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What is medical role-play?
The use of medical role-players, otherwise known as ‘simulated patients’, within the medical education system is well established. Medical students need to be trained and the public need to be confident that the doctors that emerge from the training process are fully competent, both in terms of their medical knowledge and ability to communicate effectively with patients. Medical role-play is vital to the National Health Service (NHS).
There are two broad areas where actors are employed:
- Clinical and communication skills training: where students practise their skills and receive personalised feedback, in the safe environment of a role-play and in the examination setting.
- OSCE examinations (Objective Structured Clinical Examination): actors help to provide a consistent and controlled setting for these assessments, benefitting students and examiners alike. There is a massive amount of organisation involved when setting up an OSCE. There may be upwards of 250 students per day, each will involve actors and medical examiners, and the examinations might run over five days.
To maintain consistency amongst actors, students and examiners, and continue to attract experienced medical role-players, we recommend agencies and institutions adopt the best practice contained in this guide.
Who benefits from improving medical role-play practices?
- The institutions, who are aiming for good pass rates (and fewer challenges from candidates who fail and challenge the process).
- The actors, who have needs that have to be considered so they can maintain their concentration and their well-being.
- The general public, who benefit from a team of medical practitioners given the best possible preparation for their future work within the NHS.
Pay
Rates of pay should reflect that acting as a simulated patient (medical role-player) requires specialised skills. However, many hospitals and agencies have not increased their rates in line with inflation. It is important to maintain and attract a workforce of skilled practitioners of simulation role-play for the benefit of future NHS doctors and patients, and therefore rates of pay need to be raised annually and index linked, in line with current inflation rates.
Pay is also linked to accessibility and diversity. If payment is too low, it means that disabled and black and minority ethnic people are disproportionally impacted and often precluded from participating.
A medical role-player’s work can be sporadic and precarious. The daily rate is often very low, particularly compared to other skilled work, and especially when factoring in preparation and administration time. The work can also be intensive so a fee should fairly reflect this.
Medical role-players are normally paid at a much lower rate than role-plays in a corporate commercial setting. Part of the satisfaction of this type of work is that role-players know they are contributing to training our future doctors and nurses. But this should not be used as a reason to keep rates low.
Where a role-player is booked as a simulated patient for a half/partial day, they should be paid a minimum of 60% of the daily fee or paid for five working hours (if paid hourly). This is because an actor has to give up a full day’s work elsewhere to provide a short medical role-play session.
If the trust, educational institution or agency requires more than 9 hours (inclusive of lunch) in one working session, then overtime for each extra hour, or part of an hour, should be paid for a full hour at a rate that is 1.5 times the hourly rate.
Late payment can have a devastating impact on the self-employed.
When the role-players are “genuinely self-employed”, agencies and institutions should ensure payment is made within a minimum of 30 days of the completed work.
Purchase orders and invoices need to be processed in good time to ensure the 30 day rule is maintained.
If the role-players should be considered as a worker in law (Limb B status under S230(3)(b) Employment Right Act 1996 then they will have rights which means that the employer technically must pay them for work at least on a calendar monthly basis. Please see further information on potential employment status.
No institution or agency should allow a lower quoted hourly fee or day rate for online work. Consultants in many professions still retain their pro rata salary in circumstances when agencies are used to provide services. Workers in this precarious industry should not fall victim to a lowering of terms and conditions through an institutions use of intermediaries to help provide a service, especially publicly funded institutions.
Additionally, fees should not be reduced if the role-play is changed from in person to online. Role players will still end up with home office costs, such as electricity and heating. See also Online role-play.
Travel
Many role-players travel widely to fulfil hospital role play needs. Role-players required to do so should be given expenses at the Government Guidance Rates as set out on the government website.
Role players should also be given parking costs.
Accessibility and diversity
Agencies should not charge or require unpaid training to access work.
To ensure a diverse workforce, it's important to recognise many enter the industry through various routes. This could be accredited training, youth training theatre, various modular classes, learning on the job via initial credits (perhaps as a child performer) for example. We frown upon any institution or agency citing the need for role-players to have "accredited drama school" training. This is just one route into the industry, and it’s not affordable or accessible to all. We ask institutions and agencies to allow a mix of training, experience and credits and thus overall CVs when applying for this work.
To a large degree, it is understood that there needs to be a significant suspension of disbelief in simulations. Unless vital to the role, casting should stay open on gender, age, race, etc so as not to further marginalise unrepresented groups. A wide representation of demographics should be sought in casting scenarios in order to represent the general public. It is, however, important that where there are characteristics of the patient that are medically significant that in the casting there is some approximation at least to the patient in the scenario. There should be no casting that crosses racial groups and actors should certainly never be asked to simulate the accent of a person from a racial group different from their own. There may well have to be considerable leeway with regard to age.
Dignity at Work
It is crucial that all role-players feel they are in a safe space, with a clear route to report anything that makes them uncomfortable.
Everyone has the right to be treated with respect and in a manner that allows them to maintain their dignity at all times. Any harassment and bullying should not be condoned.
All trusts and agencies must have a Dignity at Work policy that is monitored regularly and adhered to in practice. Model policies are available online including on the acas website.
Cancellations, replacements and substitutions
Many actors rely on medical role play work as a means to sustain their broader career in the arts. On rare occasions, a medical role player may wish to pull out of a job in the event of an audition recall or an acting booking. For this reason the medical role-player needs to have some flexibility on the part of the employing institution or the agency.
What is crucial is that actors and their agency have a shared understanding of how such a situation might be handled.
We do understand that accommodating role-players in such circumstances can leave those agencies in a difficult position. If the agency doesn’t already have a suitable replacement available, it is the responsibility of the role player to offer an experienced replacement of the right demographic for the given scenario. It is our experience that the institutions for which the actor is working are very happy with this, although this is often less true for agencies.
Too many role-players are fearful that withdrawing from a job might preclude them from being given future work by a role play agency. If on the other hand they decide not to withdraw and miss the acting opportunity, their acting agent might have doubts about whether or not it is feasible to represent them. This is an extremely stressful dilemma for the actor/role-player, making it more difficult to fulfil the work to the best of their ability.
It is therefore important that agencies and institutions can offer some flexibility.
Similarly, many medical role-players rely on the work of medical role-play to help meet their day-to-day living costs. Cancellations at short notice can have a major impact as they are unlikely to be able to pick-up replacement work at such short notice.
We therefore recommend that any cancellations by medical institutions or role-play agencies must be a minimum of one week, otherwise the following minimum payment should be made:
- Less than one week’s notice but more than 3 days’ notice: 50% of full expected fee.
- Less than 3 days’ notice: 100% of full expected fee.
Online role-play
Since COVID-19, online role-play has become more and more popular. As much as colleges/institutions are trying to minimise the differences between online role-play and in person role-play, there are some elements involved in online role-play that have to be addressed separately.
All institutions have their own preferred software that they use for online role-play sessions. This means role-players have to learn how to use each software platform. Some role-players may be more tech savvy than others and may not feel they require training in how to use platforms such as Zoom or MS Teams. But we believe institutions and agencies should offer all role-players optional paid training on how to use their chosen software if it is being used in a particularly bespoke manner or if the software is one that is not commonly used.
Filming
Any filming by institutions and agencies to be used for wider training should ensure permission is sought in advance of filming and that an appropriate payment is made for the use of the film. This should generally include full details of how the film will be used, for how long the agreement lasts, and how much the medical role-player will be paid for the recording and use.
This is a legal obligation under the Copyright, Designs and Patents Act 1988 for recording and use of a qualifying performance. Furthermore, medical role-players are legally entitled to “equitable remuneration” for the exploitation of a qualifying performance.
Call-times
When an agency/intermediary secures a contract there is an alarming culture of asking role-players to attend even earlier than when the client/hospital trust requires, often in unpaid time. This is done to give the agency peace of mind that all their role-players are ready for the client. The problem with such a culture is that this ends up diluting the role-player’s fee by making their working day longer. In extreme cases this has led to role-players having to arrive up to two hours before a circuit begins and, even in circumstances when they are paid, can impact on their ability to give the best performance.
The call time should be agreed by both the institution and intermediary. The former needs to be aware of the hours the medical role-player is officially being asked to work, in light of the offered fee. Consideration should be made by agencies and institutions as to whether extending the day in this way is detrimental to the overall work expected of the medical role-player.
Where it is required or demanded, institutions and agencies should reflect this in their day rate or make sure role-players are paid appropriately for extra work.
Medical role-play agencies
There is a worrying practice of agencies operating opaquely in respect of role-players’ pay. In fairness to trusts who use agencies to fulfil the medical role-play service, we believe they are not made aware of the difference between companies and what percentage of the overall fee ends up with the agency as profit rather than in the pockets of workers.
If an institution chooses to outsource the supply of role-players to a third-party agency, we ask that during any tender or commissioning process, they set minimum requirements for guaranteed pay rates role-players will receive in order to be awarded a tender/commission.
This allows the institution/hospital trust to have a more informed view when assessing the perceived value of the bid and to not work with exploitative agencies who do not fairly value the work that medical role-players do.
We understand that agencies have outgoings from administering and supporting medical role-play work, and many abide by solid pay and commission practices. However, it is vital that the actual day/hourly rate the role-player receives is an integral part of any institution’s tender decision-making process. Failure to do so affects the accessibility and diversity of this industry, contributes to burn-out and weakening of overall service provision, adversely impacting on the NHS as a whole and its patients.
Trusts should ensure that medical role-players receive a minimum hourly or daily fee and where they use a medical role-play agency to fulfil this service, this should represent a minimum of 80% of the overall fee paid to any agency. In other words, the agency fee is in addition to the role-player’s fee. This should be stipulated in any tendering or commissioning process.
Similarly, we recommend that medical role-play agencies should ensure that a minimum of 80% of their overall turnover goes to medical role-play actors.
Agency considerations
If a medical role-play agency is acting as an employment agency (under the Employment Agencies Act) for medical role-players, then the agency has legal duties to their medical role-play clients. These include:
- to have a proper written agreement with their clients
- actively seeking out employment and job opportunities for their clients
- providing payment advices which properly record the fees that role-players have earnt on an engagement and all deductions
- taken from them by agencies
- to pay the client within 10 days once an agency has received payment and being liable to pay interest if held thereafter.
The agency cannot charge a fee for the supply or introduction of a medical role-player to the end hirer as well as charge commission to the medical role-player.
In this type of agency model, the engager or employer would be the end hirer, typically the NHS trust or institution that the medical role-play takes place. However, most medical role-play agencies do not work under the employment agency model above and are the actual engager/employer.
These medical role-play agencies may seek to designate medical role-players as if “genuinely self-employed”. However, many medical role-players will be self-employed for tax and national insurance purposes, but, nevertheless, a worker in law under S230(3)(b). This means that irrespective of how the medical role-player has been contracted or designated, that they will have important legal rights. These rights include:
Paid Holiday/Holiday Pay in Lieu
Entitlement to holiday and accrual occurs from the very start of any engagement or work assignment in which worker or employee status exists. Therefore, performers and stage managers are entitled to paid holiday, or holiday pay in lieu, in line with statutory minimums (or above).
National Minimum Wage
The right to National Minimum Wage for which breaches can be prosecuted as a criminal offence with fines of up to £20,000 per worker.
Pensions Entitlement
The right to be auto-enrolled into a company pension scheme, where eligible, under Pensions Act 2008 at the point in which minimum income thresholds are met or likely to be met.
Working Time Regulations
Workers also have protections under Working Time Regulations and employers have responsibilities to adhere to them.
Health and Safety
Workers have protections under Health and Safety at Work etc Act; S44 Employment Rights Act; and The Workplace (Health, Safety and Welfare) Regulations and Employers’ Liability (Compulsory Insurance) Act amongst other protective regulations/legislation.
We believe that many agencies are technically employers and that medical role-players may suffer the denial of important statutory rights which could be of significant monetary value. We strongly encourage members to contact us if they want to explore this further and pursue their rights with our full support.
No agency should create a culture where it is acceptable to ask a role-player to volunteer their services unpaid, such as testing a software system or agree to film recording without any advance agreement.
This makes role-players feel obliged to agree to feel considered for securing work. This is especially true when they may have already invested time on interview, recruitment, or audition days (as well as previous administrative correspondence to get themselves set up with the said intermediary/agency).
Agencies should not ask role-players to undergo unpaid training, for example in equality, diversity and inclusion, in the name of being able to sell their role-players/heighten the appeal of their bid for a contract. Ultimately the cost falls on the role-players and we deem this as deeply unfair. There is also arguably a hypocrisy in asking role-players to undertake such training unpaid as it is another barrier - in terms of time and cost - to making the industry accessible and inclusive.
No agency should ever charge role-players for training they wish to give nor charge a "book fee" to be listed on their database for work (even if the agency disguises/promises to only take such fee out of any work secured for the role-player).
Furthermore, agencies should not impose (or even offer) any paid for medical role-play training. This creates a culture whereby freelancers feel the need to pay to access this kind of work . It would be another costly barrier affecting the diversity and accessibility of the industry.
Finish times
Very occasionally role-plays can run over their allotted times. Role-players should never feel pressured to stay on after their stated finish time. If medical role-play is running over time and a role-player is reasonably required to stay on, the extra time worked must be paid for.
This also applies to online role-play, where role-players have experienced sessions running over their allotted break and finish times due to technical difficulties. For many simulations, circuits need to run at the same time. So if one circuit is experiencing a delay due to an examiner/role-player/student’s connection problems, it can delay the whole circuit, causing everyone to fall behind schedule. We understand this is unavoidable. However, institutions and agencies should adjust for this, either by extending break/finish times for role-players and reflecting this in their day rate or offering role-players an option to stay on.
Info provided in advance
We understand that unlike training days, due to confidentiality and exam security a lot of scenario information cannot be provided until on the day.
However, given many trusts/institutions have differing rates of pay and "station intensity", it is important that any medical role-player is advised in advance of the number of stations (and length of station) and overall circuit hours with break ratio that is expected to occur on the day.
This allows the role-player to fairly assess whether the job is feasible for them and have an idea of what to expect on the day. This is particularly crucial when many self-employed will have to schedule in other work commitments in their week (or perhaps their evening). They rely on this information to determine whether or not this is something they can commit to.
If an agency has the contract, then the minimum information mentioned above should be provided to them, in addition to the fee when offering out the work to a role-player. Any reasonable changes must also be communicated in a timely manner.
OSCE focused conditions of work
In addition to the best practice outlined above, below are some specific considerations that should be made in order to operate best practice in OSCE medical role-play.
Many hospital trusts have struggled to find doctors to invigilate exams. This has led to institutions piling on more stations on any given OSCEs day and in extreme circumstances not scheduling in breaks for any role-players or the examiners. Some institutions cite that breaks will still likely occur due to candidate "no shows" but this is simply unacceptable. Breaks MUST be scheduled in as such breaks do not always happen and this is an unfair gamble on both the doctor and role-player. Due to the intensity of these days, many doctors will only volunteer themselves for one day in a week as OSCEs are much more intensive and hard going than a 12 hour hospital shift due to the repetitive nature of the work. In an exam season, many role-players will end up blocking out multiple days of the week for this type of work, so it is crucial that breaks are scheduled in for both role-players and examiners. It should be reiterated that this is to also ensure that the candidates are receiving the best experience from the role-player.
In cases where trusts cite there is a shortage of doctors, the institution at the very least should seek to hire more role-players who can rotate and thus split the workload. For example, a substitute/reserve role-player can rotate every three/four role-plays (depending on length of station) so that each role-play is fresh and all role-players can have a break. This is especially vital if there are physical examinations taking place or the SP role is an emotional one (i.e., breaking bad news).
Extra sensitivity and care for breaks should be given to role-players with difficult scenarios which can apply to different types of role play:
- where the medical role-player/simulate patient is ‘a body’ model and the interaction is confined to giving specific feedback in the moment.
As a body model must remain still and silent for long periods of times, this scenario would require more regular breaks. Role-players have regularly experienced being pulled and prodded several hundred times in a day!
- those that have to receive bad upsetting news such as bereavement on an OSCE circuit with numerous candidates
This can be emotionally exhausting for role-players, and can have a psychological impact for several days afterwards.
- those who have intimate examinations in the scenarios (i.e., breast examinations).
Again, having these examinations numerous times a day takes a physical and emotional toll on the role-player.
To ensure this work is accessible to all, it is crucial breaks are scheduled within any OSCEs circuit particularly those that run for 2.5 hours or more.
If, for any reason, sessions overrun, for example due to late arrivals of examiners/candidates, breaks MUST still be adhered to rather than cut to catch up. Often the “catch-ups” result in no break or reduced lunch breaks (15 mins, etc.) with no time to relax and regroup.
In addition to other breaks, there should be an absolute minimum meal break of 45 minutes for every 6 hours of medical role play work, but we recommend at least an hour.
When it comes to live performance, due to the intensive and invasive nature of this work, there should be limits on the amount of stations and circuit hours imposed. (It should be noted that "invasive" in this case refers to the kind of work that requires complete attention with no leeway for multitasking.)
This is why it is not uncommon for theatre performers to do one theatre show that, not including an interval, will span anywhere from 2.5 to 3 hours (and even then not all cast members are likely to be on stage the full time). In addition on a matinee day this would span 5 to 6 hours of performance time.
We understand that different trusts have different student numbers and resources, but with the above theatre analogy in mind we recommend trusts to have a target of no more than 5 circuit hours (with one rest station per hour). For safety levels and out of fairness to students on their exams, the number of circuit hours should not exceed six. If this has happened then resources have been allocated ineffectively. This need for such time limitation is further highlighted by the fact that unlike the example of a theatre play performance the same short "snippet" is being performed again and again on loop. This is why performers typically only have one or two days per week in which they are expected to perform matinees in addition to an evening show.
