NHS trusts — consultant's contract

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Dual roles of hospital consultants

Hospital consultants (with their firms of specialist registrars and other junior staff) have obviously been the traditional customers of the hospital representative for many years. But many of these senior consultants are now involved in national clinical policy groups, such as those surrounding the NSFs. As such, they may wear a number of different ‘hats’ to reflect their different roles. These consultants may therefore be customers of NHS influencers and local coordination is required.

The new consultants’ contract: build-up to agreement

NHS consultants are now working to a new contract. The previous contract had remained largely unchanged since 1948, giving senior hospital doctors an NHS salary, a lucrative bonus scheme and allowing them to top up their earnings with private practice.

The initial contract proposals backtracked on previous attempts by the government to ban new consultants from performing private work for seven years (as suggested in the NHS Plan). Instead, new consultants were allowed to undertake private work providing they agreed to two extra NHS sessions a week.

However at the British Medical Association (BMA) 2002 junior doctors’ annual conference, there was a call for the contract to be renegotiated because of concerns about the extension of the working day to include evenings and weekends.

The new contract was then rejected by a national ballot in 2002 for England and Wales — although it was accepted in Scotland and Northern Ireland. Worries over private practice, concerns about management control and worries about working unsociable hours seemed to have been the triggers and there was a particularly high rejection rate from specialist registrars (86 per cent of those polled). Certainly consultants delivered a huge snub to their own union as the BMA had recommended the deal.

Prime Minister Tony Blair had been clear over what the government was actually trying to do here. ‘We are embarked on a very big and radical programme. It is the only chance for the NHS to be back on its feet again in a decent way… To have a consultant contract that is effectively unchanged from 50 years ago is not compatible with health service reform.’

But following the appointment of the new Secretary of State, John Reid, the impasse was resolved. Reid met with consultant leaders and ground was given over management control of doctors’ hours and an agreement was reached with the BMA in England. NHS hospital consultants across England then voted 60 per cent at the end of 2003 in favour of the revised new contract. See the DH website section on the consultants’ contract.

The new consultants’ contract: response and evaluation

However there remain concerns among health service leaders about the implementation of the contract, particularly concerning the available monies and the number of consultants who will actually sign up to the agreed deal. It is anticipated that the new contract will be one of the major cost pressures within the NHS, along with more elective/emergency activity and more agency staff being employed.

Now the BMA has claimed that a significant number of acute trusts in England will not have implemented the consultant contract by the end of 2004. Implementation had already been delayed from March 2004. The BMA has warned government to expect ‘mass appeals’ against consultant job plans in a number of trusts across the country.

York University’s Alan Maynard has questioned whether the new contract is actually good value for money, claiming that it makes no effort to tackle doctor clinical variation and essentially preserves the status quo. ‘Overall,’ he said, ‘the autonomy of the medical profession is largely unaffected by these new and expensive contractual arrangements. In general, it appears that the NHS pipers may continue to call their own tune.’ See www.york.ac.uk/healthsciences for the report on which these comments are based.

The quality of the relationship between managers and doctors, as well as their buy-in of government targets is critical to the story of the new consultants’ contract. A key defining issue is the government wanting doctors to be more corporate-focused but they simply are not trained in this way.

So perhaps what is needed is a new concordat for doctors, which recognises a new kind of partnership between the state and clinician. The NHS Confederation and the BMA launched such a project in 2002 aimed at improving relationships between doctors and managers. This joint initiative, supported by the Health Service Journal and the British Medical Journal, and involving the royal colleges, the Institute of Healthcare Management and the British Association of Medical Managers, was also aimed at improving trust between medics and managers and also attempted to define a new ‘psychological compact’.

But professor Julian Le Grand from the London School of Economics wrote in the Health Service Journal in 2003, ‘consultants are still left with the power to ignore institutional pressures and thereby to dilute, or even nullify, the incentive effects of the new market.’

And a 2003 BMA Health Policy and Economic Research Unit (HP&ERU) bulletin contained some discussion on the rejection of the new contract for consultants and an astonishing assertion:

‘Many of the problems stem from the fact that the performance indicators currently in use do not measure what they purport to be measuring, that is, the performance of the health system. Most are measures of outcomes, such as health status, rather than of structure or process. However health outcomes are often determined by population characteristics and behaviours outside the direct control of individual health professionals.’

This is an amazing response to the government’s attempts to modernise the way consultants work. What are doctors supposed to be doing if not improving health outcomes?

Doctors’ and managers’ relationship

Even the chief medical officer, Professor Sir Liam Donaldson has acknowledged that there has been a breakdown in the relationship between doctors and managers and those leading the service at a national level. Doctors do have profound concerns over the loss of autonomy created by the managed health system and tightening professional regulation. They also worry about specific management policies — often driven by government targets — interfering with the clinical decisions they make on a daily basis. As a result, many medics have failed to engage with the government’s reforms.

Some consultants continue to remain unhappy. ‘This government is a bully government,’ one said. During the ‘darker hours’, the BMA published a guide for consultants who wanted to opt out of the NHS and set up consultants’ chambers. See www.bma.org.uk.

In 2003, BMJ editor Richard Smith wrote:

‘Doctors are losing out in modern healthcare systems because of their discomfort with leadership, organisational development, strategy, systems thinking, negotiating, economics and finance. Learning more about these things from managers may make them not only more effective but happier, less lost with modern healthcare.’ This comment from Dr Smith seems to suggest significant opportunities for NHS influencers.

Nigel Edwards, policy director at the NHS Confederation, also wrote in the same year:

‘There is still a view (amongst doctors) that health services should not really be managed, often linked to nostalgia about hospitals run by matron, the medical secretary and the hospital secretary… What is surprising is the shortage of credible solutions from clinicians. Many of those are variants of the “leave us alone approach”.’

Medicine and management: improving relations between doctors and managers

Engagement with managers by clinicians really does seem to be the way forward along with greater understanding by managers of doctors’ real concerns and, as a result of many of these comments and the initiative mentioned above, the NHS Confederation published Medicine and management: improving relations between doctors and managers.

The report contains a series of recommendations to improve the empathy between clinicians and managers including multi-disciplinary training. But the main issue seems to be the fact that doctors have a patient view on the world and managers have a population view. Doctors need educating in terms of the organisation and management of healthcare, and managers around the ethos and ethics of medicine. NHS influencers again could be of some assistance here.

Applying the modernisation agenda to doctors

There are a growing number of reports that doctors are still not being engaged in the modernisation agenda. Several recent studies have showed that many doctors are largely ignorant of the swath of policy initiatives that are the new NHS — Shifting the balance of power, Wanless, Delivering the NHS Plan, etc. Opportunities here for companies?