Renegotiating the consultant contractBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5319 (Published 05 September 2013) Cite this as: BMJ 2013;347:f5319
The government wants to renegotiate the consultant contract, and “heads of terms” for talks on the issue have now been agreed with the BMA. Helen Jaques looks at what’s on the table should a new consultant contract be negotiated
The contract governing pay and conditions for NHS medical and dental consultants has come in for considerable criticism since it was negotiated in 2003 (box), and the government has now said it wants to renegotiate the contract.
NHS Employers, which is acting on behalf of the government, and the BMA have agreed the scope of what they might bargain over should both sides decide to go ahead with negotiations.1 Pay progression, clinical excellence awards, and seven day services are all under consideration in the non-binding “heads of terms” agreed by the two organisations.
Why a new contract?
In 2003, the government and the BMA agreed a single contract that encompassed all medical and dental consultants in the United Kingdom. The goals of this contract included getting a better handle on how consultants spent their time and making sure they prioritised NHS work over private work. However, that contract has come under considerable criticism since its introduction, largely for failing to secure value for money from NHS consultants. Last year, the report on clinical excellence awards from the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) said that consultant pay mechanisms and incentives reward length of service more than performance.2 The body suggested that pay and incentives for consultants should be more closely linked to appraisal and performance.34
Earlier this year, a review by the National Audit Office concluded that, although the 2003 consultant contract had met many of its aims, it had considerably increased the cost of employing consultants.5 Between 2002-03 and 2003-04, total earnings per full time consultant increased by 12% in real terms, it reported, with an increase of 24% at the bottom of the pay scale and 28% at the top. It added that NHS trusts were paying over the odds to get consultants to do additional work outside their job plans, and consultant productivity was continuing to decline, albeit at a slower rate than before the contract was introduced.
MPs on the Commons Public Accounts Committee went further and said that the 2003 contract provided “dreadful” return on public money.6 The committee’s subsequent report called on the government to make sure that consultant pay and incentives were much more closely linked with performance.78
At present, consultants move up through the first five points of the eight point pay scale annually during their first few years in the job. They then progress through points six to eight with each subsequent five years of service. In 2012, the DDRB proposed limiting “satisfactory” consultants to the first five points of the pay scale (up to £83 829) and introducing a high paying “principal consultant” grade for the top 10% of consultants.3
The heads of terms agreed by the BMA and NHS Employers doesn’t explicitly mention the possibility of the consultant pay structure being reformed like this, and neither organisation seems especially keen on the idea of a principal consultant role.
Bill McMillan, head of medical pay and workforce at NHS Employers, says employers generally believe that the consultant job might need some stratification to allow new consultants to have more support when they come out of training.
However, the BMA is concerned that any layering of the grade will simply introduce a subconsultant grade through the back door. “We believe that a principal consultant grade is a misnomer,” says Tom Kane, deputy chair of the BMA’s consultants committee. “What they’re actually saying is that there will only be 10% of people called consultants and everyone else will be called a subconsultant.”
The document does agree to look at how to link pay progression with consultants’ contribution to the NHS, rather than their length of service, as well as to thrash out fair and objective job based criteria to judge the thresholds for pay progression.
McMillan says employers are keen for pay to be linked more closely to organisational objectives and performance at a local level. However, Kane argues that linking pay with managerial targets, rather than personal appraisal goals, risks creating a bonus culture similar to that in banks, where the focus is on how much money the organisation makes rather than on the quality of the service.
The heads of terms talks about making the consultant contract “affordable for employers.” Importantly, it states that the negotiations are not intended to reduce consolidated pay—that is, basic pay; clinical excellence awards, discretionary points, or distinction awards; and London weighting—for any individual doctor currently on the 2003 contract.
Clinical excellence awards
The DDRB recognises the importance of clinical excellence awards and the other UK incentive schemes in recruitment and retention of NHS consultants. However, as with other elements of consultants’ remuneration, it has concerns that the awards are treated “as an extension to the basic pay scale” and reward length of service, rather than contribution to the NHS.
The solution the DDRB has put forward is to limit the funding available for these awards and to cap the proportion of consultants who could receive an award, to 10% of doctors for national awards and 25% for local awards.
The heads of terms doesn’t explicitly put forward these proposals. Instead, it looks at whether national and local awards schemes should be managed together or separately. One proposal is that local clinical excellence awards should be incorporated into the consultant contract. At the moment, local and national awards are administered independently by the Advisory Committee on Clinical Excellence Awards.
Kane says that putting local awards in the contract would ensure that the appropriate number and sum of awards are given each year without fail. He points to the reduction in employers’ allowance of local awards from 0.35 per consultant to 0.2 per consultant in 2011 as an example of something that wouldn’t be possible if the local scheme was in the contract rather than a stand alone system.
“What we have at the moment is that there is a contractual mechanism for the existence of a reward system but there is no contractual right for the local CEAs [Clinical Excellence Awards] system to progress each year,” he says. “[Putting local awards in the contract] will safeguard them and make sure that the whim of a secretary of state can’t remove them.”
Another issue on the table is whether local awards should continue with the system of self nomination or whether automatic consideration should be introduced. The BMA and NHS Employers have also agreed to discuss whether awards will be time limited to encourage “sustained excellence at all stages of a consultant’s career.”
At present, consultants have the right to refuse non-emergency work after 7 pm and before 7 am on weekdays, and at weekends. Those who do work during this “premium time” receive a higher rate of pay. The fact that consultants have an “absolute right” to refuse non-emergency work in premium time creates problems for employers, says McMillan. “If you want to extend clinics to 8 or 9 in the evening, then you’re paying premium rate. It’s a disincentive to do it when funds are tight,” he says. “We end up not planning services around patients’ needs but more with the needs of the doctors in mind.”
The out of hours and premium time arrangements, as well as the handling of scheduled and unscheduled care more generally, will be key in any discussions about using the consultant contract to facilitate seven day services. The heads of terms also state that negotiators will consider the possibility of facilitating seven day working within current contractual provisions.
The DDRB report did not tackle consultants’ working patterns. However, in its response to the report, the government expressed an explicit desire to push towards seven day working in the NHS.9
The BMA supports the concept of seven day working in urgent and unscheduled care, but it isn’t keen on elective and non-emergency care being provided in the evenings and at weekends. Kane says that consultants who work out of hours shifts can’t provide good care unless all the relevant support staff, such as radiographers and porters, are working the same hours too.
“If you start looking at how elective care is provided, there’s a raft of people you need to have there [as well as the consultant],” he says. “If the NHS is being asked to reduce its costs, how it can then expand the service it provides?”
The heads of terms does mention that any work done by consultants in premium time should be sufficiently supported by other services in the hospital. That would in theory end the situation where doctors are hampered by not being able to get hold of scans or laboratory results out of hours.
Importantly, the document includes a commitment to making sure any changes to the consultant contract do not hamper consultants’ health and their work-life balance. Any contractual changes will include safeguards on the proportion of the job plan that can be delivered in premium time and on the frequency and minimum rest between duties for different periods of premium time.
The heads of terms is fairly clear that any changes will maintain a national contract, but “national” encompasses consultants only in England and Northern Ireland. The BMA’s consultants committees in Scotland and Wales have decided not to take part in the contract talks with NHS Employers. Consultants in Scotland and Wales are already on different contracts, and the consultants committees in these two regions are not convinced that negotiations on a UK-wide contract are in the best interests of doctors in their respective devolved nations.
Neither the BMA nor NHS Employers has yet formally agreed to enter negotiations on the consultant contract. The BMA needs a mandate from its members first, which it will seek at a meeting on 18 September, and NHS Employers needs a mandate from the English and Northern Irish departments of health. For any changes that are agreed, the BMA would need to put the proposals to a ballot. The best case scenario is that any contract changes will be agreed by Easter next year, although both sides agree that this is an optimistic goal.
A seemingly innocuous addition to the heads of terms is whether the negotiations will lead to a new contract or amendment of the current 2003 contract. If a new contract was introduced, it would apply only to the consultants who agreed to sign it and likely new starters. However, amendment of the existing contract would mean that all consultants on the 2003 version would be subject to the changes.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.