Consultants’ contracts: could do betterBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3701 (Published 12 June 2013) Cite this as: BMJ 2013;346:f3701
All rapid responses
I always welcome some feedback on local issues positive or negative and in general Dr Bamber makes many points which actually support my original points that the criticisms of the consultant contract are often erroneous.
However, I think it is important to stress two factual points. The (rather failed) trial of dedicated real-time email did definitely have costs associated with it: although the tariff was a whole £ 23.00 per contact: less than an outpatient consult but more expensive than just ringing switchboard. The system was much more successful when trialled in other geographical areas, suggesting that there was not a major software problem.
Also, our Trust does prefer to use and effectively uses email for clinical letters, I believe where the recipients have a confirmed secure system.
Competing interests: No competing interests
I was disappointed to read Spence's column ' Consultants contracts: could do better'
It is unclear how thoroughly Spence has researched and validated the generalised assertions made.
All Consultant SPA time in my own Trust has to be justified. Specific targets are given for governance activities such as CME, audit, appraisal. We have strict criteria for educational supervision of trainees,which is itself audited by the Deanery and the GMC.
With regard to the accessibility of consultants, in practice, the families of some of my patients tell me that it is easier to access myself, a tertiary specialist, for advice than their child's own GP. The availability of my consultant colleagues out of hours is considerably higher than the family GP given that an increasingly junior workforce requires more support and supervision than previously.
I have been a consultant for 6 years, having trained in my speciality for 12 years, after spending 3 years on a GP VTS. My pay is considerably less than some of my equivalent GP colleagues, or even some Gp’s who have been in substantive posts for less long.
Previous BMJ articles have alluded to the fact that up to 30% of GPs applying for CCG positions have been said to have vested financial interests. Perhaps this might be something that could be explored by Spence in future columns to add balance.
I hope that the BMJ readership can look forward to a more balanced and evidence based perspective in the future although I will no longer be reading Spence's columns
Competing interests: Full time NHS consultant, no private practice or CEAs
Des, come and spend a day with us Emergency Physicians and then write your article again.
The suggestion that SPA time for consultants should be removed is madness and shows a fundamental absence of understanding about what we do day to day.
Clinical shifts in the Emergency Department are all hands to the pump (you might have seen it on the national news) and SPA allocation for us is precious time.
With no SPA time, you can say "goodbye" to consultant leadership on teaching for juniors, service improvement for patients, improvement in departmental clinical standards, M&M and associated clinical governance, trainees getting exam support, educational appraisal, the list goes on.
My SPA time allows me to do what I thought consultants were meant to do: make things better.
Competing interests: I am on an NHS Consultant contract
But I still would like to disagree with this article.
I will try to do this without talking too much about the GP contract – as I am sure some my colleagues will do this - (as they might rightly argue that all the quoted “unjustifiable” terms in the consultant contract 2003 are either excluded and therefore paid generously as extra activities for GPs or not done at all by them – i.e. Education or out of hours cover – or that the time requirements for supporting professional activity has gone up considerably with appraisal/revalidation which was whilst “on the horizon” in 2003 not at all built into the contract and therefore at the moment is mainly run at goodwill at significant extra time)
I will also not argue the increased number of consultants although I wonder where they might all be - working in an organisation where new recruitment remains difficult to impossible in most specialties and several posts are unfilled or covered by long term locums which obviously does not help with productivity and effectiveness – although I wonder if all those terms were so generous why we struggle to recruit
I will try to argue for unity in the medical profession – I am not irritated, defensive or angry – if at all I am a bit frustrated by what I perceive is a fight for the biggest bone in the heap – I have seen this in other countries and am wary and afraid of the results. If doctors start this process, politicians and “opinionists” will pick up the baton – who will suffer most is not the doctors (they might lose out a bit, too – all of them) but the patients- i.e. those who have to protect most
• It will dis-empower the BMA as new trade unions that will cater to specialty and sub-specialty needs will be chosen by colleagues to get “the biggest bone”. This will doubtlessly be exploited by politicians according to the old adage “divide et impera” (has started already please see today’s NHS Managers blog News and Comment from Roy Lilley “Something to resign from!”- www.nhsManagers.net)
• Doctors that “can do” will leave the country where working conditions and/or financial incentives are better
• Other doctors will disengage and work “to the contract”, something which I believe neither large numbers of consultants nor GPs do at present, most of them do significantly more
• It will lead to reduction in teaching and training as doctors and organisations will opt out and hence further reduce doctors “on the floor” in the future, especially in smaller hospitals
This in summary will prevent and counteract the development of all the services I agree with Des Spence our patients need – 24/7 access, acceptable waiting times and good communication between secondary and primary care. It will also lead to further foreign recruitment drives, the “outsourcing” of medical work to non-medical practitioners due to staffing issues which will as a result create a shortage in AHP and nursing personnel as well as potential quality issues, and “perpetuate” the current problem
So whilst both contracts probably will need reviewing (which any contract will ever so often), I think Dr Spence’s reasons are the wrong ones. I do not think that that increased out of hours cover and essentially more work for most of the Consultants and GP s can come for “free”. I acknowledge that more money will unlikely come into the system but there are a lot of other options like flexible working hours or sessions, annualized or lifetime contracts, reduction in un-necessary administrative work towards clinical time (duplicate documentation, clunky it systems, regularly changing national IT trials and long surveys spring to mind) – this is why doctors need to be unified and strong to re-negotiate the best deal for us and our patients
Competing interests: I am employed on the NHS Consultant contract
I have a similiar line of thinking to yours in most things concerning the NHS. But I have to disagree this time, on one thing. Taking away SPAs and converting them to DCCs is a knee jerk reaction. What we do need is an external peer review of each and every consultant's job contract, their working pattern, and CPD. Essentially, an enhanced appraisal + job plan review, but by an outsider (within the NHS). We could start with CDs doing these for consultants from other trusts, or publishing yearly summary of their reviews. Things need to be in the open, if you got nothing to hide, there is no need to worry.
Competing interests: One SPA
I reply to Dr Beales' comment about the local online trial of GPs accessing a consultant. The system was extremely clunky; it broke down; it wasted time (GP time certainly, and probably consultant time too); it cost the GPs nothing to use.
It was trumped hands-down by the traditional method. The simplicity, convenience and immediacy of telephoning the hospital switchboard and asking to speak to Dr X or Dr Y could not be bettered.
I have never had any difficulty whatsoever in talking to a consultant at Dr Beales' hospital within a minute or two, via bleep, consultant mobile or secretary. New and trendy is not necessarily better. QED.
A more pertinent question is why the same hospital, a flagship PFI University Hospital, fails to allow its staff to send Outpatient letters to GPs via secure email, or via secure intranet such as its own lab uses. Its Communication Department has stated that email is not secure (and that fax is!) and prefers to use its own insecure email domain rather than nhs.net.
Furthermore it is surprising that letters do not arrive quicker since consultant numbers have increased.
Over the last decade the Trust management has paid lip service to our written requests to communicate better and faster, and to follow GMC guidelines on communication. The PCT failed to enforce the contractual agreement of communication standards. Pitiful.
Competing interests: GP practising locally to Dr I Beales
I am using this portal not to knock our colleagues as those I speak to seem to be having a bad enough time without GP criticism.
However, Des Spence's articles used to be more focused on non-evidenced medicine.
Recently while doing postnatal maternal checks (? value of this) I noted that a baby was one of the epidemic we have in this area for having a tongue tie operation. On the day of the snip there were 10 other babies awaiting the proceedure. This is in a local small DGH where we have now a few enthusiasts for this as an aid to breast feeding and prevention of speech defects. Hard to find evidence for it, and until 3 years or so ago it was a once in a blue moon procedure. PCT, sorry CCG, seems to be happy paying as not on the LPP (low priority procedure) list. Am I out of date? Des, please help.
Competing interests: No competing interests
I usually enjoy (and agree with) Spence's deliberately provactive digs about much we take for granted for in current day medicine, but this time, I do feel he has gone too far. I know I should rise above it and not take the bait, but actually I feel offended. Spence falls into the trap of regurgitating the old lines that consultants are away playing golf or doing private work when they should be doing NHS work and that the "new"contract has not fixed this. Anyone vaguely connected to consultant workload ~ 2003, when the "new" contract came in, could easily have verifined that nearly everyone was working well over their contractual 37.5 hours (in my case nearly 20 over). The revised contract recognised workload, but it was foolish in the extreme to believe it would increase actually increase productivity, when any honest appraisal would have shown that salary costs would go up but overall work would stay about the same. In many cases, such as mine, the employing Trust could not afford to actually pay for the work already being done, so the agreed and paid contract turned out to be less than already being done on the old contract.
As for inability to contact consultants: I know that Spence lives in an isolated area but in this digital age, I find it impossible to see how contact can be that difficult? I cannot imagine many hospitals do not list consultants' email and phone contacts on the web, plus all these are always on relevent correspondance. A good PA, knows where & how to find thier consultant should a GP ring up, and are their any consultants that don't have mobile phones? Perhaps Spence can't get hold of any consultants because they are all busy doing something and can't take a call right then?
Recently our Trust ran a highly publicised pilot of providing real-time 2-way conversation between consultants and GPs, during the working day and evening. Booking a conversation was via a simple online system: the pilot failed due to complete lack of interest from primary care. Or was that because this had a tarriff cost associated and was not free?
Competing interests: Consultant Physician on "new" contract. No private practice or golf.
Spence's comments are about three years too late. I review job descriptions before offering College approval. In the last three years, only a small minority of hospitals have offered more than two sessions for supporting professional activity. These are usually places which struggle to recruit Consultants. A number of places have offered 1.5 SPAs, though they have usually increased this allocation when they have failed to recruit.
Competing interests: Consultant on new contract with 2SPAs.
Many important points in there. I don't want to indulge in Consultant bashing, but it seems, at times that some of us have forgotten the reason that we are in the position we are in. To care for patients.
It can be incredibly difficult to speak to consultants about clinical matters, swathed as some of them are in ephemeral layers of part trained juniors. Sometimes it is hard just to identify who is responsible for care at a consultant level. Yes I agree it is very difficult for patients to get through to us and this too is a problem, although it never seems to be much of a problem for the private patients. I would agree that weekend cover is at times atrocious and would add in that the lack of continuity of day time cover is worryingly gap ridden.
The consultant contract needs re-organisation so we can have consultant delivered care across the gamut of specialities, with trainees aiding the services not maintaining them.
Yes it will mean major changes and some colleagues with exuberantly feathered beds may have to be there doing the work as opposed to gallivanting up and down the country in planes, trains and automobiles filled with the great, good and just, well, work shy.
The inequality between consultants in terms of SPAs is another example of those who have gone before us looking after themselves, patting themselves collectively on the back and saying that the rest of us have to earn their benefits. These are the same people bear in mind, who benefited from minimally controlled trainee hours and low expectation of consultant presence. The playing field is not only uneven but tilted head down towards those who have suckled for so long on the teat of distinction awards and CEAs that they have come to believe that they really are worth it. A putsch of the 'l'oreal consultants' is well overdue.
As to the management's role in these issues, given that many of the same consultants are involved in management and significantly teat dependent, they need to be seen to be tough on the new consultants to continue to receive their preferential treatment. They are so entwined with management that serious surgery would be required to separate the two.
So yes, let's reorganise, let's tackle these issues and get into the nitty gritty of consultant contracts. Perhaps we can rescue some of the pride that we once had in the job that we do for our communities and countries.
Competing interests: No competing interests