Decision time on consultants' contract

In 1999, the UK government promised a “consultant delivered” NHS, relying on a new contract for consultants to increase commitment to the NHS.¹ This week ballot papers have been issued to consultants and junior doctors on the proposed new contract, ending months of discussion, road shows, questions, and explanations. Now it's decision time.

The new contract represents a notable departure from the current one.² The linchpin to it is the job plan agreed between individual consultants and trust managers, which will describe personal goals for annual review and explicitly timetable a consultant's working week. Potential working hours will be extended to three sessions of four hours each per weekday and one on each weekend morning, with consultants expected to work 10 sessions (40 hours) each week and up to 12 if they wish. On-call duties and extra activities such as clinical governance can be negotiated locally to fill some sessions. Consultants wishing to practise privately must offer to work the first (the first two for new consultants) of their potential private sessions in their NHS trust. The merit awards scheme in England and Wales, seen by many as a profitable “old boys' network,” will be replaced with new clinical excellence awards to reward the consultants contributing most to the NHS. Finally, in England disciplinary decisions will in future be made locally but based on a new national framework.

In return consultants will receive increased basic salaries and a more generous pay scale— from £63 000 ($99 000; €100 000) to £85 250. On-call duties and out of hours work will be recognised financially through salary supplements, and current contract restrictions on income from private practice will be lifted.²

For their part NHS trusts must ensure that facilities and administrative support are provided for consultants to carry out their job plan. In return, they should find themselves better able to manage consultants' time and prevent private practice potentially disrupting NHS care, thereby improving patients' access to health care.²

The proposed new contract has had a mixed reception. Among a tirade of criticisms, the most prevalent is the perception that job planning will increase managers' control, not only of working hours but of pay, career progression, and time spent in private practice. Furthermore the financial incentives for relinquishing this control are seen to be dependent on the opinions of (non-medical) hospital managers, which has spawned the fear that pecuniary rewards may be withheld inappropriately.^3–5

Junior doctors, scarred after the negotiations on and difficulties in implementing their own new contract, and apprehensive that their future working lives will be scripted by managers, are particularly concerned. They have secured the right to vote in the contract ballot, and their leaders have issued a defiant “no thanks” to senior colleagues.⁶ By way of reassurance, contract negotiators have stated that no extension to the normal working day is planned and that pay progression will be delayed only where trusts can show that consultants have not met predetermined objectives.⁷ But so far these assertions have had little effect.

Many elements of the new contract are not actually new. Proposals in 1999 to streamline pay scales throughout all NHS staff groups include one to “replace automatic annual increments with career progression based on responsibility, competence, and satisfactory progress.”⁸ Consultants in fact should have had job plans for the past decade; yet, in 2001, only 14% of trusts had plans with all their consultants.⁹ New foundation trusts, which are selected hospital trusts that have earned autonomy on the basis of previous good performance, will be able to negotiate local pay deals,¹⁰ reflected in the proposed contract by the provision of additional financial “recruitment and retention premia [sic].”²

For the government, success in this ballot is seen to be imperative if targets on access and waiting times are to be met. The contract's maximum of 12 four hour sessions per week overcomes problems with the implementation of the European Working Time Directive. But since the average doctor currently works 54 hours per week,¹¹ this will necessitate the creation of new consultant posts, although where the doctors will come from to fill these remains unclear.

This proposed contract strikes at the heart of medical professionalism while attempting to improve the functioning of local NHS services. By giving more regulatory power to managers it takes away from the medical profession a part of their autonomy. Acceptance or rejection of it will mark a turning point in the relationship between doctors, managers, and the government. On the one hand, the prospect of discussions between managers and consultants about job plans and related financial rewards may be unacceptable to consultants, forcing them to leave the NHS altogether, either practising solely in the private sector or contracting their services back to the NHS through consortia or chambers.¹² On the other hand, job planning may be seen as a two way bargaining tool to protect or improve working conditions. Furthermore the constructive partnership of consultants and managers could produce the reform in secondary care that the government and the NHS so desperately needs. Trust is needed, but it is in short supply. For current and aspiring consultants the decision, as they say, is yours.