APPENDIX 2
Memorandum by HCSA (CC4)
This paper is presented to the House of Commons
Select Committee on Health as written evidence to its examination
of NHS Consultant Contracts. It argues the case for the introduction
of a "Work Sensitive Contract" to replace the current
arrangements. The Hospital Consultants and Specialists Association
would be pleased to offer oral evidence to the Committee.
CONSULTANTS' CONTRACTS
Many of the problems that now arise over Consultant
remuneration stem from a contract that has long since ceased to
be a framework within which Consultants' work can be properly
recognised.
HCSA has consistently pursued the idea of a
Work Sensitive Contract, centrally negotiated, and based upon
the concept of the existing Notional Half Day priced annually
by the Doctors' and Dentists' Review Body. The outline principles
of a new contract are set out below:
Why the Need for Change
Since 1955, when the entitlement to exercise
the option of a whole-time or maximum part-time contract was introduced
(except for those with limited commitments), contracts for Consultants
have been fundamentally flawed and have created division and friction.
The Reforms which introduced Trust Hospitals together with changing
patterns of work have meant that the present contracts have become
steadily less appropriate to the 1990s.
The whole-time contract is neither fully closed
nor fully defined. The January 1980 amendments, which followed
the failure of the 1979 negotiations, were at best a fudge.
This was seen by September 1980 when the Department
said "Ministers would expect any definition to make absolutely
clear that the duties of a whole-time post are not subject to
an upper limit of time, and would not wish to see any wording
which cast doubt on this point." And again, that an Authority
"can expect as much from a consultant on a maximum part-time
contract as on a whole-time contract" (despite the former
being paid 1/11th less in salary).
The HCSA proposals are sound and workable and
do not conflict with new NHS legislation. The NHS would get value
for money and Consultants get justly paid for the work they do.
Such proposals would also give flexibility to enable local needs
to be met within a National framework.
A work-related contract in which the work is
assessed in Notional Half Days (as defined in paragraph 61 of
Terms and Conditions of Service) must surely be the most equitable
arrangement that can be reached. With this in mind all HCSA pay
claims and evidence to the Review Body since 1978 have been related
to the value which should be placed on a Notional Half Day.
The 1990 introduction of Job Plans and Work
Programmes (HC(90)16) stipulated that most Consultants should
work five to seven NHDs per week as Fixed Commitments and the
remainder of their time flexibly.
The Work Related Contract
A study of work-loads for different specialties,
carried out by the HCSA, showed that the actual manner in which
Consultants need to employ their time varies greatly. If the work-load
and level of commitment is assessed in Notional Half Days, each
of which is remunerated at the same rate for all specialties,
then that same basic form of contract can apply to all. Any variations
between individuals will exist as a result of the agreed content
of each Job Plan and Work Programme.
By this approach the contract will be work related,
or work sensitive. Any work over and above the contractual commitment,
medical audit included, should be regarded as additional and remunerated
either by payment for additional NHDs or by a fee per item of
service payment.
Effectively, therefore, any new contract proposals
will not contain any element of part-time or maximum part-time
with the concomitant problems created by these differing contracts.
The only differences will be created by the number of NHDs for
which a Consultant accepts a contracted commitment to the NHS.
In turn it follows that there will be no limitation on levels
of private practice, but a Consultant cannot have a planned commitment
for private practice that conflicts with an NHS Fixed Commitment;
nor should a Consultant's overall commitment to private practice
act to the detriment of his/her commitment to the NHS.
Nor can any allowance for time travelling between
private consulting rooms and NHS hospitals be included within
the assessment of an NHD, but an allowance for travelling time
between NHS hospitals may be included in the overall assessment
of NHDs.
The only specific concessions to cover private
practice that must be built into all contracts is that necessary
to cover the ethical responsibility of a Consultant to all patients
whether NHS or private.
A further element is that there will be flexibility
of working within the Consultant Work Programme including the
fixed NHDs—essential for many groups including those working
in laboratories, pathology,x-ray, et cetera.
Notional Half Day
The definition of a Notional Half Day must be
established by modifying paragraph 61 of Terms and Conditions
of Service to read as follows:
ASSESSMENT OF
DUTIES
For all Consultants the Trust shall make a general
assessment, in terms of Notional Half Days and fractions thereof,
of the average time per week required by an average practitioner
in the grade and specialty to perform the duties of the post,
a Notional Half Day being regarded as the equivalent of a period
of three and a half hours.
In making this assessment, the Trust shall take
into account out-patient clinics, ward rounds, operating sessions,
laboratory work, medical audit, administration including relevant
committee work, on-call duties, emergency visits and so on in
their hospitals. This shall include visits to other hospitals,
GP Fundholders, for consultations, diagnosis or operative work,
and time necessarily spent travelling to and from them. The Authority
shall also include time given, eg, as Consultant Adviser to the
Trust on special branches of the service or by way of "pastoral
visits" to outlying hospitals. Not included in the computation
are elements of time for the care of private patients under Section
65(2) of the National Health Service Act 1977. There shall also
be excluded time required for domiciliary consultations (for which
special fees are payable) and any additional time contracted for,
and remunerated separately.
The Standard Contract
1. At the outset each Consultant will agree
with the employing authority a Job Plan and Work Programme covering
the clinical duties assessed in NHDs.
2. The standard contract will consist of
10 NHDs per week which will be remunerated by the full agreed
basic salary.
3. By agreement a Consultant may contract
to undertake more or less than 10 NHDs. Contracts of less than
10 NHDs will be of advantage to those with special family commitments;
the handicapped, those with split contracts, and those who have
high levels of private practice either within or outside the NHS
hospitals.
4. Each Consultant will have allocated as
part of the contracted commitment and included within the total
number of NHDs appropriate to the standard week, two NHDs allocated
as follows:
(a) One NHD in recognition of the basic on-call
commitment which derives from Consultants' continuing clinical
responsibility for the care of patients in their charge, or for
the continuing responsibility for their department in the case
of non-clinical Consultants.
(b) One NHD in recognition of the administrative
duties associated with the post.
For those holding contracts for less than the
standard week the allocations (a) and (b) above will be applied
pro rata.
5. On-call duty which is additional to the
basic commitment of continuing responsibility and is obligatory
will be allocated as NHDs related to the frequency, degree of
availability and level of supporting staff.
6. Emergency re-call which is obligatory
will be allocated as NHDs averaged over a period and built in
to the overall assessment.
Additional Work
All work over and above the standard or basic
week undertaken by mutual agreement is to be regarded as additional
and will be remunerated by the allocation of additional NHDs or
item of service payments, eg:
Additional duties, whether managerial or clinical,
shall be remunerated by NHD allocation or by item of service payments
as appropriate to the department.
REVIEW MECHANISM
To be established to agree the assessment of
duties and allocation of NHDs on a regular annual basis.
SUPERANNUATION
All NHD payments above 10 must carry the option
of being superannuable.
The HCSA believes that a contract based upon
these principles will give the rewards and flexibility that the
massive changes in staffing structures heralded by the introduction
of the reduction in Junior Doctors' Hours and Calmanised Training
will inevitably bring. There will undoubtedly be severe staff
shortages until the necessary projected increase in Consultant
numbers takes place and by rewarding the Consultants in post for
the additional work that they will inevitably be called upon to
undertake, will go some way to lessen the general feeling of lack
of appreciation now so widely held by the Consultant Body.
In particular it will be essential to provide
a proper recognised framework within which the increasing number
of women doctors, with their special needs, can be accommodated.
Job sharing and part-time working will need to be integrated fully
into the staffing system if the NHS is not to lose a large proportion
of specialist trained doctors because of the difficulties endured
in the competing demands of family and NHS.
The present ad hoc arrangements to which the
26th Review Body refers, that of granting additional Notional
Half Days, presents too much of a hostage to fortune as Trusts
increasingly claim that they are unable to pay and therefore place
an unacceptable moral blackmail upon the professionalism of Consultants
who as a matter of course put the interests of their patients
first.
June 2000
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