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, Area 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. The principles behind it were that recognition of special achievement must be explicit and that "there must remain for a significant minority the opportunity to earn incomes comparable to the highest which can be earned in other professions."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

Background to the distinction award system The system has provided 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. Until 1994, awards were in four bands.4 The C award was the lowest in value and was typically used for distinguished local contributions to the NHS. The successively higher awards—termed B, A, and Aplus—were typically used for distinction of national and international, as well as local, stature. A review in 1994 commented that "many gradations between professional contributions whose influence is purely local and those with a genuinely nation-wide or international influence" existed, but it formalised a division between local and national awards.4 It recommended that local awards should be funded by the local employing trust (they had previously been paid from national funds). This established the system of local "discretionary points" in place of the national C awards. The review recommended that higher awards (B, A, and Aplus) should continue to be funded nationally, so that no financial cost of awards fell on local employers for "allowing their staff to become involved in work of wider benefit to the NHS and to medicine as a whole."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} The Advisory Committee on Distinction Awards has monitored the percentage of male and female consultants and members of ethnic minorities who have obtained awards, as well as the distribution of awards among the specialties. Any analysis must take account of potential confounding factors, in particular the number of years consultants have worked in the NHS. In our analysis of the system, 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 details 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, year when the current award was first given, specialty, sex, ethnic group, employing trust, region, and type of contract. The names of the consultants were removed from the database for the study, but the General Medical Council (GMC) numbers were provisionally retained. The database does not include the consultants' country of basic medical training or the type of hospital in which each works. We used the GMC register to add the country of training. We then deleted the GMC numbers from the file for analysis. The database was that for England and Wales at 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.

Definitions
Ethnic group was that recorded by the consultants themselves. Hospitals were classified as district hospitals or teaching hospitals. Type of contract was recorded in the database as full time, maximum part time, other part time, and honorary. We grouped specialties into broad groups. The database was a cross sectional snapshot: it contained only each consultant's most recent award (B, A, or Aplus) and the date when it was first given. The consultants' specialty, hospital, region, and type of contract were those for the current post only. No copies existed of the database as it was in previous years.

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 very 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 otherwise, in calculating the percentage of consultants in each group who held an award 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. We calculated the percentage of consultants who gained an A award in 1998-2002, using as the denominator 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. We calculated the percentage of consultants who gained an Aplus award during 1998-2002, using as the denominator 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.

Statistical methods
We used logistic regression to compare award holding by consultants in different categories. We calculated odds ratios and their confidence intervals. We used the Wald statistic to assess statistical significance of the results. We did calculations for univariate and multivariate analyses, as detailed in the footnotes to the tables.

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). Table 1 shows the distribution of awards by time since first consultant appointment. Table 2 shows the extent to which the percentages of consultants who are women or from ethnic minority groups have increased in recent years.

View this table: [in this window] [in a new window]   Table 1 Consultants by current award status (as at the end of 2002), by grouped year of first appointment as NHS consultant. Values are numbers (percentages)

 

View this table: [in this window] [in a new window]   Table 2 Consultants who are women or of non-white ethnicity, by grouped year of first NHS appointment. Values are numbers (percentages)

 

Variation in award rates by single factors
Awards were less likely to be held by women, by non-white consultants, and by doctors trained abroad (table 3). 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 ("adjusted odds" in table 3).

View this table: [in this window] [in a new window]   Table 3 All awards: univariate analysis of rates of award by sex, ethnicity, and place of training. Values are numbers (percentages) with awards in each group unless stated otherwise

 

The unadjusted odds for 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 (table 4) and smaller differences for the B award than seen in the historical record of table 3. The adjusted odds, taking account of time from appointment, further reduced the differences for recent B awards, although some significant differences remained.

View this table: [in this window] [in a new window]   Table 4 Awards given in 1998-2002: univariate analysis of rates of award by sex, ethnicity, and place of training. Values are numbers (percentages) with awards in each group unless stated otherwise

 

Multivariate adjustment of the historical database
After full multivariate adjustment, the number of significant differences reduced a little further (table 5, compared with table 3). Women remained less likely than men to receive any award, with an odds ratio of 0.69. The ratio for women for A and Aplus awards combined was 0.82, and that for the Aplus award was 1.37. These ratios did not differ significantly from 1. Non-white consultants who trained abroad were less likely to receive each level of 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.

View this table: [in this window] [in a new window]   Table 5 All awards by sex, ethnicity and place of training, specialty, type of hospital, location, and type of contract, with multifactorial adjustment

 

Multivariate adjustment: recent awards
Table 6 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. At the "entry" level of the B award, as noted above, representation of both white and non-white doctors who trained abroad was significantly low, with odds ratios of 0.70 and 0.68. In other words, the 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 0.86. 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]   Table 6 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.

We distinguished between doctors who trained in the United Kingdom and those who trained abroad. The second group will have come to the United Kingdom as mature doctors and will have had to adjust to a variety of social and professional challenges. These may have influenced their opportunities and ultimate achievement. However, the opportunities and achievements of home trained consultants from ethnic minorities should be similar to those of their home trained white colleagues. For consultants who qualified in the United Kingdom, those from ethnic minorities were under-represented in the past. For awards made in recent years, no significant differences exist between white and non-white doctors once allowance has been made for year of appointment. This indicates that the apparent shortfall in recent years in awards to British trained consultants from ethnic minorities 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 of our analysis, 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 at the level of entry to the system, the B awards, and lessens or disappears as consultants progress through to the higher levels. If it occurs, discrimination can be direct or indirect. Direct discrimination involves decision making that is explicitly intended to favour some groups above others. The Advisory Committee on Distinction Awards has put considerable effort into ensuring that this does not happen. Indirect discrimination involves decision making that, although not intended to favour particular groups, does so because judgments are made about characteristics or experiences that are more common, or easier to achieve, in some groups than in others. Indirect discrimination could occur when the culture or style of working in a profession makes achievement a harder task for some than for others. For example, if the assumption is that high achievers will work full time, or that they will work very long hours, those with heavy family responsibilities may be disadvantaged.

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

A higher percentage of consultants in some specialties than in others achieve awards. This raises the question of whether some specialties are inherently more demanding, and by implication more worthy of reward, than others or whether it may be inherently harder for doctors in some specialties to achieve distinction through particular activities, such as research, because of the nature or culture of their specialty. Some specialties are more oriented than others 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.

Over the years, adjustments have been made to the criteria by which candidates for distinction awards are assessed. Recently, the award system has undergone major reorganisation, with increasing emphasis on rewarding outstanding and sustained commitment to service delivery in the NHS.⁶ In anticipation of the new clinical excellence awards, the Advisory Committee on Distinction Awards has recently introduced new, explicit, nationally applicable criteria, new guidance and application procedures, and a new process of decision making. The aim of the committee, soon to become the Advisory Committee on Clinical Excellence Awards, in setting the scene for the new awards that begin in the 2004 round is to provide all consultants with equal access and equal opportunities in a fair and transparent system.

---

An appendix and two additional tables are on bmj.com

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: EV and NM suggested the study. MJG and TWL planned the study in consultation with EV and NM. MJG and TWL designed the analysis, and TWL analysed the data. TWL and MJG wrote the first draft of the paper, and all authors contributed to further drafts. TWL and MJG are the guarantors.

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)

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