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Government is urged to improve performance management of consultants

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4291 (Published 02 July 2013) Cite this as: BMJ 2013;347:f4291
  1. Caroline White, freelance journalist
  1. 1London, UK
  1. cwhite{at}bmj.com

The Department of Health must tighten its performance management of consultants if the NHS is to avoid another “Mid Staffs,” warns a report from the parliamentary Committee on Public Accounts.1

The report, which calls for tough targets to be set for senior doctors to boost their productivity, has been published ahead of new contract negotiations on terms and conditions for consultants,2 after recommendations made by the Review Body on Doctors and Dentists’ Remuneration (DDRB) last December.34

The government now wants to change consultants’ pay structure to reflect the DDRB’s suggestions to link pay progression more closely to performance, introduce a new grade of consultant, and reconfigure national and local clinical excellence awards.

The committee’s report concludes that the current consultant contract does not provide value for money. The committee also takes the health department to task for failing to meet its primary aim of improving the management of consultants when it introduced the new contract in 2003.

The NHS employs around 40 000 consultants, 4% of all health service staff. Consultant salaries cost the health service £5.6bn in 2011-12, equivalent to 13% of the total NHS pay bill.

The report acknowledges that the expected benefits of the contract have mostly been met, but only because the department set the bar too low and was not ambitious enough when it first set out the contract. It states, “The new contract was a missed opportunity to deliver a step-change in consultant performance and has provided poor value for money to the taxpayer.”

Despite the current contract increasing consultants’ pay by between 24% and 28%, senior doctors’ productivity has since fallen, the report points out. “In its business case supporting any future renegotiation of the contract, the Department of Health should set ambitious targets that deliver significant productivity growth,” it recommends.

However, the BMA has argued that the Committee on Public Accounts is using productivity statistics as a justification to attack consultants’ terms and conditions of consultants.

“These statistics take little account of the quality of patient care or of changing working patterns elsewhere in the hospital. They are simply a crude measure of the number of patient episodes involving a consultant,” said Paul Flynn, chairman of the BMA’s Central Consultants and Specialists Committee. “The perversity of using these statistics to measure the value of consultants is that we are judged to be less productive if we spend more time with our patients.”

The MPs’ report also suggests that the contract doesn’t allow for round the clock care for patients, which it says is forcing trusts to stump up £200 an hour for additional work in the evenings and weekends. Any new contract should be flexible enough to allow for seven day working and set a cap on overtime, it recommends.

However, many consultants already work 7 days a week, said Flynn. “We are available for our patients who need it at weekends and nights, but what the current contract has, is an element of elective work after 7 pm and at weekends. That’s an entirely different thing,” he said.

Performance management structures and incentives are poorly aligned to achieving the best possible care for patients, says the report, highlighting the “patchy” use and quality of annual appraisals, many of which fail to assess whether consultants have met the objectives set out in their job plans.

Pay progression is linked to years in service rather than performance, it adds, while clinical excellence awards are the “norm rather than the exception.” Trusts should link job plan goals and clinical outcomes with the appraisal process and pay progression, it recommends.

“Improved performance management is essential if we are to avoid incidents of poor performance, such as those witnessed at Mid Staffs. We consider the failure by the NHS to implement a proper culture of performance management as a crucial factor in the poor standard of care recently witnessed,” the report concludes.

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