Examination of Witnesses (Questions 1-19)
THE RT HON ALAN MILBURN, MP, MR ANDY MCKEON, MR RICHARD DOUGLAS AND MR ANDREW FOSTER
WEDNESDAY 12 JUNE 2002
1. May I welcome you Secretary of State to this session of the Health Committee and your colleagues and ask you each to introduce yourselves briefly to the Committee?
(Mr Milburn) Alan Milburn, Secretary of State for Health.
(Mr McKeon) Andy McKeon, Director of Policy and Planning.
(Mr Douglas) Richard Douglas, Director of Finance.
(Mr Wilson) Andrew Foster, Director of Human Resources.
2. We are grateful for your co-operation with this inquiry. It probably would be appropriate for us to spend a moment or two on today's announcement on the consultant contract. I have some difficulties in that I have seen two releases, one from the Department of Health and one from the BMA and to try to square up the two is rather difficult. Would you like briefly to summarise your understanding of what has been agreed?
(Mr Milburn) You would like me to tell you the truth.
3. Briefly; yes.
(Mr Milburn) I shall do my best, Chairman. I read the BMA press release this morning and I did not think, to tell you the truth, that there was a huge amount of variance between what we were saying and what the BMA were saying. It has been a long negotiation and probably long overdue. The consultant contract has been essentially unchanged since 1948. We have 26,000 consultants today working effectively on the 1948 contract and there is a whole host of issues which we have had to deal with in the contract. There has been a variety of concerns about how consultants are employed, how they are rewarded and, crucially, how they are managed. The fact is that very often there has not been the sort of management for this one group of key employees that we would expect to see for other groups of key employees. Many of those issues have been addressed in the contract. If you want I can run through the main measures but there might be specific questions which you want to ask.
4. The seven-year issue is important. The BMA appear to be crowing about the fact that they have not given in on private practice. The last time you were with us you made clear to the Committee that your conclusion was that the best option was the sensible compromise option put forward in the NHS Plan, which is trying to get NHS consultants, when they are newly qualified, to work exclusively for the NHS for a period of up to seven years. Have you achieved that?
(Mr Milburn) Yes, I think we have. The issue of private practice has been a vexed issue since 1948 and has been at best a grey area. It has fuelled a great deal of suspicion, some justified; frankly quite a lot unjustified, about the motives of NHS consultants. For the record I should say what I believe, which is that overwhelmingly NHS consultants do a very good job of work for the National Health Service and actually over-fulfil their contractual obligations. However, the sense of actual or perceived conflicts of interests has been very debilitating for NHS consultants and for the National Health Service. What we set out in the NHS Plan was a very simple objective and we have realised that objective and I believe that we have more than fulfilled that objective as a result of these negotiations. The objective is extremely straightforward. What we wanted was to get more of an NHS consultant's time and pay more in order to do that so that we could get the benefit of the NHS consultant's considerable skill and expertise for more NHS patients. That is what we have got and we have got it essentially through four mechanisms. First of all what we have done is extended the direct clinical time, the direct face-to-face time that individual NHS consultants will spend with NHS patients. That is a big plus for us.
5. Can you be clear about what that actually means? How many sessions are you talking about? How many hours are you talking about?
(Mr Milburn) What we have at the moment is a contract which works on the basis of eleven sessions of three and a half hours each. What we are moving to is a ten-session contract of four hours each, of which eight in the first instance and then seven have to be direct clinical care for NHS patients, treating and seeing patients.
6. Over and above that, can they do private practice?
(Mr Milburn) Let me come to that but first let me come to the other elements of this. The other thing we have been able to do is back this up, as the Committee and others have been calling for and the BMA have recognised all along, with a more stringent system of job planning. For the first time what the NHS as an employer can do is actually plan and timetable the work of NHS consultants in a way that is most conducive to the benefit of NHS patients. That is the first thing. The second thing we have managed to achieve is to extend the NHS working week beyond the traditional nine to five. The NHS working week now for NHS consultants and the time in which their activities will be programmed will run from eight o'clock in the morning to ten o'clock in the evening, Monday to Friday, and from nine o'clock in the morning to one o'clock in the afternoon on a weekend. The reason that is important is that it actually fits with the way people live their lives nowadays. In my view what it provides for is much better use of NHS facilities at precisely the time many of us can access them: at weekends, twilights, first thing in the morning, etcetera. Otherwise there are operating theatres and facilities which simply lie dormant and that is an enormous waste of NHS capacity. That is the second big gain we have got, backed by the fact that because we can programme within that new NHS working week and pay at NHS rates, we will avoid some of the exorbitant sort of rates which this Committee and others have been concerned about in the past, to do with waiting list initiatives. The third big gain is around exclusivity. What we have here is an agreement that for the first seven years of a newly qualified consultant's career the NHS will have exclusive first call on the first 48 hours of a consultant's working week, which is the maximum we can demand under the Working Time Directive. I cannot demand any more than they can legally give and that is what we got. Actually that is the NHS Plan commitment and the NHS Plan commitment is therefore honoured, but we have gone beyond that. What we have also agreed with the BMA is that in future existing consultants who transfer to the new contract or consultants who after seven years want to practise privately, in order to do so, will have to give the NHS an extra four hours of their time, an extra session, at NHS rates as a condition of getting access to private practice. What all of that amounts to is that we in the National Health Service are getting more of the valuable time and skills of NHS consultants. We are paying more for it, but what I want to stress for you is this. It is a something for something deal. NHS consultants get something. They get an increase in starting salary, they get an increase in finishing salary, over the lifetime of a consultant's career their pay will increase by around 7.5 per cent. They will go through various pay thresholds. Getting access to the pay thresholds is dependent upon them fulfilling their obligation under the job plan, their specified timetabled sessions and of course they have to adhere to the new set of rules we have laid down about private practice. That is a good deal and it is a good deal for all concerned. It is a good deal for NHS consultants and it is a good deal for NHS patients.
7. My question was, arising from what you said last time about exclusivity. You have said 48 hours. Are you saying that above those 48 hours they will not be permitted to work in private practice?
(Mr Milburn) That would be a matter for them to determine.
8. So what you are saying is that yes, they could work in private practice.
(Mr Milburn) All I can do as the NHS employer is to extract from the NHS consultant the maximum that they can give us under the Working Time Directive, which is a maximum of 48 hours.
9. I understand that; I understand that fully. There is nothing to stop the consultant starting at five o'clock in the morning at a private hospital and doing ward rounds in the NHS at eight o'clock.
(Mr Milburn) That would be a matter for them. For me, it will not happen. What I get is the maximum that I could possibly get under the Working Time Directive, which is 48 hours.
10. I understand that. Where will the job plan come in? In some instances I have met doctors, and I am not knocking the fact that they are not working very hard, whom I have seen are working unsafely by the hours they are working for both the NHS and the private sector. What is to stop that continuing to happen now with this new consultant's contract? Does the job plan address that? Certainly on this Committee I have heard talk about job plans for the best part of a decade and we are still seeing examples of areas where frankly this does not operate. We need a degree of confidence, more than we do at the moment, in that being an effective mechanism and tool for monitoring this new contract.
(Mr Milburn) The job plan is absolutely critical. Inevitably most of the attention is going to be on the private practice thing, it is bound to be. I am extremely satisfied that what we have is a deal which honours the commitments we set out and in some ways gets us more than the objectives we originally set out in the NHS plan. However, I think the biggest gain of all is better management grip on how NHS consultants spend their time. The rather bizarre thing is that most NHS consultants are perfectly amenable and do what is necessary. It is true that has not been the case in all instances. You will be aware of the problems of job planning and you referred to that. What we now have as a matter of contractual obligation is that in order to get access to extra payunder the existing contract you get automatic pay increasesyou as a consultant will have to demonstrate that the objectives, the responsibilities, the timetabled undertakings that you have given as an NHS employee, are actually honoured. If they are not honoured, you do not get access to the extra pay. If you like, your pay is increasingly dependent upon your performance. That is a big change. It is a big change for NHS consultants in particular because, if you like, they have been the one group of directly employed NHS employees, unlike GPs for example as independent contractors, who have stood outside the normal contract of employment relationships. The job plan is absolutely central to that.
(Mr Foster) You rightly criticise the current job plan. The vast majority of consultants get a job plan on their appointment and then they are never revisited; a very small number of consultants have meaningful annual job plan reviews. Under the new system that will be the currency of planning a consultant's work. So there will be an annual job plan, an annual job plan review and we shall not have this woozy fixed/flexible distinction within a job plan which led to so much of the perception that some of the consultant's working life was out of control. Under the new job plan, the entire 40-hour working week will be fully timetabled. We shall know what the consultant is doing and where.
11. Have you been able to do any calculation as to the proportionate increase in NHS consultant time which will arise from this contract? What impact will this have on the use of the private sector through the concordat?
(Mr Milburn) In terms of the first, for example, at the moment there are three sorts of contracts: part-time, maximum part-time, full-time contracts. The concerns about the relationship between the private sector and the NHS have largely focused around the maximum part-time contracts. The maximum part-time contract goes under this. It disappears. What we would expect to see would be that consultants who would otherwise have gone to a maximum part-time contract would go onto a full-time contract. Rather than working ten out of eleven sessions, they will work the full set of sessions. We think that equates to an increase in time in percentage terms of 14 per cent.
(Mr Foster) Because a session is four hours rather than three and a half.
12. Over what period of time? Annually?
(Mr Foster) Immediately.
(Mr Milburn) Immediately. As from the time the new consultant contract kicks in. The deal is straightforward. What you cannot say to NHS consultants is "By the way, we want to work you 14 per cent harder and not give you a pay rise". It is important that there is an understanding about what we are doing and what we have always set out to do, because I have heard many misinformed views about this over the course of the last couple of hours. It is very, very important that people understand that what this has always been about is paying more to get more of a NHS consultant's time for the benefit of more NHS patients and that is precisely what the contract has achieved.
13. How is the on-call commitment going to be taken into account?
(Mr Milburn) We have had extensive negotiations with the BMA about this. From their point of view this has been a burning issue. We have found a way of recognising the position of those doctors who face the most onerous on-call duties. On-call is part and parcel of a doctor's life. It is. That is how things are and how things will always be in any healthcare system. Most normal on-call duties should be programmed as part of the consultant's working week.
14. As part of the eight direct clinical care sessions.
(Mr Milburn) Yes, that will be programmed as part of the eight direct clinical care sessions. However, for those with the most onerous duties, perhaps in a shortage specialty or whatever, they suffer immense disruption to their personal lives and their family lives and there should be some compensation for it. To recognise that we have found a graduated system of payment for them over and beyond the payment they would get as of right under the new contract. If you want more detail ...?
Dr Taylor: No, that is fine.
15. What sort of onerous specialties are we talking about?
(Mr Foster) There are two ways of defining onerousness. One is the frequency with which you are on call; the more frequently you are on call the more onerous it is. Second, the type of behaviour that arises from being on call. In some specialties you will get a telephone call at home and you can give advice, put the phone down and it is over. In other specialties you have to put everything down, rush into the hospital and do something. That is a higher degree of onerousness. Taking those two factors, we have contrived a table which will give a salary supplement up to eight per cent for the most onerous frequency rotas and the most onerous behaviour arising from being on call.
16. This is not just that some specialties are considered to be onerous and others are not.
(Mr Milburn) No; sorry if I gave that impression. It is not that.
17. So any consultant could be in an onerous position.
(Mr Milburn) Yes; absolutely. It is largely about the frequency. If you are doing one in three it is clearly a problem for you and we have had to find some way of recompensing consultants for that. I think that is fair.
(Mr Foster) Up to one in four is the most frequent; up to one in eight is medium frequency. Low frequency is one in nine or less.
18. It strikes me that there is one big snag, which I am sure you have faced, but I should love to know how.
(Mr Milburn) Just one?
19. At the moment we have consultants who are not using all their NHS time, because of a shortage of nurses, staffed beds, staffed theatres. You are very commendably making a lot more NHS time, but how are they actually going to use it unless you can put nurses, staffed beds, staffed theatres on the go immediately.
(Mr Milburn) Would that I could immediately, but I cannot and you know I cannot. You are quite right. The NHS consultant is a valuable resource, an immensely valuable resource, key resource within the NHS with unrivalled skills and expertise, but they cannot use those skills and expertise unless there is support, and not just from nurses. A heart surgeon cannot operate without the perfusionist. They cannot operate without the backup in diagnostics. They cannot operate without the cleaners and porters and everybody else around the service. They cannot operate without the beds and support facilities, including discharge arrangements and so on. Yes, you are right, but what this provides us with an opportunity of doing is growing the two crucial elements which count for patients at one and the same time: the infrastructure, the other staff, the beds, the hospitals, the equipment and growing the amount of NHS consultants' time we can buy for the benefit of NHS patients. It has been that latter element that we have never had a means of doing effectively. It has been complicated frankly by lack of definition for perfectly understandable reasons which have been there between NHS consultants' private practice and NHS consultants' NHS work since 1948. Somebody said to me today that the one great virtue of this, however complex all of this is, is that for the first time it is understandable. I believe it is. I believe there are some very straightforward deals on offer here for consultants which means that there are good deals on offer for patients.
Dr Taylor: Thank you. I am glad you recognised the difficulties.