Consultants’ contracts in the NHS
The SHA has given careful consideration to the position of consultants working in the NHS. Our concerns in this area cover the efficiency of the consultant’s contribution to the NHS, the effectiveness of outcomes and the accountability of consultants to the NHS and their patients.
It should go without saying that the vast majority of consultants work extremely hard for the National Health Service and work longer hours on average than they are required to do under their contract. They are professionally committed to effective patient care.
As the government is aware the key issue is the operation of the consultants’ contract, particularly of those consultants on part-time contracts. Unlike other professions, consultants are allowed to work for two different employers during the working week without there being a clear dividing line on when and where the different employment takes place. Whilst the BMA has asserted the right of doctors to work in the private sector, the SHA wish to secure the right to work within the NHS. We are concerned that many consultants’ job plans are not being properly monitored.
The Issues
The work of John Yates and others has exposed the unsatisfactory nature of the present position. It is well known that a small but significant proportion of consultants abuse their NHS contracts by the amount of private practice they undertake. This situation does not apply generally to all specialities in all parts of the country. The problem commonly occurs across the range of routine elective surgery where there are usually waiting list problems.
This is a waiting list issue. Where private practice is rife, e.g. in orthopaedics and general surgery in certain parts of the country, there is a strong association with long waiting times for NHS treatment. This does not apply to anything like the same extent in medical specialities, particularly in the less glamorous areas of geriatrics and psychiatry where recruitment is more difficult, and the private market is weaker.
The reality is that many Trust managers do not use job plans proactively and root out offenders. Complicity in the current situation is common practice and this contributes to the waiting list problem the NHS has to solve. The financial benefit to hospital Trusts of private practice taking place on site is a disincentive to effective management action – as are the concerns about taking on the profession.
Furthermore, as a result of the private workload of many consultants much of NHS treatment is carried out by junior doctors. Of course this is acceptable where supervisory arrangements are well organised. However, the NHS has a right and responsibility to ensure patients get full benefit from the long state funded education and training provided before consultant status is achieved. It should be a requirement that skills and experience so obtained are passed on to NHS junior medical staff.
There are gaps in the availability of information concerning consultant’s activities that should properly be in the public domain. This should encompass the detail of work performed in both the private sector and the NHS. The Inland Revenue should be required to analyse details of earnings of consultants who carry out private practice as well as work for the NHS and the information made available to ensure probity Private hospitals should be required to contribute to the national information database, covering hours of work and types of activity. The issue of clinical governance should not be ignored both in terms of the standards applied in both the NHS and private practice and in the overall time worked by consultants and its effect on health and safety of patients.
Towards a Resolution
At the heart of the issue is the consultants contract and the control of consultants workloads. The SHA proposes the following actions by government which would begin to tackle this so far intractable problem:
1. The Government should set up an inquiry to examine the available evidence. Although the work of consultants has been surveyed from time-to-time there needs to be a systematic examination of the situation, with its evidence and conclusions then available for public discussion. This should cover private practice as well as the NHS.
2. Government should require the NHS Executive to produce clear guidelines on consultants’ contractual obligations. We should move to a position where the whole time contract, with voluntary renunciation of private practice, is regarded as the norm.
3. The package of pay and conditions should be attractive enough to achieve this change. Access to the discretionary distinction awards system should be more readily available to full-time consultants. Panels considering awards should include academics who do not perform private practice for personal gain.
4. Maximum part-time consultants should not be allowed to work more than one planned session a week in the private sector. The EU maximum 48 hours working week needs to be enforced, with private work outside the NHS counted in the total. On safety grounds the ability to opt out of this limit should not be available.
5. As an issue of clinical governance records of the time spent at work, both in the NHS and in private practice, should be maintained and open to inspection at any time. Standards of work required in the NHS should likewise be required in private hospitals/clinics, reinforced by effective monitoring systems.
6. The DoH should define performance statistics that Trusts are required to produce on the workload of consultants, e.g. hours in theatre/clinic, ward rounds, number of operations per week actually performed, number of operations per week supervised. Full details of all treatments and outcomes should be recorded and maintained. In addition to providing management information this is a necessary formal monitoring of agreed employment contracts.
7. The DoH should carry out surveys by speciality to establish more precisely where the problems lie and how they might be tackled. Service indicators such as waiting times by speciality and private activity by speciality are needed to better understand and deal with resource/service issues.
8. Government should require the Inland Revenue to maintain records of earnings of consultants across the NHS and private sectors. A top limit on private practice earnings as a proportion of total earnings should be set. Arrangements should be put in place to ensure that senior NHS management can monitor and oversee the situation.
By taking this approach the SHA is seeking to ensure a more comprehensive and equitable delivery of service within the NHS in a more efficient and effective manner