Examination of Witnesses (Questions 220-239)
MS SIAN
THOMAS, MR
DAVID AMOS,
MR WARREN
TOWN, PROFESSOR
SIR ALAN
CRAFT AND
MS JOSIE
IRWIN
18 MAY 2006
Q220 Sandra Gidley: The consultants
appear to have done very well and what we are trying to establish
in this Committee is whether the NHS is getting as much out of
the contract as perhaps could have been achieved. The success
of the contract from a patient point of view probably revolves
around the introduction of effective job plans, and a few years
ago we know that there were very few in case. Is it not the case
that the job plans that have been developed to date have been
somewhat inconsistent and not of the standard that we might expect?
How would this situation be addressed?
Professor Sir Alan Craft: Really
you should be asking the BMA and not me, but I will answer it
as best I can.
Q221 Sandra Gidley: Why should I
be asking the BMA?
Professor Sir Alan Craft: Because
they are the people who are responsible for terms and conditions
of service, not the Royal Colleges.
Mike Penning: You must have a view.
Q222 Chairman: Let Sir Alan answer
the question as best he can.
Professor Sir Alan Craft: I am
excusing myself because that is the terms and conditions, which
is the union's job, which is the BMA's job. The new consultant
contract is a time sensitive contract and what it did was to identify
the huge amount of work that actually was being done by consultants
and a lot of that is now being squeezed out of the system, that
consultants are being told that they must work their contracted
hours, whether it is 10 sessions, 11 sessions or 12 sessions,
and I think because of that—to go back to Mr Campbell's
point—productivity probably has gone down in some places.
Q223 Sandra Gidley: Productivity
has gone down? Can you clarify why you think that?
Professor Sir Alan Craft: Because
doctors are now working to a fixed contract, which they never
did before. They also have to fit in with the contracts of everyone
else.
Q224 Sandra Gidley: So are you saying
that a consultant does not put the six hours extra a week that
we have been told a nurse does?
Professor Sir Alan Craft: They
do, yes, but they used to put in a great deal more than that in
the past. Most doctors are still working way above their contracted
hours, yet because of the system the productivity has probably
gone down compared to what it was before.
Q225 Sandra Gidley: Can you give
me a practical example of that because I cannot quite understand
how we are paying more, we have a set contract and you are saying
that productivity has gone down?
Q226 Professor Sir Alan Craft: Most
consultants were probably working 60-odd hours a week, which is
probably too much. The standard working week has now gone down
to 10 sessions, which is probably slightly less than 40 hours
a week, and if you want any more than that then contractually
the employer has to pay you to do that. But employers have been
working towards reducing everybody to the minimum number of contracted
hours; therefore for each individual consultant you are getting
less. In the long run it will be safer for patients because that
work still has to be done so you have more consultants doing that
work, but each of them are doing less hours than they were in
the past, and you will get better consultants because they are
working 40 hours a week instead of 60 hours a week.
Q227 Sandra Gidley: It has been put
to us that we were not always clear what consultants were actually
doing before and that the job plans are a chance to clarify this,
but maybe we do not have the data on it?
Professor Sir Alan Craft: I think
that you are now much clearer, you have to be much more explicit
about what you are doing in every session of the week. I think
the myth that was around was that a lot of consultants were abusing
the system by spending quite a lot of time at the local private
hospital, and I think that has been shown to be a myth; the vast
majority of consultants were working way above their contracted
hours, and that is now explicit in the contract. That is the situation.
Ms Thomas: The first thing to
say is that our evidence next week will give fuller answers on
this point and there is also a report shortly due out by the consultant
contract implementation team on exactly some of these issues,
which I would commend you to read. But overall we have to say
that job planning has improved an understanding about what our
consultants are doing and how to manage the flexibility between
the types of work that they do. Before the contract if you wanted
to switch the way a consultant worked between their emergency
work, their planned work and their weekend work it was really
an impossible thing to try to do. The contract is a framework
which enables employers to do that. Some employers are implementing
that better than others, which is what we would expect, and our
role is to help people with that. I think the other thing that
has been missed in the point here is that we have increased the
consultant workforce, so it may well be that doctors' hours have
come down in some of those roles but that is because in some specialities
the consultant workforce has increased significantly. I do not
know if David would like to give a specific example?
Mr Amos: As a general observation
and a specific illustration I guess that with a reform of this
nature you do not always get it right the first time, but I think
what we have is a platform, and I am sure that this Committee
could make some suggestions that through negotiation with the
BMA and others the new consultants' contract, which is now in
its third year, can be improved in order to meet the objectives
that it set out to do. I would say that you need to remember what
it replaced, and we now have a currency and a method for a dialogue
with 30,000 colleagues across the NHS in a way that we never had
before with the existence of a more 1940s, 1950s style employment
contract. The currency I think is good for the organisation, good
for patients, good for the individual to be able to agree objectives,
to be able to agree priorities, to be able to agree what personal
professional development and support those individuals need in
order to do their day job and if they need to change in order
to do tomorrow's job what needs to happen. I think you are already
starting to see that across the NHS. I know that employers will
have views on how we can improve the contract to deliver more
on the original objectives, but we can now have a dialogue and
agree objectives and standards and, as I said, I think that is
good for the individual patients and the organisation as a whole
in a way that we could never do before.
Q228 Sandra Gidley: As an employer
do you think that the government probably missed a trick when
negotiating the consultant contract because they spurned the idea
of a fee for service contract, which is something that might have
improved productivity?
Mr Amos: That is maybe one of
the things that needs to be considered, but having observed negotiations
at the time I am pretty sure it was very unlikely that that would
have been accepted.
Q229 Sandra Gidley: Should it be
a case of what the consultants will accept?
Mr Amos: I think when you are
making such a dramatic change you do need to carry people with
you and the important thing is to make sure that it hits the overall
objectives in terms of improving patient care and improving recruitment
and retention. As I said, if you remember what it replaced it
does represent a massive step forward in terms of where we were
four or five years ago.
Ms Thomas: Could I just add that
one of the things that we are doing in NHS Employers at the moment
is that within these contracts helping employers improve the way
they have implemented them and will continue to work with them,
and I do believe that within the current consultant contract there
is every way that we can try and improve those, and certainly
some employers we have brilliant best practice to show that they
are exemplary in the way they have done that and others need more
help.
Q230 Sandra Gidley: How is that being
shared because the NHS is traditionally appalling at sharing best
practice?
Ms Thomas: What has just been
said is that through our organisation and through our website
we have just established a Medical Workforce Forum in NHS Employers,
which for the first time we have over 100 employers engaged in
that and they are in dialogue about the vast range of medical
workforce issues we have talked about here today, including the
consultant contract, and getting employers together like that
has never happened before on some of these issues, it has normally
been the Department of Health and the BMA and the profession,
and for the first time we have had an organisation with a voice,
that is the employers' voice, to implement the very things that
you are describing, and that is what we aim to do.
Mr Amos: Just to add, we may have
something in the jargon—and I will explain the acronym in
a second—PA for service, Programmed Activity, which as you
know makes up the consultant contract, and in discussion with
individuals we can now give levels of PA either on a temporary
or a permanent basis for part-timers above six and full timers
above 10 on the basis of delivering either a specific quality
of service that is not there before or a specific volume and I
am sure we can find many examples of that, and that is probably
quite a good way of testing what a measure of fee for service
feels like, what effect it has and whether that can be extended
in order to get greater benefit for patients.
Q231 Sandra Gidley: So are we actually
tracking what improvements and what increased activity we are
achieving, and how is that being done?
Ms Thomas: We are collecting evidence
of best practice and case studies of best practice and we are
very happy to send a note to you of some examples of those.
Q232 Sandra Gidley: That is just
evidence though, I am talking about so that we have a global picture.
Ms Thomas: Centrally?
Q233 Sandra Gidley: Yes.
Ms Thomas: It is not our role
to collect central data on such issues.
Q234 Sandra Gidley: Whose role is
it?
Ms Thomas: It may be a question
to put to the Department but it would not be for us to collect.
We would certainly help employers benchmark. For example, a group
of Trusts we have just gone to in psychiatry are benchmarking
between themselves the very thing that David has talked about,
which is in a geographic patch and they have worked together,
benchmarked how many PAs they are all giving their psychiatrists
against how much agency staff they are bringing in in psychiatry,
to see if they benchmark well within one another, but our role
is to help local people do things for themselves and improve things
for themselves. If you are asking about a national collection
of data, that is not something that we would do, but maybe something
that you should consider as a Committee.
Mr Amos: We are certainly happy
at a local level within organisations as part of the business
planning what organisations are setting out to achieve to look
at the level of PAs by speciality in connection with what individuals,
clinical teams and the acute hospital as a whole is trying to
achieve. As Sian has indicated, the Association of UK Teaching
Hospitals is doing some benchmarking work on precisely that issue.
Q235 Dr Taylor: You have talked about
changing practice, Sir Alan. Can the clinical excellence awards
be used as a tool to make people change practice, for instance
to increase day surgery rates? Is that what they are designed
for? What can they be used for?
Professor Sir Alan Craft: I think
the local discretionary points are there to award local innovations
in practice, people who have done more than they might have done
to improve local services, then they would be rewarded by local
discretionary points. The clinical excellence awards are where
there has been innovation at a higher level than that. They would
certainly reward people for that but I do not think that they
should be used to drive innovation.
Q236 Dr Taylor: So what is there
available if people are still doing, for example, cataracts as
inpatients or anything like that? What tools do employers have
to enforce change there?
Ms Thomas: As David described,
within the consultant contract there are two or three main levers
you have as an employer. One is the job plan itself, which describes
on a day-by-day basis where somebody is, what they do and what
type of work they are doing.
Q237 Dr Taylor: So that would actually
say that it was a session for day surgery rather than inpatient
surgery?
Ms Thomas: Absolutely. The second
thing is every year that job plan is reviewed so it is not a static
thing, and it can be reviewed at any time by both parties. So
once a year is a minimum and then more frequently if some innovation
came in or some standard came in and a Chief Executive saw that
their Trust was an outlier within a certain level of practice
it could call for a job plan review with its clinician. The third
thing is the objectives and the standards, as David said, which
is each clinician is now expected to have some objectives through
the years. So if you were not doing day surgery because your competence
would not allow that to happen you certainly would not want to
make somebody do it at the next day, but your objective would
be to help that clinician move towards that goal.
Q238 Dr Taylor: Has the system been
going long enough to show that that is happening?
Ms Thomas: Some employers embraced
that from day one; others are taking longer, and as David said
we are seeing that happening all through the contract and our
job is to make sure that share the best across the service.
Q239 Anne Milton: Can I come in on
a couple of points? I think you said that it was not NHS Employers'
responsibility to collect data?
Ms Thomas: No, I said central
data. We have not been asked by the Department and we certainly
would not see our role to collect from the service data for performance
management or policy purposes. What we are doing is collecting
data and sometimes we are collecting that from large numbers of
employers to enable employers to improve what they are doing and
to benchmark their work. There already are organisations that
do that job, and I think you heard from one just last Thursday,
Workforce Review Team and Workforce Planning Teams at SHAs collect
data for that purpose. We would not see ourselves as replicating
the work of other bodies.
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