Ethnic and sex bias in discretionary awards

George Bernard Shaw, in his preface to The Doctor's Dilemma, summarised his conclusions as follows: “Nothing is more dangerous than a poor doctor.” His solutions included making doctors into “civil servants with a dignified wage paid out of public funds” and “municipalise Harley St.”¹ Shaw's reaction to the NHS, which arguably made hospital doctors into civil servants, is not recorded. Although he was aged 92 in 1948, he would probably have pointed to the implications of failing to municipalise Harley St.

The United Kingdom is unusual in the extent to which the state employs hospital consultants in state owned hospitals. International trends towards greater autonomy for local organisations have been partly reflected in the United Kingdom with the development of NHS hospital trusts from 1991 and, more recently, the plans for foundation hospitals.

Any economist reviewing how hospital doctors in the United Kingdom are paid would be struck by the following. Firstly, NHS national pay scales, which have survived the shift of consultants' contracts from regions to hospital trusts, make up 71% of consultants' income (table). These pay scales take no account of performance, let alone regional differences in the costof living, nor of the costs of qualifying and remaining up to date, which plausibly vary by specialty. Secondly, around half of all consultants hold NHS discretionary awards, which vary by specialty, sex, and ethnicity and account for some 6% of consultants' total income. Thirdly, private practice, which varies by specialty, sex and ethnicity, accounts for 23% of consultants' income. Fourthly, NHS salaries qualify for generous pensions based on final salaries—which are boosted by the additional NHS awards.

To get the NHS to deliver services more predictably, changing the way in which consultants are paid has become a priority. According to the NHS Plan, “the current consultants' contract is far from satisfactory. Too few have proper job plans setting out their key objectives, tasks, and responsibilities and when they are expected to carry out their duties.”²

Or, taking a much cited analogy: “No normal company would contemplate it. Take your most highly skilled and talented staff . . . Give them a job for life, an index linked pension, and six weeks' paid holiday. Then let them go and work for the opposition—not just out of hours but during the normal working week. It sounds crazy. Yet that is more or less exactly how the NHS consultants' contract works.”³

What of discrimination in NHS discretionary awards? For the first half century of the NHS, consultants controlled the distribution of distinction and merit awards. This provided incentives to performance as judged by peers, at a time when few other criteria existed. It also encouraged doctors to commit to the NHS and academic medicine. But as doctors became more heterogeneous in terms of ethnicity and sex and as their performance became more measurable, the entire system has come to seem archaic. The awards have been renamed (currently distinction awards and discretionary points) and reformed to take the views of hospital managers into account.

The process of unmasking how these awards are allocated has been causing some amusement to outsiders. Attention has long ago been drawn to differences by specialty.⁴ From being top secret, the names of award holders are now available on the internet. Over the past decade, disparities by ethnicity have been highlighted, mainly by Esmail, who as a general practitioner does not qualify for one of these awards, and his coauthors. They have highlighted disparities by ethnicity in admissions to medical school,⁵ then distinction awards,⁶ and now discretionary points.⁷

What of their recent findings? More white consultants get discretionary points than those from other ethnic groups (56% v 41%) and more male ones than female ones (55% v 44%). The authors claim that discrimination cannot be excluded as a factor accounting for these differences, and that continuation of the scheme is difficult to justify. Both being non-white and being female are associated with lower chances of getting an award. Where possible, the authors have allowed for age, type of hospital, and specialty, showing that these make little difference.

Two caveats apply. Firstly, any discrimination by ethnicity applies less to entry than to progress in the medical profession. The NHS employs a disproportionate share of non-white (if not female) consultants. Secondly, the degree to which consultants' choice affects their career progress is unknown. Choices of specialty, between NHS and private work, and between work and leisure, all reflect preferences and constraints. Constraints may be fair or otherwise, but career paths reflect individual choices to some extent. Attempts by the advisory committee on distinction awards to identify potential candidates from female and non-white consultants have had little success.⁸

This time the government has been listening. Having accepted that “institutional racism” exists in many public sector bodies including the police and the NHS it sees disparities in distinction awards as inbuilt biases against particular groups and specialties.⁹ The government has committed itself to sweeping away bias and outmoded working practices as part of modernising the NHS. In return for record increases in NHS funding, national performance targets to do with waiting times and standards will have to be met.

A new employment contract for hospital consultants is part of the modernisation programme. A recently proposed contract would have required NHS consultants to commit to the NHS, restrict private work, and be paid according to their performance, via a unified discretionary awards scheme. After its overwhelming rejection by consultants in England and Wales its future is unclear. What is clear is that if other elements of the modernisation strategy are to succeed, particularly greater autonomy for the best performing hospitals in the form of foundation status, then contracts that reflect the commitment of consultants to the hospital that employs them seem essential.

Failure to modernise the NHS, claim its advocates, could lead to much more radical reforms, including a greater role for private hospitals. Either way, distinction awards and discretionary points, along with national pay scales, all of which can be seen as part of the civil service, seem unlikely to survive much longer.

Table.

Estimated total income of consultants, 1999

	£ million (%)
NHS gross pay	1877 (71)
NHS awards	169 (6)
Private earnings	601 (23)
Total	2647 (100)

Author's estimates, based on references 3 and 9. 

See Papers p 687