House of Commons - Health

Select Committee on Health Third Report

II THE NATURE OF THE CONTRACTS

5. The Department's evidence stated that "hospital medical and dental consultants on national terms and conditions may be employed on a whole-time, maximum part-time or part-time contract. For pay purposes only, consultants are assumed to work a 38.5 hour week - 11 sessions or notional half-days".[16] However, the introduction of trusts has made the situation, in theory at least, more complicated. As the BMA's evidence stated, "until 1991 the contracts of all NHS consultants automatically followed these national arrangements. However, the NHS and Community Care Act established NHS trusts which became the direct employers of consultants and were free to introduce different forms of contract. Consultants who were employed at the time when their hospital became an NHS trust were entitled to retain their national contracts; those who have since been appointed.... will all have received local contracts. In practice... it is our strong impression that trusts have on the whole chosen not to exercise their freedom by offering substantial different forms of contract.... We know that the majority have retained the national form of contract unaltered, and where variations have been introduced these have only been minor changes".[17]

6. In practice then, the three main types of contracts - whole-time, maximum part-time and part-time - are still in place. Consultants on part-time contracts agree to work between 1 and 9 notional half days for the NHS. We have concentrated on whole-time and maximum part-time contracts, which apply to the vast majority of consultants. Consultants on both types of contracts have a duty to devote "substantially the whole of their professional time to their NHS duties".[18] The distinction between them is that:

consultants on whole-term contracts receive a full NHS salary. In addition, they can earn money from private practice, but this must not exceed 10% of their NHS salary. They are expected to work for the NHS for 11 notional half days (3.5 hours each);
consultants on maximum part-time contracts receive 10/11 of the full NHS salary and are not subject to a limit on their private earnings. They are expected to work for the NHS for a minimum of 10 notional half days (3.5 hours each).[19]

7. Consultants' NHS workloads are broken down into 'fixed' and 'flexible' commitments. The Audit Commission described fixed commitments as "work scheduled for a specific time and location often with extensive commitments of other NHS resources, eg operating theatre sessions or out-patient clinics".[20] The time and location at which flexible commitments (for example audit, research and management) are undertaken are not specified. Departmental national guidelines state that "for a consultant on a whole-time or maximum part-time contract, between five and seven notional half days, depending on the specialty, should normally be allocated to fixed commitments".[21]

8. The NHS Executive told us that 58% of consultants are on whole-time contracts, 24% on maximum part-time contracts and 11% on part-time contracts. In addition, 7% are on honorary contracts, "that is, people who are effectively employed by a university or other employer and who are associated with a particular hospital for clinical duties".[22] The breakdown of consultants by type of contract and specialty is as follows:

Hospital Medical Consultants by type of contract and specialty group[23]

England: 30 September 1999

	percentage
	All	Whole time	Max Part-Time	Part-Time	Honorary
All Specialties	100	58	25	11	6
A & E[24]	100	88	7	5	0
Anaesthetics	100	56	35	8	2
Clinical oncology	100	57	25	12	7
General medicine	100	58	20	12	10
Obs & Gynae[25]	100	42	42	10	6
Paediatric group	100	78	4	12	6
Pathology group	100	64	14	10	12
Psychiatry group	100	73	4	17	6
Radiology group	100	46	37	14	2
Surgical group	100	46	43	8	3

Source: NHS Executive medical and dental workforce census.

9. The Department's evidence explained that "the average NHS earnings of a consultant are around £68,000. The current basic pay ranges from £48,905 to £63,640. In addition, consultants can earn up to eight discretionary points (worth £2,550 each) or a distinction award worth between £25,455 and £60,640. In 1999, 34% of consultants in England held discretionary points and a further 13% a distinction award. Exceptionally, employers can award consultants up to three temporary additional notional half days for work undertaken outside their notional contractual duties.... A survey carried out in 1998 suggested that 27% of consultants were in receipt of.... additional half days. They are most commonly awarded to Medical Directors and Clinical Directors to recognise their managerial responsibilities".[26] In oral evidence the NHS Executive told us that "we are also negotiating with [the BMA] a system of intensity payments to reward those doctors who are.... working hardest and longest in pursuit of NHS duties".[27] These payments are being implemented as a result of recommendations made by the Doctors and Dentists Review Body in 1999 and the BMA told us that they would put an additional £37.5m into consultants pay.[28]

10. The BMA told us that a 1998 MORI survey of consultant workload showed that "the average hours worked by consultants in the NHS were 50 per week (excluding emergency recall).... While the survey revealed a range in these hours, only 5% of the sample were shown to be working less than 35 hours per week, and.... the survey excluded....on-call duty, which counts for at least one notional half day, so that it can only be a tiny minority of consultants who are not fulfilling their basic contract. On the other hand, two thirds of whole-timers and maximum part-timers were working between 40 and 60 hours per week, and 4-5% were working more than 70 hours".[29]

11. Professor John Yates has pointed out that such figures are based on self-reported surveys.[30] When this point was put to the BMA, their representative told us that he was "sceptical about all statistics," although he did go on to make the point that the figures seemed reliable to him given the amount of work (and the resulting stress) he had noticed colleagues undertaking.[31] It seems to us extremely surprising that accurate and independently recorded figures are not available assessing the average hours worked in the NHS by consultants. As we note below, this seems symptomatic of a general absence of information regarding the way consultants work. This needs to be rectified by the introduction of a much more systematic collection of objectively recorded data. This data should be held centrally by the Department, as well as on a local level.

16 Ev., p. 30, para. 4. Back

17 Ev., p. 42, para. 2.1. Back

18 Ev., p. 42, para. 3.1. Back

19 Ibid. Back

20 Ev., p. 1, para. 2. Back

21 Consultants' contracts and job plans, HC (90) 16, Department of Health, 1990. Back

22 Q 102. Back

23 Appendix 9. Back

24 Accident and Emergency. Back

25 Obstetrics and gynaecology. Back

26 Ev., pp. 30-31, paras. 7-8. Back

27 Q 101. Back