Education And Debate

Options for change in the NHS consultant contract

BMJ 1994; 309 doi: (Published 20 August 1994) Cite this as: BMJ 1994;309:528
  1. R W Clarke,
  2. C Gray
  1. Centre for Health Service Management, University of Nottingham, Nottingham Harrogate General Hospital, Harrogate HG2 7ND
  1. Correspondence to: Dr Gray.
  • Accepted 28 July 1994

The lead negotiators for the management and consultant sides in an NHS trust in northern England responded to debate in their trust about consultant contracts by offering to research the attitudes of their peers towards a variety of contract options. The options tested included the current contract; models already examined in the trust and elsewhere, such as time sensitive and mild performance related contracts; and some more radical and speculative possibilities, including consultants franchising their services to the trust. Beyond the predictable conclusion that consultants would prefer no change while managers desired it, a time sensitive contract emerged as having potential for successful negotiation. On the other hand, neither consultants nor managers favoured a strict performance related contract or a fee for service contract. There was a strong similarity of opinion between the two groups on the relative salary values of the options, though the consultants consistently priced these higher than the managers.

Since 1948 change to the contractual relationship between consultants and their NHS employers has been slow, gradual, and carefully negotiated nationally. The relative autonomy of NHS trusts raises the real possibility of locally determined change to the established order. Typically trusts wish to forge closer links between consultant activity and business practice. The Review Body on Doctors' and Dentists' Remuneration substantially accepted government proposals to introduce local performance related pay for consultants.1 Few trusts have so far introduced a new contractual package for their consultants, though new terms and conditions have been introduced for some new appointees.

Published reports on the link between motivation and reward of employees are unhelpful in that the benefits are unproved 2,3; while health economists recommend new reward systems based on methods of assessing doctors' work,4 others have expressed doubts about the applicability and benefits of such …

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