Shurely shome mishtake?

EDITOR—I think that there must be a mistake and I have downloaded the wrong contract from the BMA's website.1 The one I downloaded offers a 4% pay rise in return for a 16% increase in my clinical workload. Further pay rises are at the whim of my managers, to be paid five years in arrears provided that I meet conditions over which I have no control or work unpaid overtime.

The contract I downloaded is a licence to enable my managers to order me in for routine surgery and clinics on weekday evenings, Saturdays, and Sundays, for no extra pay, while paying me £1 an hour to be on- call at other times. Could someone please send me the other contract that Peter Hawker and the BMA are hailing as a resounding victory for my colleagues and me2 while I vote no to what is clearly a different contract.

So called victory in private practice obscures real contractual problems

EDITOR—Reports on the proposed consultant contract have focused too heavily on the concessions obtained over private practice and the headline figure of a 20% pay rise.1 The pitfalls of the contract far outweigh this victory.

Firstly, few doctors will immediately, or in the near future, get a 20% rise in pay. Essentially we are being promised a 20% rise staged over 20 years, or 1% a year. For many this rise will be offset in part by loss of domiciliary fees, category 2 work, and the loss of intensity payments. My own pay rise will be 2-3%—hardly a princely sum given I work full time for the NHS.

Secondly, the new contract seeks to make evening working up to 10 pm and weekend morning work an acceptable part of the working week, remunerable at standard rate. I find this appalling. Junior doctors have spent years fighting to be remunerated at above the standard rate for working unsociable hours. Should it be any different for consultants? And if the aim is to keep people in hospital medicine why pursue such family unfriendly initiatives?

Thirdly, too much control is being handed to managers—both in terms of when work is done and when salary increments are paid. The new salary introduces two forms of performance related pay: the revamped merit award scheme and the basic pay spine. Didn't the BMA fight a long campaign against performance related pay a few years ago? What happened?

The contract does not fulfil any of its core objectives. I now feel undervalued by my employer and my trade union. I want to retire even earlier. I think a no vote can be taken as read.

Private practice is unlikely to be main cause of long waiting lists

EDITOR—The new consultant contract introduces job plans for hospital consultants1 Full time consultants are to have a working week made up of 10 “programmed activities” of “typically four hours each,” seven of which will be “devoted to direct clinical care.” The contract also states that “NHS consultants' commitment to the NHS must take priority over any work undertaken for other organisations.” The clear implication is that consultants, because of their perceived focus on earning private income, are at least one of the causes of inefficiency and long waiting times, particularly for elective surgery.

In November and December 1997 we carried out a prospective audit of all elective general, vascular, urological and breast procedures in patients scheduled for preoperative assessment or admission to Southampton University hospitals to establish the proportion of operations cancelled and for what reasons. There were no red alerts during this time.

Of the 851 patients identified, 847 (99.5%) had data available. Of these, 106 (12.5%) received urgent planned admissions, the remainder being asked to attend a preoperative assessment clinic. Of these, 61 (8.2%) did not attend. Of those who did attend, 30 (4%) had their procedures postponed or abandoned, 22 because of medical problems and eight because of social problems or patient preference.

Altogether, 756 patients were scheduled for admission, including those receiving urgent planned admission. Of these, 123 (16.3%) had their operations cancelled before admission, and three failed to attend hospital on the due date. Eighty five operations were cancelled because of lack of a bed, nine because of lack of theatre time, and six for medical reasons; 13 admissions were cancelled by patients, and in only 10 was the reason for cancellation not recorded. Of the 630 patients admitted, a further nine had their operation cancelled, five for medical reasons, three because of lack of theatre time, and one because the patient refused to give consent. No cases on which data were available were cancelled because of the lack of availability of a surgeon to conduct the operation.

Although this study was carried out in 1997, there has been no material change in the service provision in most NHS hospitals since. Anecdotally, Southampton University Hospitals NHS Trust is typical of most large teaching hospitals. Lack of beds and theatre time constitute by far the largest reasons for cancellation of planned surgical admission. Increasing the available time of surgeons will accomplish little without a corresponding increase in the number of available bed days and theatre hours. The NHS infrastructure needs urgent attention, not consultant contracts. Whatever the attitude to the desirability of private practice, such practice is unlikely to be a significant cause of long waiting lists in the NHS.

Weak negotiators strike again

EDITOR—I left the NHS two years ago when the morale of consultants was, I thought, at an all time low. We had been rendered essentially powerless by hospital managers, were paid a low salary for our expertise and clinical commitment, and were the victims of continual government spin depicting us as lazy, uncaring, unsafe Bentley-driving moneygrabbers with huge private practices. I was particularly frustrated that our representatives, the BMA, repeatedly failed to assert our real position and always seemed to climb down when challenged by negative spin. I can see now that nothing has changed.1

This new contract is an appalling deal, and I am astounded that the BMA negotiators consider it a victory. If you offered the equivalent deal to any other professionals, such as barristers or dentists, they would laugh at you. Hospital porters would not accept the extension of the normal working day as proposed in the contract. Some consultants in the middle bracket will actually take a pay cut. The only significant pay rise is the £10 000 for newly appointed consultants, who, in reality, will no longer be able to do any significant private practice as the extra eight hours' commitment to the NHS will prevent it. The £10 000, in fact, is not a pay rise because any consultant doing eight hours a week in the private sector would make far more than £10 000 a year.

The BMA negotiators think that the government has climbed down on the seven year rule for newly appointed consultants when, in reality, consultants' private practice has been restricted for life. Any consultant wishing to pursue private practice will have less time to do so under the new contract. He or she will almost certainly not get the £5000 pay rise every five years that is given at the discretion of hospital managers (who now, more than ever, are the powerbrokers).

In the Republic of Ireland, consultants are represented by a very strong organisation fronted by people who are not medically qualified. They are hard negotiators who are not dependent on merit awards or potential inclusion in the Queen's honours list. Thus they act excusively on behalf of consultants.

If consultants accept this deal, it is only a matter of time before they will be clocking in and out with the cleaning and catering staff. The new contract is an insult to highly skilled dedicated professionals who have made significant personal sacrifices to be where they are today.

New contract means cut in pay for part time consultants

EDITOR—I have been a consultant for 14 years. I work part time, seven sessions, and participate in a 1 in 4 on-call rota. If I transfer to the proposed new contract I will take an immediate cut in pay of £1000. I will not regain my current salary level until 2006, and it will be 2008 before I recoup my lost earnings. My so called pay rise will begin in 2008-9, an average of 2% per year over the following five years (subject to managerial approval and assuming that there are sufficient funds to afford it. This is the reality of the proposed new contract for me. It seems a long way from the headlines of 22 June.1

My vote will be a clear no to the negotiating team's proposals. The proposed move to a 40 hour week significantly disadvantages all consultants who work on a less than full time basis. It would seem the negotiating team either forgot we exist or believe we are a low priority group compared with others.

I recommend all consultants who work part time, particularly those who have been in post around four or five years, or more, get out their calculators. You may well find that your negotiators have negotiated a pay cut for you.

The negotiating committee should come up with a new agreement

EDITOR—The framework agreement has removed our ability to work in a professional manner and organise activity for the benefit of our patients.1 The idea of the rigid session during which attendance in the hospital is mandatory means that no activity will be started in future if it might over-run the end of a session. In addition, there will be no stimulus to be efficient and get more done as an early end to the session is now not rewarded. Although this flexibilty is abused by a small minority of doctors, the vast majority use it to organise work as efficiently as possible.

Am I to be paid for my meal breaks? If not, I will have to take them as a matter of right as I would be a complete fool if I worked over a lunchtime without being paid. The new contract rewards the clock watcher and treats the doctor who stays until the job is done as an idiot. The only staff left on a professional contract will be managers, and I am afraid I simply do not trust statements such as “we would never interpret the contract in that way.” If it is written down, it can be enforced.

I do not understand why, as a consultant of some 14 years, it will take me 23 years from appointment to reach the salary maximum, whereas a newly appointed consultant would take 19. I wrote to Douglas Bilton, acting secretary of the Central Consultants and Specialists Committee on this matter and was told that this was the best that could be done to bring the deal in under the financial limits imposed. I have no problem with new consultants being awarded a decent salary, but I object strongly to my colleagues and me being discriminated against. We are the group who did a large number of appalling rotas and did not get the salary or time off given to current trainees. Why should we be penalised again? If the contract needs to be phased in, then an equitable scheme for all should be sought.

Although the idea of payment for emergency work and so on out of hours is laudable, sessions to cover onerous on-call commitments have always been negotiable locally. All that has happened so far is that this principle is to be formalised nationally, but with the loss of recognition of the nature of unsocial hours.

We can do much better, and for the good of the service we certainly ought to. The negotiating committee should take this framework back.

Summary of responses

EDITOR—By 3 July 22 respondents had sent us 23 responses to the two news items on the consultants' new contract. 1 2 Sixteen respondents were scattered throughout England, from Truro to Newcastle; three wrote from Scotland, and one each from Belfast, Dublin, and Jersey. Four were consultants in various subspecialties of anaesthesia or psychiatry, two were consultant physicians, and two were consultants in accident and emergency medicine. The 10 other respondents were from a wide range of disciplines, including academia, radiology, endocrinology, and clinical neurophysiology.

Condemnation of the contract was unanimous.

Graeme Weiner, a consultant otolaryngologist in Exeter, rushed to read the latest on the contract in the BMJ of 22 June but was incredulous to find there was none. He suggests the journal commission an article “by a couple of employment law specialists (and perhaps a human rights lawyer) so that we may see how truly awful the proposed framework is.”

Others criticised the use of spin in reporting the new contract. Lesley Wilson, consultant old age psychiatrist from Jersey, said that the BMJ's headline was unfortunate and “will tend to support the widely held view that all that consultants are interested in is keeping their private work.

“Perhaps a better one (though not quite as catchy) would have been: ‘BMA submits to government demand that its members work evenings and weekends for standard rate of pay.’”

Indeed, has the BMA, and by extension the BMJ, “fallen victim to the government's spin as much as the rest of the media?” asks consultant physician Guy Clifford from Kettering. Both the extension of normal working hours and the effective introduction of performance related pay “are headline news as far as the 26 000 consultants in the UK are concerned, but in your most recent article regarding the new contract, no mention was made of this. Can there be any excuse for such biased and poor reporting of the facts to your own members?”

John Carter, consultant anaesthetist in Chelmsford, agrees that the main problem “is the spin being put on this draft, not by the government (I can live with that), but by my trade union. I do not want the BMA to ‘sell’ this draft to me. I want the negotiators to go back to the table and get more. The trainees did it. We should too.” Change the negotiating team if necessary, he says.

A lack of accountability and clarity also militates against acceptance of the new contract.

Negotiations started off well, points out John Morgan, senior lecturer in psychiatry at St George's Hospital Medical School: “As a public relations exercise, the BMA invited consultants to pose questions concerning the new contract with the welcoming words ‘We will attempt to answer all emails individually.’” But when he did so he found that the BMA was “unable to enter into detailed correspondence on an individual basis.”

“After such a protracted period of negotiation, the BMA should have placed itself in a position whereby it could answer queries with speed and accuracy. In failing this, fear of the unknown will surely cause us all to vote no.”

James Anderson, consultant radiologist in Darlington, would be grateful for further information on what exactly the proposed contract offers in terms of pensions “as this subject seems to be couched in rather vague language” along with the “many clauses preceded by should, usually, and is expected” scattered throughout it.

Finally, consultant anaesthetist Michael Jordan from Ashford, exhorts his fellow consultants to look closely at the hard copy of the framework posted to them in the last week of June: “The cover depicts two prisms bending light in ways that defy the laws of optics. There's a metaphor there somewhere.…”