Examination of Witnesses (Questions 280-299)
DR JONATHAN
FIELDEN, MS
KAREN JENNINGS
AND MR
ALASTAIR HENDERSON
8 JUNE 2006
Q280 Dr Naysmith: Would it be true
to say you were not enthusiastic about having a pilot?
Dr Fielden: I do not think we
felt, on this particular aspect, that it was going to be the best
way of bringing in this contract. There was a choice aspect, where
the consultants went across to it, but job planning should have
been done from 1991, so it was not a radical change. The increased
clarity that was brought in with the contract was going to bring
that in and then reward and recognise the hours and work the consultants
were doing.
Q281 Dr Naysmith: You are probably
aware that there were job plans long before this new contract
was agreed.
Dr Fielden: Yes.
Q282 Dr Naysmith: And we have had
evidence before this Committee on many occasions that hospital
administrators did not take up the question of job plans with
consultants because they would know that they would be told where
to go. That sort of thing has been said two or three times before
the Committee. Might it not have been a good idea to see what
effect the new contract would have on job planning before we actually
agreed it?
Dr Fielden: As I say, we did not
feel there would be a substantial benefit of piloting in this
particular example. Our recollection from the time is that piloting
was also not something that was pushed centrally. I believe the
issue of piloting ideas with doctors goes back even as far as
Ken Clarke. It was felt that you would not pilot things because
doctors would wreck things, and therefore you pushed things in.
I would not agree with that, but we believe the pressure to pilot
came from other sides.
Mr Henderson: I was involved with
Andrew in the consultant contract negotiations through both stages—an
assortment of delightful BMA negotiations, phase 1 and phase 2
of them. We were keen to talk about piloting and it was something
that we were not able to progress. It is not the easiest thing
to do to get a pure pilot. That is a slight difference in some
of the Agenda for Change piloting of new pay systems, with
some of what was proposed there, but I think it was something
that we did wish to explore.
Q283 Dr Naysmith: Do you regret it
not having happened?
Mr Henderson: It might have been
nice to have some sort of pilots, yes, though one of the important
things about the contract that I think is most important is the
potential cultural change that the contract implies. That takes
place over time. That is always quite difficult to get in a three-month
pilot. It might tell you something about how x payment
system works, but you are probably unlikely to get information
on what the cultural changes mean with the workforce.
Q284 Dr Stoate: We are talking about
very large sums of public money and we cannot even agree on who
did and did not want a pilot. I am very concerned about what I
am hearing. I would like to explore further Mr Henderson's statement
earlier on in the session about gradually getting improvements
and things sorted out with the new consultant contract and things
gradually coming into place and seeing improvements over time,
but we were told quite clearly by David Amos that rigorous job
planning and objective setting are crucial to the end benefits
of the contract. Should this not have been sorted out before the
contract rather than hoping it would all come right a year or
two afterwards?
Mr Henderson: As was said, there
should have been job planning in the NHS before. Frankly, I think
it was very patchy. I do not think it is surprising that having
a good and rigorous system of job planning and appraisal is something
that develops. I do not think it does land fully formed in one
go. It is something that you do on an annual basis and hopefully
you get better at. I am not saying that you do not want it as
good as possible first time round, but you do get better at it.
Both managers and the doctors involved in the process will begin
to understand the process better and will be given to understand
how to get more benefits out of it. The fact that it is an improving
process is unsurprising.
Q285 Dr Stoate: I think the taxpayer
has a right to know why, for example, a 49.4% pay rise between
2001 and 2005 for consultants was not backed with rigorous improvements
in productivity and job planning before that very large sum of
money was spent.
Mr Henderson: As Jonathan has
said, there is a whole series of measures on the success. I think
that introducing what I have talked about—this new currency,
this new dialogue for consultant—is a benefit that has been
worthwhile. I think we have seen improvements in service and I
think we have seen improvements in the management of consultants
and the way that consultant time is managed, and that is going
to take some time.
Q286 Dr Stoate: But we cannot even
agree on what productivity is. Sir Alan Craft has told us that
he thought productivity would go down; Dr Fielden has told us
he thinks productivity has gone up. All I do know for certain
is that there are huge amounts of public money being spent. We
do not seem to be getting very far in terms of even deciding what
has happened and why.
Mr Henderson: By what you measure
productivity, yes, there is a whole series of things. There is,
of course, straightforward output of consultants, which is a subject
of considerable debate on which I know your advisers have some
keen views as well. I was talking to Jonathan Michael, the Chief
Executive at Guys and Thomas's, saying that the way he has been
viewing that as an organisation is not just productivity in terms
of throughput of operations, important though that is, and contact
with patient time, but it is about also the use of consultants
in their teaching, in their research, in their clinical audit
and clinical governance. It is ensuring that the contract is used
for full and getting all the benefits of that as well. That single
productivity measure is then quite difficult to work out what
you want.
Q287 Dr Stoate: It is a very long
answer but it does not really reassure me. Let me put a more straightforward
question. When will job planning and objective setting be fully
operational to improve productivity?
Mr Henderson: I think it is. Job
planning is fully in. It will continue, year on year, to continue
more benefits.
Q288 Dr Stoate: I am still not convinced
that we have got very far. The money has gone in, job planning
seems to have partly gone in and productivity possibly is improving—but
we cannot even agree on that. I simply want to know when taxpayers
can say, "We've got our value for money."
Mr Henderson: Job planning is
in. Job planning and objective setting is happening in every organisation.
It is happening to different degrees of success, but it is getting
better each year. I think the public can say they are seeing improvements
from the consultant contract.
Dr Stoate: Thank you.
Q289 Anne Milton: Mr Henderson, I
wonder if I could ask you to do the "man in the pub"
test. Anybody reading this transcript—and I have some sympathy
for what Dr Stoate was saying—would not understand a lot
of the words you use. I wonder if you could explain what "currency
and method for engaging consultants" means to the man in
the pub. Is it surprising that it was not there before, really?
Mr Henderson: Yes, it is surprising
that it was not there before, but it has not been. The way that
organisations engaged with consultants over the past has not been
terribly—
Q290 Anne Milton: Man in the pub,
who does not talk about engaging.
Mr Henderson: Fair enough.
Q291 Anne Milton: I think it means
something physical rather than intellectual.
Mr Henderson: There has to be
a proper way that trusts manage the work of their doctors, like
they manage the work for all their other staff. That did not always
happen in the past. This contract provides a better way of planning
the use of consultants' time, so that what they do can tie in
with what the local organisation wants, so it can deliver the
best form of services for local patients that is most appropriate,
so that we are using the consultants time most effectively and
the best way to deliver services for patients.
Q292 Anne Milton: So a management
tool for encouraging—forcing if necessary, and I know you
do not like that word—consultants to do what management
wants them to do to produce better outcomes—I mean, I do
not mean to be prejudicial—to produce better outcomes for
patient care.
Mr Henderson: Yes, indeed.
Dr Fielden: It gives you the tools
so they can have that discussion.
Q293 Anne Milton: Tools, meaning?
Dr Fielden: The framework. You
have to sit down on at least an annual basis. You have the blocks
of time, you have the objectives for supporting resources, the
aspects to a discussion that you must go through to ensure that
what a consultant is doing and when they are doing it is appropriately
focused on what the trust needs for patients and what the current
doctors feel they need for patients. One of the reasons that did
not happen before is that the trusts were concerned that the closer
they look, the more they realise consultants are doing. As we
shared with you in previous sessions here, the hours that consultants
were doing were substantially in excess of the old contract. They
continue to be in excess of the new contract. The closer you look
and the harder you try to force people to do things, the more
they are likely to react and say, "Okay, you do not get this
bit for free if you are not going to treat me like a professional."
I think one of the reasons the trusts avoided it for so long is
that they realised what a huge amount was going on—and the
closer you look you reveal even more.
Anne Milton: Thank you.
Q294 Dr Taylor: Back to productivity.
We have really only talked about activity, which is the easy part
of productivity to measure. We can easily measure FCEs, the outpatient
scene, but what about health outcomes? What measures are there
to include a measure of health outcomes in these contracts?
Dr Fielden: I think it varies
a lot between trusts and the amount of data they are actually
using. We would certainly advocate, and we are advocating in the
information we put out to consultants and into the public domain,
"You should be including all aspects of how best to improve
care for patients as part of the information that informs your
job planning process." Let me take an example of myself in
intensive care. There is clear evidence of the benefit of patient
outcome of having more consultant time on the floor in the intensive
care unit throughout the day and into the evening and night. That
presence improves the quality of care and outcome for patients
in intensive care. My job plan now allows us to focus more consultant
time in intensive care for those patients and we are seeing benefits
in the improved care of patients going through our unit. Similarly,
in A&E.
Q295 Dr Taylor: What are your measures
of outcome coming out of the ITU?
Dr Fielden: Survival. In intensive
care terms, survival.
Q296 Dr Taylor: So that is easy.
Dr Fielden: You can then map it
in. You can then, if you like, look at quality of care outcome
as well. We have managed to ensure that our follow-up clinic in
intensive care is properly focused within a job plan, so that
we can make sure the morbidity aspects related to intensive care
are also looked into. We have examples around the country, in
obstetrics and paediatrics in Plymouth, where they focus their
emergency work into a week. That allows separation of the emergency/elective
workload, which, as Alastair has already mentioned, means you
get less cancellation of elective work but also a greater fully-trained
presence, like consultants, in for emergencies, which improves
outcome. There are multiple examples of that. If you are measuring
just fixed consultant episodes going through in cardiac surgery,
for example, they are going to go down because our radiologists
have got particularly clever at boring out arteries, so the number
going through is going to go down. If I am a cardiologist, the
more patients that I put on beta-blockers, ACE inhibitors and
otherwise, the fewer should be coming back to my clinic, so my
productivity is going down but my health outcomes are going up.
I think you have to throw the productivity question back to them.
If I may come back to Howard Stoate's comment about a 49% increase,
I think that is an interesting figure to quote because the hours
in the contract went up from 35 to 40 for the base hours and there
was a small rise associated with that. The majority of the increase
in that period of time was because you are paying for the extra
hours that are being worked. Most consultants are being paid now
for about 44-45 hours of work, which means that trusts can guarantee
and decide on which hours they want to be done and focus that
for patients, rather than it not being paid for and then maybe
or maybe not being done. So the majority of that increase is,
if you like, paid-for overtime.
Q297 Dr Stoate: This was in a report
from the King's Fund. They said consultants' basic pay rose by
49.4% between 2001 and 2005. That is not from us, it is not from
Government. That is from the King's Fund.
Dr Fielden: The King's Fund report
was limited to five trusts in London. Everyone pretty much recognises
it is a very limited report. Those figures focused on the early
years. The biggest pay rise in the contract was for consultants
in the first few years. That is partly a recruitment measure and
partly a factor that junior doctors' salaries had increased and
therefore there was a need to increase consultants' salaries,
otherwise you would have juniors taking a drop in salary before
they went in to taking much more responsibility. That was an appropriate
increase. If that increase was high, the increase at the end,
to retain doctors, was higher. In the middle, it was about 4.5%
or 5%, if you look at it, until you add on the additional paid
overtime. The King's Fund report was fairly choosy with how it
picked its figures because I think it gave them the headline to
give them the publicity they wanted.
Chairman: We are going to move on to
the Agenda for Change.
Q298 Mike Penning: I will speak to
my friends from UNISON, who must have felt a bit left out for
the last 10 minutes or so. The Committee has heard that about
4.5% of staff so far have moved on to Agenda for Change
contracts on protected pay. Is that a figure which you understand
is correct?
Ms Jennings: That is a figure
which we would support. It has been produced through partnership
with the Department of Health. It is a figure which is rather
supported—in terms of, we were expecting a larger number
to be on protected pay. As a result of developing better job profiles,
we have been able to reduce that figure down to 4.5%.
Q299 Mike Penning: Which are the
areas of professional expertise which have been most affected
by this? Many of us have been written to, in my case by the pharmacy
profession and senior nurses. Are there other areas which have
been affected dramatically by this?
Ms Jennings: I think the group
that has been affected most by this is the admin and clerical
sector, medical secretaries and so on. I think they have begun
to improve in the bandings that they have achieved as a result
of looking at better job development programmes and the profiling
of them.
| 
