Consultant performance under scrutiny

In October 2003, the Department of Health introduced a new consultant contract, with the objective of improving the management of NHS consultants. By 2012, an estimated 97% of consultants were on the new contract, which significantly increased consultant’s pay – with the bottom of the consultant pay band increasing by 24% and the top by 28%. However, a recent report by the Public Accounts Committee has described the new contract as ‘a missed opportunity to deliver a step-change in consultant performance’ and concluded that it had provided ‘poor value for money’ to the taxpayer.

Productivity: in decline?

The report claims that consultant productivity has continued to decline, while the contract does not facilitate around-the-clock care for patients. The committee pointed out that the contract allows consultants to refuse to work during evenings and weekends, which has ‘contributed to hospital Trusts paying consultants up to £200 per hour for additional work’. In her accompanying statement, the Rt Hon Margaret Hodge MP, chair of the Committee of Public Accounts, highlighted concerns that the use and quality of annual appraisals in Trusts continued to be ‘patchy’, pointing out that 17% of consultants had not received an appraisal in the last year, while nearly half of Trusts failed to assess whether consultants had met the objectives listed in their job plans. “Pay progression for consultants is linked to years in the job rather than how well they are performing,” she commented, adding that Clinical Excellence Awards, which are aimed at rewarding consultants whose performance is exceptional, are held by 60% of consultants. These awards, costing £500 m per year, have become ‘the norm rather than the exception’, in the view of the committee. “This nonsense highlights how badly consultants’ performance is being managed,” Margaret Hodge commented. “A proper culture of performance management for consultants and other NHS staff must be implemented if we are to avoid incidents of poor performance. “Despite the increased pay, there is still a shortage of consultants in some parts of the country, in hospitals in deprived areas and in speciaities such as geriatric medicine. This makes some Trusts reliant on locum consultants, who provide less continuity of care for patients, as well as being more expensive for the NHS. The Department must consider measures to attract consultants to such areas and specialties without financially disadvantaging the organisations concerned.” Responding the Public Accounts Committee report on the management of hospital consultants, Dr Paul Flynn, chairman of the BMA Consultants Committee, said: “The Public Accounts Committee report tries to use productivity statistics as a justification to attack the terms and conditions of hard working doctors. But, 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. “The Public Accounts Committee itself admits that the information on which it is basing its findings is inadequate. 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 BMA is currently in exploratory talks with NHS employers about many of the issues discussed in the report. The barbed rhetoric from the Public Accounts Committee describing the system for awarding excellence as ‘nonsense’ is particularly unhelpful at a time when we are trying to come up with some broad principles for potential negotiations. Doctors are crucial to innovation in the NHS, and their work not only improves quality, but also frequently saves taxpayers’ money.” The Royal College of Surgeons added: “Far from refusing to work at the weekend; the majority of surgeons already do so. A seven-day service which is led by consultants is vital for patients. However, it is not just about consultants working weekends. It is also about making sure there is seven-day access to the right facilities in hospital and support available in the community for the next steps in the patient’s treatment. It is vital that we focus on the productivity of the whole hospital, and not just consultants, if we are going to deliver a high-quality sevenday service for patients regardless of when they are admitted.”