BMJ  2004;328:1347 (5 June), doi:10.1136/bmj.38062.639190.44 (published 16 April 2004)

Paper

Characteristics of consultants who hold distinction awards in England and Wales: database analysis with particular reference to sex and ethnicity

¹ UK Medical Careers Research Group, Department of Public Health, University of Oxford, Oxford OX3 7LF, ² ACCEA Secretariat, Department of Health, Room 531B, Skipton House, London SE1 6LH

Abstract

Objective To determine whether women, ethnic minorities, and particular specialties are discriminated against in the receipt of NHS distinction awards.

Design Analysis of database of consultants eligible for distinction awards.

Setting England and Wales, 2002.

Main outcome measures Holding of B, A, and Aplus distinction awards, analysed for all awards, irrespective of when made, and for awards made in the last five years studied.

Results Women and doctors from ethnic minorities were substantially under-represented among award holders when no account was taken of potential confounding factors. Differences diminished after multivariate analysis, but some remained significant. For example, the adjusted odds ratio of women holding awards compared with men was 0.69 (95% confidence interval 0.59 to 0.82) for any award and 1.37 (0.86 to 2.20) for Aplus awards; the odds ratio for any award for non-white doctors trained abroad compared with white doctors trained in the United Kingdom was 0.45 (0.37 to 0.56). In the last five years studied, the adjusted ratio of women to men was 0.94 (0.79 to 1.10) for B awards and 1.54 (0.85 to 2.83) for Aplus awards. The adjusted ratio for non-white British trained consultants was 0.86 (0.62 to 1.17) for B awards and 1.20 (0.37 to 3.87) for Aplus awards; for non-white consultants trained abroad it was 0.68 (0.54 to 0.85) for B awards and 0.69 (0.15 to 3.10) for Aplus awards; and for white consultants trained abroad it was 0.70 (0.54 to 0.91) for B awards and 0.90 (0.38 to 2.15) for Aplus awards.

Conclusion Historical under-representation in award holding by women and doctors from ethnic minorities was partly explained by time spent as a consultant. Recent awards showed no under-representation of women and no appreciable under-representation of ethnic minorities overall. However, doctors who trained abroad—both white and non-white—remained under-represented for B awards.

Introduction

A system of distinction awards for medical and dental consultants was established at the inception of the NHS.¹ The principles of the system (see box) have been endorsed at various times,^2-4 but the precise criteria used were somewhat obscure. The criteria have been progressively refined and increasingly publicised.⁴

Some people have been concerned that women, doctors from ethnic minorities, and consultants in certain specialties are discriminated against in the awards system.^{4 5} In our analysis, the most comprehensive undertaken, we report on the distribution of awards for all award holders and for those given awards in the past few years.

Method

Database—The Department of Health maintains a database of all consultants who hold substantive or honorary contracts with the NHS in England and Wales. This includes year of first appointment as a consultant, current award status (B, A, or Aplus) and date when it was given, sex, ethnic group (as recorded by the consultants themselves), and, for the current post, specialty, employing trust, region, and type of contract. We used the GMC register to add the country of training. The database was for the end of 2002 and included all consultants who had been appointed up to 31 December 2001, with details of award status at the end of 2002.

Background to the distinction award system The system provides a mechanism, through recommendations made by the Advisory Committee on Distinction Awards, for additions to be made to the basic salary of consultants in recognition of high achievement. Since 1994, there have been local "discretionary points" funded by the employing trust (in place of earlier, national C awards) and successively higher awards—termed B, A, and Aplus—typically used for distinction of national and international as well as local stature and funded nationally.4

Analysis of all awards—We calculated the percentage of all consultants in post in 2002 who had received any award (B, A, or Aplus), an A or Aplus award, and an Aplus award. It is rare for a B award to be received within five years, an A award within 10 years, or an Aplus award within 15 years of the first appointment as a consultant. Accordingly, except where specified, in calculating the percentage of consultants we restricted the denominators to those who had been consultants for at least five years for the first calculation, 10 years for the second calculation, and 15 years for the third calculation. We made an additional adjustment, after restriction, by stratifying the time from appointment into bands of five years and standardising the achievement of awards by strata.

Analysis of recent awards—To study the progression of award holding in recent years, we analysed the data for consultants who received an award in 1998-2002. We calculated the percentage of consultants who gained a B award in 1998-2002, using as the denominator all those who had been a consultant for at least five years by 2002 and who had either no award by the end of 2002 or a B award during 1998-2002. For A awards gained in 1998-2002, the denominator was all those who had been a consultant for at least 10 years by 2002 and who held either a B award given before 1998 or an A award given during 1998-2002. For Aplus awards gained during 1998-2002, the denominator was all those who had been a consultant for at least 15 years by 2002 and who held either an A award given before 1998 or an Aplus award given during 1998-2002.

Results

Of the 26 644 consultants in practice in 2002, 18 977 had been consultants for at least five years, 11 409 for at least 10 years, and 6888 for at least 15 years. Data items were missing for some consultants in each group (see appendix on bmj.com). At the end of 2002, 23 174 (87%) consultants held no award, 2155 (8%) held a B award, 968 (4%) held an A award, and 268 (1%) held an Aplus award. See bmj.com for tables showing the distribution of awards by time since first consultant appointment and the increasing percentage of consultants who are women or from ethnic minority groups.

Variation in award rates by single factors
Univariate analysis of all awards showed they were less likely to be held by women, by non-white consultants, and by doctors trained abroad. These differences diminished substantially when we restricted the analysis to consultants in post for at least 5, 10, or 15 years and when we incorporated an adjustment for length of service in the model.

Univariate analysis of awards made during the last five years of the analysis (1998-2002) showed no significant differences by sex, ethnicity, and place of training for A and Aplus awards and smaller differences for the B award than seen in the historical record. The adjusted odds, taking account of time from appointment, further reduced the differences for recent B awards, although some significant differences remained (see bmj.com).

Multivariate adjustment of the historical database
After full multivariate adjustment, the number of significant differences reduced further. Women remained less likely than men to receive any award, with an odds ratio of 0.69 (95% confidence interval 0.59 to 0.82). The ratio for women for A and Aplus awards combined was 0.82 (0.65 to 1.04), and that for the Aplus award was 1.37 (0.86 to 2.20). Non-white consultants who trained abroad were less likely to receive each level of award: 0.45 (0.37 to 0.56) for any award, 0.32 (0.21 to 0.48) for A or Aplus award, and 0.47 (0.18 to 1.19) for Aplus award. Consultants in anaesthetics, radiology, and pathology were less likely to receive awards. Differences for other specialties were small. Consultants with honorary contracts, who are almost exclusively those with academic posts, were much more likely than others to hold awards at all levels. Consultants outside the former Thames regions were less likely to hold awards than consultants in those regions.

Multivariate adjustment: recent awards
The table shows odds ratios, after multivariate adjustment, for B, A, and Aplus awards made in the last five years of the analysis. The appendix on bmj.com illustrates how the odds ratios change as successive factors are included in the model. The results after adjustment show no evidence of under-representation of women. For the B award, as noted above, representation of both white and non-white doctors who trained abroad was significantly low; under-representation was more a function of overseas training than of ethnicity. Representation of non-white doctors trained in the United Kingdom was low, though not significantly so. At the level of A and Aplus awards, we found no evidence of under-representation of white consultants trained overseas or non-white consultants trained in the United Kingdom, but a non-significant under-representation existed for overseas trained consultants from ethnic minority groups.

View this table: [in this window] [in a new window]   Awards given in 1998-2002 by sex, ethnicity and place of training, specialty, type of hospital, location, and type of contract, with multifactorial adjustment

 

Discussion

Women consultants received fewer awards than men in the past. This, however, is not the case for awards made in the last five years of our analysis. For consultants who qualified in the United Kingdom, those from ethnic minorities were under-represented in the past, but no significant differences exist in recent years between white and non-white doctors, once allowance has been made for year of appointment; any apparent shortfall in recent years is mainly an effect of length of service as a consultant. Consultants from ethnic minorities who trained abroad were under-represented at all levels of award. In the last five years doctors who trained abroad, both white and non-white, have received lower levels of B awards than British trained doctors. Recent under-representation seems therefore to be a function of place of basic medical training rather than ethnicity.

Under-representation of consultants in some categories is most striking for the B awards, and lessens as consultants progress through to higher levels. The Advisory Committee on Distinction Awards has put considerable effort into ensuring that direct discrimination favouring some groups above others does not happen. However, indirect discrimination could occur when the culture of working makes achievement a harder task for some than for others. For example, if high achievers work full time or very long hours, those with heavy family responsibilities may be disadvantaged.

A higher percentage of consultants in some specialties than in others achieve awards. Some specialties may be inherently more demanding, and by implication more worthy of reward than others, or it may be inherently harder for doctors in some specialties to achieve distinction through particular activities, such as research. Some specialties are also more oriented to innovations that might be recognised nationally and internationally. Women and doctors from ethnic minorities have been under-represented, historically, in some of the more highly awarded specialties and in teaching posts.

What is already known on this topic Distinction awards are held by a higher percentage of men than women and a higher percentage of white doctors than those from ethnic minorities Concern has been expressed that the award system may discriminate against women and doctors from ethnic minorities, although other explanations for under-representation are possible What this study adds Under-representation of women and ethnic minority doctors diminished substantially after adjustment for confounding variables, but some under-representation remained Under-representation of ethnic minority doctors mainly occurred among those who had received their basic medical training abroad Women and British trained ethnic minority doctors were not under-represented in recent years, but white and ethnic minority doctors who had trained abroad were still under-represented

Recently, the award system has undergone a major reorganisation, with emphasis on rewarding outstanding and sustained commitment to service delivery in the NHS.⁶ In anticipation of the new clinical excellence awards, the committee, which has now become the Advisory Committee on Clinical Excellence Awards, has introduced new, explicit, national criteria and guidance and a new process of decision making for the 2004 awards.

---

Editorial by Rodwin

An appendix and additional tables are on bmj.com

This is the abridged version of an article that was posted on bmj.com on 16 April 2004: http://bmj.com/cgi/doi/10.1136/bmj.38062.639190.44

We thank the Advisory Committee on Distinction Awards for making its database available for analysis and the Department of Health for access to data provided by the General Medical Council. We thank the General Medical Council for permission to use its data in this study.

Contributors: See bmj.com

Funding: The UK Medical Careers Research Group is funded by the policy research programme of the Department of Health.

Competing interests: EV is chair and NM is medical director of the Advisory Committee on Distinction Awards. Each is concerned to ensure that the system works fairly. NM and MJG have been members of regional advisory committees. NM has been, and MJG is, an award holder.

Ethical approval: Not needed.

References

1. Spens W. Report of the interdepartmental committee on the remuneration of consultants and specialists. London: HMSO, 1948. (Cmnd 7420.)
2. Report of the Royal Commission on Doctors' and Dentists' Remuneration 1957-1960. London: HMSO, 1960. (Cmnd 939.)
3. Report of the Royal Commission on the National Health Service. London: HMSO, 1979. (Cmnd 7615.)
4. Kendell R. Report of the working party on the review of the consultants' distinction awards scheme. London: NHS Executive, 1994. (EL (94) 99.)
5. 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: 193-5.[Free Full Text]
6. Department of Health. Rewarding commitment and excellence in the NHS: consultation document—proposals for a new consultant award scheme. London: Department of Health, 2001.

(Accepted 5 March 2004)

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Articles

Promotion to hospital consultant: regression analysis using NHS administrative data

Kostas Mavromaras and Anthony Scott
BMJ 2006 332: 148-151. [Abstract] [Full Text] [PDF]

Doctors trained abroad are less likely to win merit awards
BMJ 2004 328: 0. [Full Text]

Financial incentives for doctors

Marc A Rodwin
BMJ 2004 328: 1328-1329. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Sidhu, R., Rajashekhar, P., Lavin, V. L, Parry, J., Attwood, J., Holdcroft, A., Sanders, D. S (2009). The gender imbalance in academic medicine: a study of female authorship in the United Kingdom. JRSM 102: 337-342 [Abstract] [Full text]  
• Morris, S., Elliott, B., Ma, A., McConnachie, A., Rice, N., Skatun, D., Sutton, M. (2008). Analysis of consultants' NHS and private incomes in England in 2003/4. JRSM 101: 372-380 [Abstract] [Full text]  
• Abel, P., Esmail, A. (2006). Performance pay remuneration for consultants in the NHS: is the current system fair and fit for purpose?. JRSM 99: 487-493 [Full text]  
• Mavromaras, K., Scott, A. (2006). Promotion to hospital consultant: regression analysis using NHS administrative data. BMJ 332: 148-151 [Abstract] [Full text]  
• Rodwin, M. A (2004). Financial incentives for doctors. BMJ 328: 1328-1329 [Full text]  

Rapid Responses:

Read all Rapid Responses

The Last Inequality

William G Notcutt
bmj.com, 6 Jun 2004 [Full text]

Service specialities suffer?

Paul E Sigston, et al.
bmj.com, 24 Jun 2004 [Full text]

Other goals in life!

Alastair Lack
bmj.com, 30 Jun 2004 [Full text]

Online poll

Find out more >>