We are grateful to Drs Budd & Everett for drawing attention to our omission of relationships between non-consultant career grade (NCCG) doctors and other grades in our article. This reflects the changing nature of medical staffing: a significant increase in the number of NCCG doctors has been stimulated by the European Working Time Directive restriction on junior doctors’ hours and, for some, the unattractiveness of taking up a substantive consultant post at the earliest opportunity when they perceive that consultants face increasing bureaucracy and impingements on their professional freedom.

NCCG doctors indeed have a more complex relationship with other medical colleagues. Trainees and senior psychiatrists tend to have followed more predictable career patterns, whereas a striking diversity of pathways eventually lead a doctor to choose to apply for an NCCG post. Part of the difficulty arises from the fact that there are vast differences in the expectations of NCCG doctors: some see the post as a stop-gap or interval in their career, or have positive reasons for choosing not to proceed to consultant posts; others purposefully seek an alternative route to that grade, or take the job for the considerable financial gains of employment through locum agencies. All these will affect relationships in different ways.

We think it is fair to say that, until recently, NCCG doctors were appointed principally to fill in service requirements and had a second-class status within the hospital hierarchy. Only in the past few years has there been recognition that NCCG doctors have continuing development requirements, and that they need to be in regular supervision and appraisal scrutiny. The fact that there are accepted routes to the Certificate of Completion of Specialist Training (CCST) and possible consultantship from associate specialist positions has altered the status of NCCG doctors. This has inevitably affected the relationship between grades, to the point that now NCCG doctors are not infrequently represented on senior medical staff committees and, if experienced enough, are likely to take on management responsibilities. It is interesting that, with the shorter time that trainees (at both SHO and specialist registrar levels) are now expected to remain in each post, NCCG doctors have the opportunities to be involved in service development, audit and even research, which their other colleagues may find difficult.

There are still some incongruities in the position, however, which have an impact on job satisfaction for NCCG doctors. On the one hand, regardless of their experience they are likely to have to take on responsibilities that are similar to those of training-grade doctors; whereas on the other, the fact that they are likely to remain in post longer than their junior counterparts gives them an ascendancy akin to the consultant, and often they are asked to act for consultants in their absence. The introduction of the European Working Time Directive is likely to influence this relationship, as NCCG doctors will be called in to cover for absent trainees when they are working shift patterns. This inevitably creates a tension, which is difficult to resolve.

As Budd & Everett point out, relationships will also depend on the respective career stage at which consultants and NCCG doctors find themselves. We do think, however, that with increasing acceptance of clinical governance and recognition of professional development needs, NCCG doctors can take advantage of clinical and career opportunities that are opening up for them in the NHS. However, this will require considerable work in clarifying both roles and relationships with colleagues in the other grades.