas, or returning to practice, are not on the specialist register but demonstrate the ability to practise medicine at consultant level via a formal interview and assessment process. The job plan will most commonly be designed to support a doctor at this level through to specialist registration into a substantive consultant post. This is most commonly a 12 month arrangement and is a salaried role on the consultant pay scale (not to be confused with a temporary hourly rate candidate working on a shift by shift basis).

Remedium – here to help doctors of all grades find their next NHS post

No matter where in the world you practise, the career progression of a doctor is never as simple as student to junior to mid-grade to senior. The NHS is no exception. As you can see, even with our brief summary of NHS doctor grades, there’s a lot to cover – much of which changes over time as the UK National Health Service adapts and evolves to meet new needs, too.

If you’re an international doctor or IMG seeking an NHS position, register your details with us. One of our expert onboarding team will reach out to discuss your current experience, how it fits into the existing NHS doctor grades, and what steps you need to take to start building your career as an NHS doctor. We pride ourselves on our commitment to candidate care, and this shows in everything from our 24/7 support through to our award-winning Red Carpet Platform, which has made relocating to the UK a simpler process for thousands of international doctors. Have a look through our available positions and register with us today to begin your journey. We look forward to hearing from you soon.

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