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. 2002 Sep 7;325(7363):545.

More on the consultant contract

Framework doesn't consider anomaly of £100 000 in lost earnings for some

Colin J P Welsh 1
PMCID: PMC1124064  PMID: 12217999

Editor—Like most correspondents, I am filled with a mixture of disbelief and horror about the proposed new consultant contract.1 At a recent BMA meeting in Leeds the audience did not leave “reassured and ready to spread the word” like those described by our chief negotiator, Peter Hawker, in the press release of 8 July. The general mood was one of disappointment and at times open hostility. Several points arose which have not been addressed in the correspondence—here are two.

Firstly, the new contract contains an iniquitous anomaly affecting consultants recently appointed at the bottom of the existing pay scale. This is not included in any BMA document. Under the new framework, existing consultants appointed at the top of the pay scale will receive five years of seniority credit in comparison with those appointed on exactly the same date at the bottom of the scale. In the current contract those who start on minimum salary take five years to achieve parity of pay. Under the new contract it will take 20 years. For consultants recently appointed at minimum salary this equates to lost earnings in excess of £100 000. Appointments to top scale are rarely made on the basis of experience or merit but are commonplace where posts are difficult to fill—this is blatant discrimination against those of us appointed on minimum salary.

Secondly, the BMA reassures us that regular evening and weekend sessions are unlikely to become the norm because of the difficulty in finding non-medical staff to support them. It seems blindingly obvious to everyone except our negotiators that this is the cheapest way for the government to deliver a 50% increase in outpatient and operating theatre capacity. Our new outpatient manager pointed this out to me four months ago: she would have no difficulty in recruiting nurses for evening clinics but conceded that consultants would prove a much harder obstacle. Cynical consultants would expect the Department of Health to suggest such a move, but it is quite astonishing that the BMA should not just suggest but commend this to us—and at standard rates of pay.

The whole approach of the BMA has been to sell rather than explain this proposal. In the press release of 8 July it even describes the consultation process as the vote yes campaign. The negotiators have clearly had a gruelling two years, and we can conclude only that their apparent enthusiasm for the framework results more from a dread of further negotiations than from a belief that it is a good deal.2 We must send them back to renegotiate with a resounding no vote.

References

BMJ. 2002 Sep 7;325(7363):545.

Consultants are at risk of losing both independence and democratic rights

N E Cetti 1

Editor—The BMA has promised to put the proposed new consultant contract to the vote by consultants and specialists registrars, members and non-members.

Recently, both Peter Hawker, chairman of the Consultants and Specialists Committee, and John Hutton, health minister, have said that the contract is not renegotiable if the vote is negative. Why then have a vote? I detect echoes of the democratic vote in the Reichstag when Hitler ensured that he was returned as chancellor.

Briefings have been circulated to trusts by the NHS Executive which instruct chief executives how to proceed with implementing the new contract from April 2003. There is no mention of the doctors' vote or what happens in the event of rejection.

I doubt that I am in the minority in suspecting that the opinion of the consultants is of no consequence and the contract will proceed whatever the result of our vote. We are to lose both independence and democratic rights.

BMJ. 2002 Sep 7;325(7363):545.

Consultants should assess the detail of new contract

John Storrs 1

Editor—The negotiations for the new consultant contract have been difficult and protracted. The outcome is, as agreed by our negotiators, a compromise. Those who have suggested that the new contract is a sell out have not thought through the detail. The contract is work sensitive, recognising time spent on administration, teaching, training, audit, and other extra-patient activities.

The deal is not as good as the junior doctors negotiated. However, we as consultants currently have an open ended contract that is not in our interests. Our working conditions are increasingly open to management manipulation; job plans are likely to be increasingly enforced. If so, we might as well be recompensed. We may end up clocking in and clocking out, so let's tie the employer down.

All the talk of enforced working until 10 pm and midday on Saturday is poppycock. Nobody will be forced: it will depend on local negotiation. Given the logistics of running an outpatient clinic until 10 pm, staff are unlikely to be available unless they are adequately paid. The proposed contract would be based on a 40 hour week, of which 28 hours would usually be spent on direct clinical care. Most consultants do more than this now, without recognition. So, what is the problem?

A fear that we may be more accountable? That is going to come anyway.

Our professional lives may become less flexible? Not if you look at the detail. Some of my colleagues have argued that this is a geographical contract: those in the north of the country with little private practice will vote yes while those in the south will say no. In fact, private practice is not the issue, except for the few who perhaps do not currently meet their NHS obligations. I suggest that those who have “shot from the hip” think again. I am 58 and intend to retire at 60, so I am least likely to benefit from the proposed contract (the assimilation deal is not very good).

I believe that the contract represents a good deal. If we reject it we are back to square one. In the meantime, managers would most likely invoke the powers they already have to nail our feet to the floor. I suggest that every consultant look at their current working life and work out what they are worth now and what they would be worth if the new contract were to be introduced.

Footnotes

JS is chairman of the Surgical Specialties Subcommittee of the Consultants and Specialists Committee. This letter describes his views and not those of the committee. He has been well informed about the BMA's negotiations but has not been involved in the process.

BMJ. 2002 Sep 7;325(7363):545.

What about consultants in frontline specialties? . . .

Jonathan D Beard 1

Editor—The framework agreement on the new consultant contract offers little benefit for consultants in frontline specialties such as vascular surgery, obstetrics, intensive care, and paediatrics. An increasing number of such specialties are becoming consultant based, especially for emergency work. This is because of the reduction in junior doctors' hours and the requirement for better supervision of less experienced trainees.

Hawker claims that the inclusion of emergency and on-call work within the 10 session contract is a major advantage.3-1 I see no advantage and believe that there should be separate contracts for elective and emergency work. The maximum of two sessions for unpredictable emergency work (only one until 2005) is woeful—a single complex emergency such as a ruptured aortic aneurysm will consume this. Hawker claims that recognition for the disruption of on-call availability was an important objective for the negotiators. Presumably, they aren't doing on-call in a hard pressed specialty or they would have insisted on more than a maximum supplement of 8% for work that causes intense disruption of family life. The new contract will also create a paradox that consultants will have to become resident when on-call to have their work properly recognised whereas junior doctors will not.

Junior doctors and staff grade doctors are now paid a proper rate for emergency and on-call work and every hour on-call is an hour worked. Specialists need the same deal: the current junior doctors will certainly view the lack of such an arrangement as a major impediment when they become consultants. Adequate remuneration of such work also allows flexibility for senior consultants who find it increasingly difficult to cope with the rigours of emergency work. Consultants will not be able to opt out of emergency and on-call work because the small amount of money released will not pay for the cost of covering this.

The failure of the negotiators to address these crucial issues will impair the future provision of consultant based emergency care for the NHS as it will create a staffing crisis in frontline specialties. Yes, a pay increase would be nice, but most of us would prefer a better quality of life. What we need are many more consultants to provide such a service. This will cost more than the government would like, which is why we are being offered the carrot of a salary increase to accept the status quo.

In reality, this new contract does not offer a new or creative solution to the problem of emergency and on-call work faced by an increasing number of specialties. I will not support this charter of enslavement, and I urge our negotiators to return to the negotiating table.

References

BMJ. 2002 Sep 7;325(7363):545.

. . . And what about the teaching role of consultants?

John B Cookson 1

Editor—The proposed new consultant contract has a number of positive points.4-1 I am, however, concerned that it devalues the teaching role of consultants when this role needs to be increased.

There is to be an unprecedented increase in the number of undergraduate medical students in England and Wales and four new medical schools have been founded. At the same time, rightly or wrongly, the delivery of medical education has shifted from universities to the NHS. This increased load will fall very largely on the consultant body. The alternative, a large scale shift to community based teaching, though perhaps desirable, is unlikely given the recruitment difficulties in general practice.

Soon most hospitals of any size will have a significant number of students on site for much of the year. The need for postgraduate education will increase at least in proportion to the new graduates. Most consultants will need to have their teaching duties as clearly defined as their clinical ones, and they will need to develop an expertise and professionalism commensurate with the importance of the role.

It is therefore disappointing that in the proposed contract teaching duties compete with many others in the two or three sessions designated as supporting professional activities. The focus will probably be on delivering the other seven or eight direct clinical care sessions with everything else pushed into whatever time remains. Extra sessions above 10 are available and may help if consultants want them and managers will pay but they are likely to be out of hours and reinforce the impression that teaching is an optional extra. There is scope for local variation in applying the rules, but this is no substitute for an expectation that teaching receives its due in all cases.

Most consultants will require protected time for teaching to do their job properly. The protection needed is from direct clinical care duties; without it the students will suffer and the quality of the product decline.

References

  • 4-1.Correspondence. Consultants' new contract. BMJ. 2002;325:99. . (13 July.) [PubMed] [Google Scholar]
BMJ. 2002 Sep 7;325(7363):545.

Consultants need to take the lead in using funds for stimulating new ways of working . . .

Nigel Dudley 1

Editor—The correspondence about the new contract framework shows consultants moaning about the derisory remuneration for being on-call and the lack of additional payments above standard rates for unsocial hours in the evening and at the weekend.5-1 However, these are not unreasonable whinges about a contract framework which, according to the government, should inspire people to deliver a new consumer style NHS offering patient centred care with genuine patient choices while making the most effective use of NHS resources.

The hypocrisy is that both whinging consultants and their BMA leaders are willing to ignore a part of the pay system that consumes more than £100m year after year in a manner that is not fair, defensible, or necessary under the terms of the new consultant contract framework. These payments also provide hard evidence contradicting the views of the negotiators that they are building a contract which is fair to all specialties and that puts the maximum possible into the basic contract.

What other group of NHS staff can gain 40-95% of their basic salary as a bonus from a few friends with some seemingly ineffectual lay members present to try to see that fairness prevails? White men still come out on top, with London dominating the awards. In the latest round of distinction awards, the London north west, London north east, and London south regions, with 5216 consultants, took £36 000 000 while 11 other regions with 21 414 consultants received £79 000 000.

Whole time contract holders, who give most time to the NHS, are 58.5% of the 26 630 consultants in England and Wales and have a 93% chance of not holding an award. Maximum part time contract holders make up 24.5% of the workforce and have an 85% chance of not holding an award. The bulk of the awards go to honorary contract holders, who give less directly in terms of clinical care to NHS patients than do other types of contract holder.

Consultants must tell the negotiators how best to use the total pot of money on offer to motivate people and stimulate new styles of working for the benefit of patients. Intensity payments, over £50m, are available with the new contract, so why not the money attached to distinction awards or even discretionary point awards?

References

  • 5-1.Correspondence. Consultants' new contract. BMJ. 2002;325:99. . (13 July.) [PubMed] [Google Scholar]
BMJ. 2002 Sep 7;325(7363):545.

. . . and in job planning

Justin J Waring 1

Editor—That the contract covering the work of medical consultants remains, in essence, unchanged since the formation of the NHS in 1948 is surprising.

The contractual arrangements have been described to the health select committee as “the ineffective hand in hand with the inequitable” (John Yates); “vague and woolly” (Consumers' Association); “a conflict of interest . . . a blatant invitation to mischief”(Donald Light); “an odd situation” (John Denham); and “the worst of all worlds” (BMA).

The NHS plan made it clear that modernising the NHS would require renegotiation of the working relationship between the NHS and consultant staff, including a revision of the consultant contract.

The proposed changes to the consultant contract emphasise the need to reward those who do most for the NHS. There will be little complaint about extra pay, but complaints are likely about the arrangements for ensuring that the most is done for the NHS and the way in which this is managed. The framework for change can therefore be seen as comprising rewards and measures to ensure that more is done (box).

Framework for change

Rewards

Higher starting salary

Access to clinical excellence awards

Easier access to threshold awards

Measures to ensure more is done for the NHS

Restriction on private practice for up to seven years

Phased careers to enable more experienced doctors to become leaders and free up spaces for new consultants

New system of mandatory job planning supported by changes in the appraisal system, drawn up between doctors and management to ensure more effective use of consultant time

Specific detailing of job content, including hours of commitment to clinical work, teaching, and research

What becomes apparent from the proposals from the NHS plan and the framework for change is that consultants are potentially being offered a sweetener to accept greater managerial and bureaucratisation of their work. The problems will be whether the management capacity of the NHS can implement and accommodate these changes, whether medical compliance will be obtained, and whether resistance can be minimised. This is particularly so for job planning.

Some crucial problems for management will be whether it will be able to meaningfully penetrate medical work to develop and appraise job plans, whether managerial expertise in medical work will be sufficient to assess whether work objectives are complete, and whether managerial-medical relations will be capable of facilitating change.

The proposed changes show that there will be a close proximity and potential overlap between consultant appraisal and the contractual changes. Thus considerable medical rather than managerial leadership is needed to make any change happen. Thus the future for consultant contracts may lie in greater medical control in ensuring that job plans are meaningful and relevant and that their appraisal reflects medical understanding of consultant work.

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

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