Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change servers in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7126 Volume 316 Editorial Saturday 17 January 1998 Distinction awards and racial discrimination Uncomfortable questions but no easy answers Distinction awards are as old as the NHS. They were established in 1948 to reward specialists for "more than ordinary ability and effort"(1) by increasing their salaries, and this aim has remained essentially unchanged. Any system that tries to identify and then reward distinction is likely to have its critics, and distinction awards are no exception. Suggestions that the system favoured men and certain specialties were made long ago,(2) and now Esmail and Everington add the accusation of racial bias (p 193).(3) Most consultants don't have a distinction award.(4) Those who do have achieved wide recognition in their specialty, often nationally or internationally, and receive a pensionable salary enhancement of £22,590 to £53,645, subject to review every five years. The system is run by the Advisory Committee on Distinction Awards, which has 33 members, most of them doctors, with a few NHS managers. The committee receives nominations from the royal colleges and faculties, other professional organisations, national employers such as the Medical Research Council, and regional committees of award holders drawn from a representative cross section of specialties. Regional committees gather information from their professional members - who are expected to "take soundings" in their locality on who should receive an award - and from other local interests such as trust chief executives and deans of medical schools. Nominations take the form of a questionnaire completed by the nominee and a citation prepared by his or her sponsor. The questionnaire seeks information on how the consultant has contributed to the broader aspects of the NHS, including national or international responsibilities, research activities, number of peer reviewed papers, books published, and journals edited. Doing a good job locally in the absence of wider achievements is unlikely to result in a distinction award, although such consultants receive discretionary points, which are administered separately. Using surname as a surrogate marker of racial origin, Esmail and Everington found a disproportionately low number of award holders from ethnic minority groups: 14% of consultants were classified as non-white compared with 5% of award holders.(3) Data produced by the advisory committee show an almost identical imbalance for female consultants, with 5.7% holding an award compared with 14.5% of men. There are other anomalies: in the medical specialties upwards of 20% of consultants have an award, while the figure is less than 10% for some other groups such as geriatricians and psychiatrists. The figures are clear enough: finding an explanation is not. Had Esmail and Everington carried out their study using type of hospital rather than ethnic background as their comparator, they would undoubtedly have reached the conclusion that consultants from non-teaching hospitals are also under-represented. Teaching hospitals, however, tend to select consultants with a strong academic background and provide the environment necessary to achieve high productivity in research, spend time on national committees, and engage in the myriad of other activities which are necessary to receive an award - so a skewed distribution is inevitable. This is not the same as saying that those who allocate the awards are prejudiced. Against this background, are not Esmail and Everington's findings telling us more about patterns of employment in the NHS over the past 30 years than about the workings of the distinction award system? To test their hypothesis they should have established whether ethnic minority consultants in the same age group, specialty, and type of hospital are less likely to receive an award than their white colleagues. Only then would they be assessing the allocation of awards rather than historical employment opportunities. More and better data are needed to make an informed judgment on these difficult and important issues - not just to do with race but the other anomalies too. In the meantime, how might the distinction award system be improved? Indeed, should it exist at all? The committee that originally devised it believed that distinction awards were necessary "if the best possible recruits are to be attracted to specialist practice." Over the years there have been several reviews of the system,(4) but none has disagreed with this central premise or come up with a better way of achieving it. However, the committee also observed that the system "must command the confidence of the profession" and it is here that we do need to pay attention. It is important that all consultants understand the system and that the process is transparent. The distinction award criteria do not easily lend themselves to a scoring system, and, although this may be a weakness, it also reflects the varied ways in which consultants contribute to the NHS. None the less, a more explicit statement of the minimum requirements for each level of award could be helpful, as would an indication of the relative importance of different professional achievements. Most important, the process of taking soundings would benefit from a thorough review to ensure that no one is disadvantaged. For example, each eligible consultant could be invited to complete the questionnaire if they wanted to do so. This would serve two purposes: consultants would have a better understanding of the achievements necessary to get an award, and each case would be considered on its merits. Conflict of interest: I have a distinction award and make nominations for awards but am not on the advisory or regional committees. Peter Rubin Dean Faculty of Medicine and Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH References 1 Interdepartmental Committee on the Remuneration of Consultants and Specialists. Report. London: HMSO, 1948. 2 Bruggen P, Bourne S. The distinction awards system in England and Wales 1980. BMJ 1982;284:1577-8. 3 Esmail A, Everington S, Doyle H. Racial discrimination in the allocation of distinction awards? Analysis of list of award holders by type of award, specialty and region. BMJ 1998;316:193-4. 4 Working Party on the Review of the Consultants' Distinction Awards Scheme. Report. London: HMSO, 1994. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline