| (a) | 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 (paragraph 11).
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| (b) | While we appreciate that the contract needs to cover a wide range of issues, some of which will be complex, its effectiveness will be severely limited if it is incomprehensible to all but a tiny minority. We recommend that it should be a central objective of the current renegotiation that the contract be simplified and clarified wherever possible (paragraph 12).
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| (c) | Fixed sessions are vital because they give the most unambiguous statement of what work consultants are expected to do, and when. We accept that not all the work of a consultant can be fixed to a certain time or location. We also accept that there are circumstances in which different consultants should have different numbers of fixed sessions, depending on specialty, and availability of other resources, for example. However, we note the findings of the Audit Commission that there seemed to be no good reason for the wide variability in the number of fixed sessions specified. We agree with them that there should be a presumption in favour of consultants performing seven fixed sessions. Where there are good reasons as to why this is impossible, they can be stated and agreed, but we think there needs to be a strong stimulus to increase the numbers of fixed sessions being performed and that this could provide it (paragraph 16).
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| (d) | We support the BMA in their espousal of a return to national terms and conditions for consultants. In relation to the 10% rule, we think it is unfair that some whole-time NHS consultants have their private earnings capped, while others do not. We also think that this is a point of principle and that to move away from it on an ad hoc basis will cause confusion and resentment. If the principle of allowing NHS consultants to work in private practice is allowed to continue, any contractual arrangements governing that private practice should be national. We believe more generally that a national contract would be more equitable and comprehensible and would better provide for the National aspects of the NHS (paragraph 19).
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| (e) | It is astonishing that job plans - which are supposed to be a key tool in accountability and assessment of consultants' work - are not in place for every consultant and reviewed annually. We support the assertion of the BMA that job plans are necessary for their members as well as for the NHS in spelling out what each can expect of the other. It is shocking that almost 10 years after job plans were supposed to be introduced, some trusts have tolerated this lax state of affairs and that the Department seems to have stood by and allowed their guidelines to be ignored. We call on all trusts to adopt an effective system of job planning as a matter of priority (paragraph 23).
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| (f) | We welcome the support for a rigorous job planning and appraisal system demonstrated by both the Minister and the BMA. Given this agreement we would hope to see a speedy resolution of this issue in their negotiations, with the result that consultants have a contractual obligation to hold annual appraisals. It will then be necessary to ensure that the system is implemented effectively and not frequently ignored, as is the case with current job plan regulations. Similarly, if the system is to be meaningful, the Department should set minimum standards, in terms of information to be collected and criteria to be applied to ensure that all trusts have to engage in this process in an effective way. We have seen what happens when trusts are allowed leeway over job plans: many consultants have none. The Department must set minimum standards, collate information on their attainment, monitor the results, and take action against trusts which fail to deliver the goods. A rigorous system ought to be in everyone's interest, especially that of patients (paragraph 26).
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| (g) | It is regrettable that almost a third of consultants were missing fixed sessions when evidence was last collected on this. We accept that there may be good reasons in some circumstances for them doing so, but this highlights the need for NHS chief executives to be able to monitor the working patterns of consultants in order to ensure that their valuable time is being used effectively. We recommend that where consultants fail to meet fixed commitments, their explanations for doing so are collected. Consultants persistently failing to meet these commitments, without adequate explanation, should be subject to disciplinary proceedings. Trusts should collect information and publish figures regarding the number of fixed sessions missed on a monthly basis. The Department should set targets and be prepared to act in cases of underperforming trusts (paragraph 28).
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| (h) | There is no hard evidence which can confirm that consultants are meeting their important 'flexible' commitments. Given the fact that so-called 'fixed' commitments are missed surprisingly frequently, we are not confident that the situation will be better for flexible commitments. Also, we are not convinced that trusts are able to hold individual consultants to account concerning their flexible commitments. Therefore, we recommend that trusts require consultants to provide accurate figures for hours worked on flexible commitments on a regular basis. Again, action should be taken against consultants who persistently fail to meet flexible commitments (paragraph 33).
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| (i) | Evidence from consultants' self-reported surveys suggests that, when combined with private work, consultants spend an average of over 60 hours working each week. Some will spend many more than this. This raises serious issues of patient care. We believe that NHS trusts should know the total number of hours worked by consultants overall, so that they can take action if those hours appear to be inappropriately high. Therefore we recommend that trusts require consultants to provide accurate details of weekly hours worked in the private sector. We believe that the Department should give guidance regarding the maximum number of hours it is safe for a consultant to work. Although it should be possible to exceed this limit in exceptional circumstances, trusts should be able to tackle those consultants who do so regularly, be it as a result of NHS and/or private work (paragraph 35).
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| (j) | For as long as NHS consultants are allowed to undertake private practice, any contractual arrangements governing that private practice should be applied uniformly. It is unsatisfactory that the 10% rule may not be consistently applied, and that trusts do not routinely collect accounts. We recommend that all trusts require to see the accounts of all consultants who do private practice and that they implement the rule rigorously on the basis of those accounts (paragraph 37).
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| (k) | In practice, it is not possible to ascertain the extent to which consultants are failing to meet their NHS obligations because of their private practice, because the information collected on consultants' workload is, as we have noted, currently inadequate. In addition, we are not convinced that NHS trusts themselves have the information they need to be able to make this judgment about their consultants. This is why we believe it is vital that the trusts should have confidential access to accurate information about the hours spent by consultants in their different activities. Without that information, we are not convinced that the minority of doctors who abuse their NHS positions - as Rodney Ledward did - will be called to account (paragraph 47).
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| (l) | We support the suggestion that an independent waiting list and booking office be used as a way of reducing the 'perverse incentives' which exist in the system and we welcome the Minister's enthusiasm for this proposal. We recommend that an evaluation be carried out of such an office in order properly to assess the benefits and disadvantages it might bring (paragraph 50).
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| (m) | It has been put to us that some consultants are driven by perverse incentives into maintaining long NHS waiting lists in order to stimulate lucrative private practice. This, however, has not been proven to us. What is indisputable is that NHS patients wait longer than private patients, and that private earnings are highest in those specialties where NHS waiting times are longest. We recommend that the Department examine ways in which the suspicion of perverse incentives can be removed from the system (paragraph 56).
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| (n) | In order to get a better picture of what is happening in practice, we recommend that research be conducted into the comparative treatment of patients with similar clinical needs on the NHS, and of those who receive private treatment, in terms of waiting times, quality of treatment, and outcomes of treatment (paragraph 58).
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| (o) | We believe it is indefensible that patients with similar clinical needs receive significantly different treatment purely because of their ability to pay. Therefore we believe that the Government should make it a long-term objective that consultants in the NHS do not undertake private practice. We recommend that the Department commission research into what the effects of any such separation would be, and into ways in which incentives could be implemented and afforded which would help to keep the best consultants within the NHS. The NHS was founded on the principle of equity: it should put that principle into practice (paragraph 60).
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