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The Secretary of State for Health ignores the wishes of Consultants

Mr Milburn took a vote on the new consultant contract. A majority of consultants and an even larger number of senior registrars voted against it, across the country.

How does he respond to this democratic action?

He brings in devisive actions to get the contract terms in by hook or by crook. This is acting in bad faith, abusing the position of power of the NHS as monopoly employer.

First, the Consultants in Scotland voted for the contract, so push it onto them.

Then tell Consultants in England they can have the contract if they want,

........but if not........ all the crap of performance related pay and jumping to target of the week will come in if consultants want "incentives" to improve their performance!

This to a group of people who worked 50 plus hours for the NHS.

Performance related pay is not a good long term motivator of people, this is well established. Consultants are not used car salemen but professionals hopefully not prepared to dance to management imperatives for a pittance.

......Oh and if you want your incentives you will have to sign up to a new code of conduct for private practice.

I suppose the next thing will be a Prescott manoevre...make a law forcing us to accept the new terms. Milburn seems convinced that the reason the government's strategies for improving the health service are not working is down to the consultants, and everything will work out once command and control is established. This will divert attention from the mess of micromanagement, the explosion of non productive management, the clinical governance and audit schemes which have become tick box exercises and in no way improve care, but they do generate paper and waste time, and keep more managers in work. George Orwell had it right and as Marcus Aurelius observed, nothing changes.

What could happen is melt down, with the consultants exiting from the NHS as it expires in a puddle of performance indicators. That will be good, the demise can be blamed on the consultants and not the idiocy of government.

So the games have started, sham "talks" but no renegotiation, the probably true perception of a weak ineffectual union without strong leadership and with a long tradition of appeasement and compliance. All HMG have to do is wait, and despair and self interest will do the trick. Is not now the time to consider industrial action?

Below is an article quoting Andrew Foster, head of the HR at DoH central, as well as Milburn's letter to Dr Bogle of the BMA.

Abandon hope all ye who work for the NHS.

There is another way, there is another system, opt out now!

This is a private opinion.

For some cold comfort see http://www.despair.com

From Alan Milburn to

Dr Ian Bogle Chairman of Council British Medical Association BMA House Tavistock Square London WC1H 9JP
Dianne Jeffery Chairman NHS Confederation 1 Warwick Row London SW1E 5ER

23 January 2003

Dear Ian and Dianne,

Improving rewards for NHS consultants and modernising medical careers

1. Ministerial colleagues and I were naturally disappointed that a majority of consultants in England decided to vote against the contract framework that the Health Departments, NHS Confederation and BMA agreed in June 2002. The parties to that agreement had unanimously reached the view that the proposed framework offered significant advantages for NHS patients and for NHS consultants. We nonetheless respect the decision taken by NHS consultants.

2. The framework agreement was essentially based on an approach designed to ensure that consultants' time and activity were planned and used in ways that best met local priorities for improving patient care, whilst at the same time offering a more flexible approach to working patterns and better opportunities to control consultant workload. A majority of consultants in England who voted in the BMA referendum rejected this approach.

3. In our view, the concerns expressed by those who voted against the contract misjudged the nature of the agreement that our organisations reached in June. There is clearly, however, no value in going round that course again, and this is why we have consistently said that re-negotiation would be pointless.

4. As you are aware, in Scotland the Health Department and the BMA are working to develop terms and conditions of service for the new consultant contract and, subject to a satisfactory conclusion, will be taking forward implementation across Scotland. In Wales and Northern Ireland, the key stakeholders are considering further how best to reform the existing arrangements to maximise benefits for patients. In England, our overall objectives remain the same, namely to give more to NHS consultants who do most for NHS patients. We want to ensure that more NHS patients can benefit from more of consultants' time and skills and that investment brings with it reforms in the way the NHS delivers patient care.

5. We are today launching a short period of consultation on the proposed action set out below, with a view to begin implementing this new programme of action from the beginning of April. We would like to discuss with you and other stakeholders how we can most effectively implement the proposed action to achieve the greatest possible benefits for NHS patients and for NHS consultants and other doctors. A draft framework for the NHS is attached to this letter.

A new framework of incentives

6. Our approach involves using the considerable resources we had set aside for implementation of the contract to realise our objectives, but in keeping with the Government's programme of devolution and decentralisation, we intend to give the NHS considerable local discretion as to how these resources are used to meet the needs of different local communities. To ensure that the extra investment we propose delivers improvements in capacity, productivity and value for money – and helps reform ways of working – there will be a national framework within which local health services will have a choice of:

· investing in local implementation of the new contract where there is significant consultant support for doing so

· investing in new annual incentives for consultants who make the biggest contribution to improving patient care

· investing extra resources in the new system of clinical excellence awards.

7. This will also offer extra choice to NHS consultants. The benefits will accrue to NHS consultants through extra financial rewards and to NHS patients through improved productivity and quality of service.

8. NHS revenue allocations include a total of £133 million (2003/04), £186 million (2004/05) and £234 million (2005/06) to support consultant incentive payments, extra clinical excellence awards (where Trusts wish to increase investment locally) or implementation of the contract. Trusts will have the choice how to deploy the investment between these three areas.

Local implementation

9. In some Trusts and PCTs, these resources will be used to support implementation of the contract. Where there is a high level of support for the contract locally amongst consultants and the Trust considers that this is the most effective way of achieving the intended benefits for capacity, productivity and new ways of working, we will give the go ahead to Trusts to implement the contract. To date, over 50 Trusts have expressed an interest.

10. Elsewhere, where Trusts and consultants choose not to proceed in this way, there need to be fresh ways of providing incentives and rewards to achieve the objectives that underpinned the contract.

Annual consultant incentives

11. Clinical excellence awards will recognise sustained commitment and performance for the NHS over the course of a consultant career. But we need to do more to recognise and reward from year to year the outstanding efforts that consultants make to drive up the quality and responsiveness of patient services.

12. We will therefore be asking Trusts and PCTs to introduce a new system of annual incentives to reward consultants who achieve the most for NHS patients. The new framework will be based on an improved approach to consultant job planning. Trusts and PCTs will agree overall organisational objectives for improvements to patient services. NHS employers will then use job planning to agree objectives with individual consultants or consultant teams that best support delivery of these organisational objectives. Consultants who achieve the most, measured against these objectives, will get the highest rewards.

13. NHS employers and NHS consultants will have flexibility to design incentive schemes that best reflect local priorities for improving the efficiency, quality and responsiveness of patient care. But to ensure overall fairness and consistency, we will be issuing guidance that sets out national standards for the design of the schemes. This will ensure, in particular, that rewards are based on objective measures of consultant performance rooted in job planning and that the schemes operate fairly across different specialties.

14. Trusts and Strategic Health Authorities will be expected to ensure that this investment is deployed in ways that, as with the investment originally intended for consultant contract reform, most effectively support their local contribution towards the following workforce objectives at national level:

· the 10,000 planned increase in the number of trained doctors by 2005 (from a 2000 baseline)

· increases in consultant productivity nationally of around 1.5 per cent per year, including both activity-generating of around 1.0 per cent per year and quality-enhancing improvements of around 0.5 per cent per year, leading to a 3 per cent gain in workforce capacity by 2005/06

· improvements in skill mix and process aimed at freeing up around 3.5 per cent of current consultant time nationally by 2005/06.

Clinical Excellence Awards

15. We intend to press ahead with the proposed new system of clinical excellence awards for consultants from April 2004. Last year, we consulted the profession and other stakeholders on our proposals for the new scheme. The new scheme will be more open and transparent than the current system of discretionary points and distinction awards. It will more fairly reward the consultants with the greatest sustained levels of performance and commitment to the NHS.

16. Amongst the key features of the new scheme:

· all awards will be determined according to a common rationale and objectives. Consultants will be considered within a uniform, fair and transparent process. There will be standard, well-publicised criteria that fully reflect the standards of quality and commitment we expect from consultants working in the NHS

· there will be a stronger emphasis on quality of care

· there will be extra safeguards to help ensure a fair distribution of awards between specialties, geographic areas and different NHS organisations and to ensure that women consultants and consultants from minority ethnic groups are fully and fairly considered for all levels of award

· the commitment to equity will be supported by a move to encourage greater use of self-nomination

· we will ensure that both nationally and locally there are clear processes to operate the scheme, with auditable procedures and outcomes

· the commitment to recognise outstanding contributions to local hospital or community services will be reflected throughout the system. Consultants who have achieved the maximum level of Trust-based awards (of around £30,000) and are demonstrating sustained levels of excellence locally will be encouraged to apply for higher awards, rising from around £40,000 to £65,000. There will be nothing to prevent consultants delivering a wholly locally contribution from progressing to the top level of these higher awards

· the scheme will continue to recognise the importance of academic and research work in contributing to the knowledge base of the NHS and to promoting evidence-based practice.

17. Current investment plans assume there will be around 19,000 extra awards locally and 550 new awards nationally over the next three years. We are particularly keen to see a greater number of consultants rewarded for sustained and high quality care at local level in both hospital and community services. Trusts will have the discretion to add further investment at local level, if they wish, using some of the new resources set out above.

Capital incentives

18. As part of a new incentives framework for the NHS, we are also introducing a system of capital incentives for NHS Trusts and PCTs that achieve the biggest improvements in patient access. These bonuses will be designed and operated by Strategic Health Authorities, with input from their PCTs and NHS Trusts.

19. Providing operational capital to successful organisations will enable Chief Executives in NHS Trusts and PCTs to reward all staff in their organisation who have made a contribution to improving access. They can use the resources to pay for specific improvements in the working environment, equipment and other improvements in patient care that staff would like to see.

20. As part of the framework, we are asking Trusts and PCTs to engage consultants and other NHS staff in helping decide locally how best these resources can be deployed. We are also recommending that Trusts invite consultants to decide, in consultation with members of the wider clinical team, how 50% of the resources are spent.

New standards for job planning and conduct of private practice

21. Although the proposed new contract as a whole was not accepted in England, elements of it are widely recognised as vitally needed improvements on the current system. We therefore intend to introduce new standards for job planning and new standards governing the relationship between private practice and NHS work. Consultants will need to comply with these standards to be eligible for the new incentive payments and to demonstrate that they are meeting the standards expected of consultants under the new clinical excellence award scheme.

Job planning

22. The new standards for job planning will be designed to help NHS employers and consultants provide more varied and flexible careers and a better control of workload. They will develop a more productive, collaborative approach to planning and annually reviewing consultants' work.

23. The key objectives are:

· to ensure the best possible use of consultant resources and greater transparency about the commitments and workload expected of consultants

· to clarify the support consultants can expect from employers, for instance in terms of administrative and secretarial support

· to support varied and rewarding consultant careers, with better opportunities for flexible working, for professional development, and so forth.

24. In line with this approach, we intend to work with the profession and with NHS employers to introduce a system of sabbaticals to support and refresh the careers of experienced consultants and to help encourage older consultants to remain working for longer in the NHS. As part of a phased approach to introducing sabbaticals, we intend to make available new investment of £15 million annually by 2005/06 to help reimburse Trusts for the locum costs involved. By 2005/06, this funding will enable around 800 consultants per year to have sabbaticals of around 2-3 months. Initially, these would typically be consultants who have completed around 20 years' service, with a view to extending coverage on a phased basis to consultants with 15 years' service as workforce capacity expands. We will look to Trusts to use this funding in ways that best support the career and professional development of senior NHS consultants and help ensure continued commitment to the NHS.

25. We also wish to explore how we can strengthen the roles of medical directors and clinical directors, so as to help drive forward more effective, collaborative partnerships between the profession and NHS management at local level. We intend to work with the British Association of Medical Managers (BAMM) and other stakeholders to explore new job descriptions, responsibilities and rewards for medical managers.

Private practice

26. The framework agreement included new standards that should govern the relationship between private practice and NHS work. Building on this approach, we will now introduce a 'Code of Conduct' which provides a clear set of standards defining best practice in managing the relationship between NHS and private practice. This will improve transparency and protect consultants from any real or perceived conflicts of interest.

Disciplinary and suspension procedures

27. The consultation document 'Supporting Doctors, Protecting Patients' set out a radically new approach to poor clinical performance based on early recognition to protect patients and rehabilitative solutions for doctors in difficulties (rather than exclusively disciplinary routes). Suspension would be rarely used under these new mechanisms. The recommendations of the report became policy in the NHS Plan. This led to the establishment of the National Clinical Assessment Authority (NCAA). The NCAA has already provided help and support in managing 400 cases of poor performance. However, it cannot become fully operational until the old-style draconian disciplinary procedures are removed.

28. We will therefore introduce new improved disciplinary procedures from April 2003 and we will abolish the para 190 procedures . This will ensure faster, fairer and more effective procedures that benefit Trusts and consultants alike and discard the existing discredited arrangements.

Reforming medical careers

29. One of the issues that we sought to address through the new consultant contract was concern about controlling and reducing consultant workload. The great majority of consultants work very hard for the NHS.

30. As well as improving the job planning process, we will take action to allow a much wider range of doctors to deliver in a more effective way the treatment patients need most. We must deploy our medical workforce so that patients get the maximum benefit and doctors themselves have the chance to develop their skills fully.

31. I am very pleased that we have now agreed a joint memorandum with the Academy of Medical Royal Colleges on the way we train, recruit and deploy our doctors. We shall now be working closely with each individual Royal College on:

· modernising training and introducing more competence based assessment so that we deliver specialists more closely geared and directly skilled to providing the frontline care patients need

· shortening some courses of specialist training to enable doctors to move quickly to generalist consultant posts and provide a better balance between generalists and sub-specialists;

· testing and introducing systems to free up doctors to deliver patient care and perform more operations without direct supervision as soon as they have been accredited as having the right skills

32. This is not about creating junior consultants or sub-consultants. It is about creating consultants better matched to patient and service needs. As part of this work we need to invest in and reform the current Non-Consultant Career Grades to enhance the role of these doctors, to enable them to practise more autonomously and to provide them with better opportunities for progressing their careers. We are already reviewing the role, education and training and career opportunities for doctors in these grades. In taking this work forward we will:

· work with the profession to develop competencies for NCCGs which are linked with those required of senior trainees to enable them to resume training more easily and achieve entry to the Specialist Register

· change the law so that more of their skills and qualifications can be assessed, recognised and used to advance their careers

· provide them with better career development and give them more access to Continuing Professional Development

· give them more opportunities to practise without direct supervision, to take on work currently done by consultants and to develop their careers

Conclusion

33. The great majority of consultants are highly committed to the NHS and to improving the quality of NHS patient care. In keeping with the objectives behind the consultant contract we negotiated, my intention is to ensure that the NHS consultants who do most for NHS patients are better recognised and rewarded. Within this new framework of incentives, there will be greater flexibility for local health services to reform ways of working to secure gains in capacity and productivity. They will be able to choose how to use the extra resources that are available in order to improve the quality both of local services and consultants' working lives.

34. I am writing to individual consultants and SpRs and to local health services setting out these plans.

Yours sincerely,
Alan Milburn

improving rewards for NHS consultants
January 2003

· The Department of Health has made extra investment available to NHS Trusts and PCTs in 2003/04 to 2005/06 to support an improved system of rewards and incentives for consultants, as part of a new NHS incentives framework. This draft guidance sets out how we propose NHS Trusts, PCTs and Strategic Health Authorities should deploy this extra investment, in conjunction with wider proposed action to improve rewards for consultants and modernise medical careers.

· Primary Care Trusts, NHS Trusts and Strategic Health Authorities will be asked to agree incentive schemes (initially for 2003/04) that will support delivery of agreed Local Delivery Plans in line with this guidance.

· The key principle will be that there should be extra recognition and rewards for those consultants or consultant teams who achieve the most for NHS patients, whether this is based on improving productivity, access, quality or service development.

New framework of incentives for NHS organisations and staff

· The new system of consultant rewards and incentives will form part of a new overall framework of incentives for the NHS that will mean extra rewards for NHS organisations and for NHS staff who make the biggest contribution to improving the quality and responsiveness of NHS services. Within this framework, mutually reinforcing incentives will operate at different levels within health economies:

· incentives at the level of the local health economy will be focused on rewarding NHS Trusts and PCTs who make rapid progress in delivering faster patient access to inpatient and outpatient elective surgery, treatment in A&E departments and primary care (see paragraphs 33-37 below);

· hospitals will have new incentives to provide additional activity agreed with PCTs at the start of the year;

· Strategic Health Authorities and NHS employers in their area will devise schemes that give extra rewards to consultants or consultant teams who do the most to contribute to these improvements in patient access and patient activity and to wider improvements in the quality and standard of patient care, based on a job planning process that links Local Delivery Plan objectives and individual or team objectives for consultants;

· the proposed new GMS framework will include a quality framework that links extra rewards to GP practices that achieve improved outcomes for patients;

· Trusts and PCTs will continue to have flexibilities to offer extra rewards for teams of NHS staff who make the greatest contribution to improving the quality and responsiveness of patient care, building on the emerging lessons from team bonus pilots.

Investment in consultant rewards and incentives

· Following the outcome of the BMA referendum on the proposed new consultant contract, the Department of Health made clear that the extra investment originally set aside for contract reform would be used in other ways to improve rewards for NHS consultants. The underlying objectives remain to:

· offer greater rewards for NHS consultants so that more NHS patients benefit from their time and skills

· properly value and reward those consultants who do most for the NHS

· ensure that investment brings with it reforms in the way that the NHS delivers patient care.

· To ensure that the available investment delivers improvements in capacity, productivity and value for money – and helps reform ways of working – there will be a national framework within which local health services will have a choice of:

· investing in local implementation of the contract where there is significant consultant support for doing so

· investing in new annual incentives for consultants who make the biggest contribution to improving patient care

· investing extra resources in the new system of clinical excellence awards.

· NHS revenue allocations include a total of £133 million (2003/04), £186 million (2004/05) and £234 million (2005/06) for investment in these three areas.

Local implementation of new consultant contract

· Where there is a high level of local consultant support for implementing the contract negotiated between the Health Departments and BMA in June 2002, and where Trusts or PCTs are able to demonstrate commensurate service benefits, Trusts or PCTs will be able to use their share of the resources set out above to meet the costs involved. Small levels of top-up funding may be available from the Department to these Trusts or PCTs to support contract implementation, depending on the expected level of take-up locally.

New consultant incentives

· Elsewhere, where Trusts and consultants choose not to proceed in this way, Trusts and PCTs will be asked to introduce a new system of annual incentives to reward consultants who achieve the most for NHS patients. These local schemes will operate within a framework of national standards – as set out in the remainder of this guidance – that will:

· ensure all consultants have opportunities to benefit, whilst recognising the diversity of the contributions made by different specialties and different consultants

· ensure that local incentive schemes meet certain core national criteria to ensure consistency and equity

· within these parameters, give local health economies the flexibility to implement schemes that reflect local priorities for improving the quality and responsiveness of patient care

· support wider incentives to improve patient access by ensuring extra rewards for those consultants who make the greatest contribution towards improving access to NHS services

· promote improved standards of consultant job planning and close engagement by consultants in local decision-making on how to deliver organisational objectives for improvements in patient care.

· To ensure an equitable and consistent approach to awarding incentive payments in each health economy, Strategic Health Authorities will have overall responsibility for managing consultant incentive schemes in their areas. PCTs in each StHA area will be asked to pool their shares of these resources accordingly.

· PCTs, NHS Trusts and Strategic Health Authorities will be asked to supplement these pooled funds using resources that have in previous years been devoted to funding waiting list initiatives and other premium payments for extra consultant activity. Local incentive schemes should provide a more equitable and effective way of rewarding consultants for their contribution to improving levels of activity.

Design of incentive schemes

· Strategic Health Authorities will work with NHS Trusts and PCTs in their area, in particular with medical managers and consultants, to implement local schemes in line with the criteria set out below.

· Payments to consultants will be in the form of annual non-recurrent bonuses.

Standard criteria

· The objectives or criteria against which consultants' performance is assessed should be based on objective measures of performance, so that schemes are fair to consultants and rewards are proportionate to achievement. The criteria may be set either for individual consultants or consultant teams and it would be good practice to allow local consultant bodies to choose between the individual or team approach.

· Strategic Health Authorities should ensure that incentive schemes are designed in such a way as to support delivery of the local targets for capacity, productivity, quality, skill mix and process improvement in line with agreed Local Delivery Plans.

· The systems for monitoring and measuring performance against objectives or criteria should be agreed and clearly recorded in advance. The Department will be working with the NHS to improve and broaden the range of measures of clinical performance, building on the pilot analysis described in the letter and information package sent to Trust Chief Executives by Andrew Foster and Sir John Pattison on 16 December 2002.

· The objectives or criteria and the systems for monitoring performance should be agreed through the system of consultant job planning. The job planning process should be designed to enable employers and consultants to agree:

· how consultants and consultant teams can best support achievement of organisational objectives

· the resulting individual or team objectives that should be incorporated into job plans

· how the organisation can best support consultants in meeting these objectives.

· To be eligible for incentive payments, consultants will need to adhere to proposed new standards governing the job planning process (see paras 25-27 below) and to abide by a new code of conduct governing the relationship between private practice and NHS work (see paras 28-31 below)

· All consultants should have an opportunity to receive incentive payments. In other words objectives and criteria should be similarly stretching for all consultants and all specialties. Incentive schemes should be applicable to all consultants, including clinical academics.

· The chosen objectives or criteria should relate to consultants' activity and performance during the totality of their work for the NHS. Incentive funding should not be used to pay premium rates for extra activity undertaken outside a consultant's main duties and responsibilities

· Strategic Health Authorities should ensure clear decision-making and funding arrangements to ensure that consultants receive awards that properly reflect their performance against the agreed objectives or criteria. The amounts paid to consultants or consultant teams at the end of each year will depend on the extent to which individual or team objectives are met, and Strategic Health Authorities will be responsible for ensuring that this is reflected in the funds released to employing organisations.

Specific suggested criteria

· The nature of the objectives agreed for consultants will vary between different specialties and individuals, depending on the nature of their contribution to delivering and improving patient services. Objectives may, depending on the circumstances, relate to output, access, quality or service development, or a mix of these measures.

· In surgical and other specialties where it is possible to benchmark patient activity and adjust for case mix, objectives should be linked to output measures, for instance based on the level of additional activity above a locally agreed benchmark, either for the individual consultant or consultant team. These objectives should be combined with objectives related to meeting minimum standards on access, linked to the organisational objectives for capital incentives.

· In other specialties, where appropriate activity measures are not available, schemes should be designed to incentivise and reward consultants who make the biggest contribution to achieving Local Delivery Plan objectives for patient access, service quality and/or service development, in line with the priorities in the Priorities and Planning Framework for 2003-2006. It will be up to Strategic Health Authorities, NHS Trusts and PCTs to decide appropriate measures locally, linked to consultant job planning. Annex A provides some examples of the sorts of measures that could be used.

Best practice in job planning

· Part of the developmental work undertaken between the UK Health Departments, the BMA and the NHS Confederation for the proposed new consultant contract involved devising a modernised system of job planning. The Department of Health, working closely with the profession, intends to develop these proposals into new standards of best practice that can apply to job planning under current contractual arrangements.

· These standards of best practice will be designed to help employers and consultants develop a more productive, collaborative approach to planning and annually reviewing consultants' work. They will also directly support the proposed system of consultant incentives described above and, where it is locally implemented, the new consultant contract. The objectives will be:

· to ensure the best possible use of consultant resources and greater transparency about the commitments and workload expected of consultants

· to clarify the support consultants can expect from employers, for instance in terms of administrative and secretarial support

· to support varied and rewarding consultant careers, with better opportunities for flexible working, professional development and sabbaticals to support and refresh the careers of experienced consultants

· The aim is to publish these standards in March 2003. To be eligible for the consultant incentives described in this guidance and to demonstrate that they are meeting the standards expected of consultants under the new clinical excellence award scheme (to be introduced from 2004/05), consultants will need to adhere to these standards of best practice.

Code of conduct governing the relationship between NHS and private practice

· The development of the proposed new consultant contract included work to define best practice in managing the relationship between NHS work and any private practice undertaken by NHS consultants. Working with the profession, the Department of Health intends to develop these proposals into a new Code of Conduct.

· The fundamental principles underpinning the Code will be that there should be no real or perceived conflict of interest between private and NHS work and that the interests of NHS patients must always come first, in particular:

· the provision of services for private patients should not prejudice the interests of NHS patients

· private practice by NHS consultants should not disrupt the provision of NHS services, nor have any adverse impact on NHS performance

· work outside NHS employment should not adversely affect NHS employment, nor conflict with the interests of NHS employers or NHS employees

· agreed NHS commitments should take precedence over private work

· NHS facilities, staff and services should be used for private practice only with the agreement of NHS employers.

· The proposed Code of Conduct will include provisions governing:

· disclosure of information about private practice

· scheduling of private work

· transfer of patients between the NHS and private sector and management of NHS waiting lists

· use of NHS facilities and staff for private and other fee-paying work

· engagement with measures to increase NHS capacity, including appointment of new consultants.

· The aim is to publish the new Code in March 2003. To be eligible for the consultant incentives described in this guidance and to demonstrate that they are meeting the standards expected of consultants under the new clinical excellence award scheme (to be introduced from 2004/05), consultants will need to adhere to the provisions of the Code.

Discretionary points and clinical excellence awards

· Health service allocations include extra investment to enable Trusts to make around an extra 19,000 local awards over the next three years. Trusts may choose to use part of the extra resources set out in paragraph 7 above to add further to the number of clinical excellence awards that can be made locally.

Capital investment in incentives for access at NHS trust and PCT level

· As part of the overall framework described above, the Department of Health has recently announced local access incentives for NHS Trusts and PCTs. These bonuses will be designed and operated by Strategic Health Authorities, with input from their PCTs and NHS Trusts. The bonuses will be available to all Trusts and PCTs that improve access, particularly in A&E and elective care.

· By providing operational capital to successful organisations, this will enable Chief Executives in NHS Trusts and PCTs to reward all staff in their organisation who have made a contribution. They can use the resources to pay for specific improvements in the working environment, equipment and other improvements in patient care that staff would like to see. NHS Trusts and PCTs will be expected to engage consultants and other NHS staff in helping decide locally how best these resources can be deployed, for example by allocating 50% of any bonus for staff to determine how it is spent.

· The incentives will be funded from operational capital - £100m in 2003/04, 2004/05 and 2005/06. This will be issued to Strategic Health Authorities on a fair shares basis who will then pass it onto NHS Trusts and PCTs according to their performance against access measures. Local health communities can choose to supplement this with local resources, but this will be optional.

· These bonuses are intended to complement the incentives for individual consultants and consultant teams described in the rest of this document.

· A description of the access incentives, their objectives, how they are intended to operate and an exemplar scheme are set out in Annex B.

Department of Health

annex a - framework for the development of local incentive schemes
23 January 2003

A1. Introduction
This guidance is designed to provide a framework within which an incentive scheme appropriate to local needs can be devised. In each instance, there will need to be clearly demonstrated coherence with Local Delivery Plans (LDPs) and sustainable benefits to patients such as improvements in quality of care or access to services, decreased waiting times and/or increased capacity, with better, more effective ways of working.

It will be for Strategic Health Authorities, through their performance management function, to ensure that the objectives agreed reflect LDPs. StHAs must also ensure that, where not already implemented, existing best practice guidance is fully incorporated into all incentive schemes.

A2. Ojectives
Local schemes should ensure that consultant incentives are aligned, in particular, with local objectives for achieving the NHS-led (or jointly led) priorities in the Priorities and Planning Framework for 2003-2006:
improving access to all services through:

· better emergency care

· reduced waiting, increased booking for appointments and admission and more choice for patients

focusing on improving services and outcomes in:

· cancer

· coronary heart disease

· mental health

· older people

· improving the overall experience of patients

· reducing health inequalities

Section A4 gives examples of how consultant incentives can be aligned with Local Delivery Plan objectives in some of these areas.

Local schemes should also align consultant incentives, where appropriate, with:

· targets and milestones in National Service Frameworks (where not already reflected in the PPF), e.g. the new diabetes NSF

· other national and local objectives for improving the quality of patient care, for instance implementing guidance from the National Institute for Clinical Excellence, or implementing action plans following a Commission for Healthcare Audit and Inspection review, responding to issues raised by patients, carers and the public.

· other objectives for delivering new ways of working that put patients at the centre of service delivery and provide services at times and in ways that meet the needs and expectations of those who use the service.

A3. Structure of incentive schemes
Incentive schemes can be focused at an individual or organisational level. No single consultant or clinical team will be expected to achieve whole organisational objectives in isolation. It is the purpose of the incentive scheme that clinical efforts are aligned with local priorities as set out in the Local Delivery Plan, agreed locally and endorsed by the Strategic Health Authority. Neither can these targets be met by clinicians alone, but rather by teams of clinicians and managers working together, and with the full involvement of users and carers. Organisations and teams within organisations will need to determine how each target will be met and the roles of the individual team members.

New strategies are being developed that will improve standards of care in other clinical areas. As these are published, their principal targets and milestones will need to be aligned with objectives for consultants in the relevant specialties.

A4. Incentive examples
Whilst it will be for each local health community to determine the nature and content of its incentive scheme, the following examples are intended to illustrate how incentive schemes can support service and access improvements in selected areas of the Priorities and Planning Framework.

Better emergency care
By March 2004 for those Trusts who have completed the Emergency Services Review and by December 2004 for other Trusts, no patient will wait for more than four hours from time of arrival to admission, transfer or discharge. Reaching this target is a complex task, involving many individuals, specialties, professional groups and organisations.

Consultants in Accident and Emergency will be expected to develop services that ensure that patients with more minor complaints or medico-social problems are seen by appropriate staff. This may involve developing a service which uses more fully the skills of other staff, such as nurses, therapists, paramedics and social care staff, or introducing a general practitioner advisory service.

All steps should be taken to ensure that patients are not admitted to hospital unnecessarily, nor that their stay in hospital is longer that clinically indicated. Consultants should:

· review their admitting procedures to ensure that the decision to admit is made by a clinician of sufficient experience and seniority to make that decision

· once admitted, commence discharge planning immediately to ensure that the patient is enabled to go to the most appropriate place of discharge as soon as is clinically appropriate

· ensure that investigative services are organised and scheduled to minimise the length of time patients spend in hospital awaiting such investigations

· ensure that, where appropriate, active rehabilitation is commenced as soon as is clinically indicated.

Improving access to outpatient care
By March 2004, no patient will wait for more than 17 weeks to be seen in outpatients and by the end of 2005, no patient should wait longer than thirteen weeks to be seen. Consultants need to play an active part in reaching this target. Specifically, all consultants and other service leaders need to review services to ensure that they are provided in accordance with best clinical and operational practice. Local communities need to jointly manage outpatient waiting lists, ensuring that they are also utilise available demand management techniques and increase the activity that takes place in primary and community settings so that more outpatients appointments (around 10%) take place in the community rather than hospital.

Improving access to elective care
By March 2004, no patient will wait for more than nine months for inpatient care and the numbers waiting more than six months reduce by at least 40%. Consultants will need to play an active role in managing waiting lists to ensure that these targets are met. Furthermore, all steps should be taken to ensure that patients are not admitted to hospital unnecessarily, nor that their stay in hospital is longer that clinically indicated.
Consultants should in addition to the actions set out above for emergency care:

· where a procedure can be performed as a day case, it should be assumed that the procedure will take place as a day case unless this is not possible, moving to increase the day case rate to 75%

· introduce practices that ensure patients receive appropriate and effective pre-operative assessment

Health communities may wish to introduce schemes that financially reward individual consultants or consultant teams who exceed a defined benchmark level of case-mix adjusted activity in their specialty, i.e. by giving a payment for each unit of activity above the benchmark up to a defined maximum. The benchmark could be a weighted average of local (StHA/Trust) performance and median national performance in the relevant specialty. This approach could be extended to include non-surgical consultants whose work is integral to achieving greater surgical activity. The size of the unit payment for activity above the benchmark would depend on the total resources available, including resources that have historically been deployed on waiting list initiative payments for the relevant specialties, and current levels of performance

Health communities may also wish to introduce schemes that provide opportunities to undertake extra work in Diagnostic and Treatment Centres - or through the Patient Choice initiative - at enhanced rates to NHS consultants or consultant teams who meet defined standards of performance in relation to activity and access. These schemes are likely to be most effective where they are organised across a wide health economy and consultants from across that whole economy are given the opportunity to undertake the extra work provided they meet agreed criteria

Cancer
By the end of 2005, no patient will wait for more than one month from diagnosis to treatment and two months from urgent referral to treatment for all cancers. As with other access targets, consultants have a crucial role, in collaboration with other service leaders, in ensuring this target is met.

All consultants involved in the cancer teams will implement NICE improving outcomes guidance.

Consultants should advise patients on lifestyle, including smoking cessation, whenever possible and appropriate.

Consultants should support the extension of the breast screening programme to all women aged 65 to 70 by 2004.

Once published, consultants should ensure compliance with NICE guidance on supportive and palliative care.

Coronary Heart Disease
Local health services should have local targets to make progress towards the National Service Framework goal of a three month maximum wait for angiography and to ensure that no patients wait longer than three months for revascularisation by March 2005, or sooner if possible. As with other access targets, consultants have a crucial role, in collaboration with other service leaders, in ensuring these targets are met.

The proportion of people suffering a myocardial infarction who receive thrombolysis within 60 minutes of calling for professional help should increase by 10% per year. Consultants need to lead or support the review of patient pathways that ensures these patients are seen and treated as quickly as possible, ensuring this target is met.

Cardiologists should support the continuing development of rapid access chest pain clinics, to ensure that no patient waits longer than two weeks to be seen.

Once published, care of patients with cardiac failure should be improved in line with NICE guidance, with consultants contributing to the achievement of local targets for the consequent reduction in patients admitted to hospital with a diagnosis of heart failure.

All relevant consultants should actively participate in national audits of paediatric and adult cardiac surgery and myocardial infarction and prepare to contribute to the planned national audit on angioplasty.

Mental Health
Consultants should lead or support others leading in the development of 24 hour crisis resolution services, so that a service can be offered to all eligible patients by 2005.

Consultants should lead or support others leading in the development of assertive outreach services for people with severe mental health illness and complex problems, with such services in place by December 2003.

By 2004, the duration of untreated psychosis will be reduced to a median of less than three months, with no individual waiting for longer than six months, and young people developing a first episode will be supported for three years. Consultants will need to play a key role in ensuring this target is met.

Consultants need to play a key role in reducing the number of deaths from suicide and undetermined injury by leading the development of safer services.

Services for Older People
By April 2004, all general hospitals caring for people who have suffered a stroke will have specialised stroke service. Where such a service is not established, consultants will need to play a key if not leading role in the establishment of such a service.

By the end of 2005, all health and social care communities should be part of an integrated falls service. Where such a service is not established, consultants will need to play a key if not leading role in the establishment of such a service.

Consultants should work with primary care colleagues to develop and implement protocols for the support and care of older people with mental illness.

Tackling health inequalities
Clinical services need to support the achievement of the national health inequalities targets – to narrow the gap in infant mortality by social class and to narrow the gap in life expectancy by geographical area. Ensuring equity of access to services, and working to break the "inverse care law" whereby individuals in greatest need are frequently least likely to receive the health services that they require, is fundamental to narrowing the health gap. Consultants should
· review their admissions to identify geographical areas or patient groups which are not achieving access to services, or receiving services as soon as would be clinically indicated with a view to ensuring equity of access for all groups relative to need.
· consider the reasons for poor access to services by these groups, in liaison with patient groups and communities and local PCTs, and make appropriate arrangements to address the issues raised, for example by increasing capacity in community settings, providing adequate interpretation, advocacy and translation services, ensuring services take account of cultural, religious and other needs.

annex b - local access incentives
23 January 2003

Introduction
B1. The Department of Health is inviting Strategic Health Authorities to take the lead in designing local access incentives for NHS trusts and PCTs. The incentives are to be:
- designed and operated locally by Strategic Health Authorities in conjunction with PCTs and NHS trusts
- available to NHS trusts and PCTs for progress towards NHS Plan targets for access, including waiting times in A&E and for elective inpatient admissions
- funded from capital which will be made available by the centre at around the same time as capital allocations are issued

B2. This approach is to be introduced in all Strategic Health Authority areas from 2003/04 and will operate for 3 years, with evaluation at the end of the first and second years.

Objectives
B3. The purpose of the incentive is to reward NHS trusts and PCTs who make rapid progress in improving access. Clearly this could include any of the NHS plan targets for access, both in hospital and primary care. Initially, however, we expect the main focus to be on:
a) reducing waiting times in A&E (progress towards the maximum 4 hour total wait in A&E)
b) reducing IP and OP waiting times (progress towards the maximum 6 month waiting time target and the maximum 13 week wait)
c) reducing IP and OP waiting lists.

B4. This is one of a series of reforms which will strengthen incentives at every level in the NHS to deliver the government's objectives for a modernised health service. Other changes include pay reforms already underway for NHS staff, changes to financial flows and increased patient choice.

Resources
B5. Alongside the capital allocations now issued, we are allocating £100m of capital resources to Strategic Health Authorities in 2003/4 to fund the locally designed incentives. This will provide nearly £4m in an average StHA area which can be used to offer successful NHS trusts and PCTs the opportunity to earn additional capital to spend as they (and their staff) see fit.

B6. The £100m will be a separately identified resource – distinct from strategic and operational capital allocations - but once earned by trusts and PCTs can be spent by them in the same way as operational capital is typically used. The intention is that they will be able to use it to fund improvements in equipment and facilities that will improve patient care and that will improve the services, both in range and quality, that staff want to provide for patients. In this way, staff will be rewarded for the contributions they make across their organisations.

B7. Since StHAs differ in size, the distribution of capital for the incentive schemes between the StHA areas will be on the basis of fair shares (weighted populations). Within each StHA the distribution will of course reflect the performance of local PCTs and trusts and the design of the local incentives.

Who will get the bonuses?
B8. The incentives should be made available both to PCTs and NHS trusts, and all such organisations should have the opportunity to benefit. The balance of resources between PCTs and NHS trusts is for local agreement, reflecting the contribution each make to improving access for NHS patients.

How will the incentive operate?
B9. The design of the incentives will be decided locally, led by Strategic Health Authorities with input from the PCTs and NHS trusts in their area. Clearly the schemes should be aimed at having the maximum effect on performance. It will be for local organisations to agree how this can best be achieved, including:
- the overall design and operation of the scheme
- the measures of performance used
- the amounts of rewards
- how the rewards are spent within NHS trusts and PCTs
- the starting points and thresholds for triggering payments
- the precise balance of resource between NHS trusts and PCTs.

B10. The national requirements are that:
- Every STHA must operate a scheme, using the capital resources made available from the centre (plus any resources which communities agree to put into schemes locally)
- The incentive must be focused on access, with a strong emphasis on reducing waiting times in A&E and delivering the 6 month maximum wait for elective in-patient admissions.
- The incentive should be available both to NHS trusts and to primary care trusts to reflect, for example, the contribution expanded primary care services make to improving waiting times for emergency treatment.
- The incentive should be triggered only by significant improvements in performance; it should not be paid for delivering or maintaining existing levels of performance.
- Capital resources must be used for capital expenditures
- Where an NHS trust earns an incentive payment, at least half of it should be offered to teams of staff (led by consultants) within the organisation who have delivered i improvements in access. They can then decide how it should be spent.

Support
B11. The amounts for each Strategic Health Authority area are set out in the capital allocations announcement. StHA chief executives are invited now to work with leads from NHS trusts and PCTs in developing incentives in their areas for use in 2003/04.

B12. To help with this process, there will be support from the centre as follows:
- An example scheme is being developed – see Appendix. We will be encouraging StHA leads to use this as the starting point for designing their own scheme and/or to feed back comments to the centre on how it can be improved.
- Workshops will be organised for StHA leads (and other local representatives) to share their ideas and develop their thinking.
- Researchers will be commissioned to evaluate experience in the first year and this will be fed back to leads in each StHA to help benchmark their own ideas and learn from others for 2004/5. Each area will be asked to provide information and feedback to an external evaluation team, so best practice can be identified for the second year.
- This guidance, further information on the amounts of capital resource for each Strategic Health Authority area, and a further version of the example scheme will be issued during January. This guidance will be reviewed after 12 months and revised for 2004/05, drawing upon the evaluation of the experience in the first year.

Appendix - Example of Access Incentive for NHS trusts and PCTs
1. In this example, NHS trusts and PCTs are measured against four dimensions of access
- total waiting time in A&E (% waiting over 4 hours)
- IP elective waiting time (% waiting over 6 months, % waiting over 3 months)
- IP waiting lists (relative to Manifesto commitment)
- OP waiting lists

2. At the end of each quarter, they receive operational capital payments (which can be spent on equipment or other refurbishment locally in the normal way) which are determined by:
- whether the level of performance is better than the threshold level
- the % improvement in performance during the quarter

3. The thresholds and the fixed amount of payment per % point improvement are shown in Table 1. These have been set with the following criteria in mind:
- the overall size of the rewards should be as large as possible at the margin to maximise the impact on behaviour.
- the cost of the scheme should be within the resource limit of £3m-£4m for a typical Strategic Health Authority, on reasonable assumptions about improvements in performance
- there should be a reasonable balance between all areas of access. In practice this means that more of the incentives should be targeted at A&E and IP waiting times than on waiting lists for inpatients and outpatients.
- in some areas, achieving a 1% improvement is a bigger improvement in performance compared with the overall distribution of performance than in others, so the amount per % improvement is larger for these areas.
- the incentives are designed to reward improvements in performance, not levels. Specifically, an overriding requirement has been to avoid significant 'deadweight costs', i.e. paying incentives for levels of performance which would have been achieved anyway.
- the thresholds are set at relatively high levels compared with the existing performance in 2002/3.

4. Setting the thresholds at a high level ensures that the available resources can be targeted most effectively in two ways:
- at those who achieve very significant improvements in access
- by offering a relatively large incentive per % point improvement in performance

5. In several areas the required information was not available at national level to model the impact and cost of the incentive or to give a definitive suggestion:
a) total waiting time in A&E by PCT.

Data not available nationally for 2002/3. A suggested measure is the average of the A&E access measure for the main NHS trusts which serve the PCT's population
locally.

b) OP waiting lists.

The measure suggested in Table 1 is indicative only and may need to be changed or refined.

BMA consultant leaders respond to plans for better rewards for NHS consultants

Press release date: Thursday, 23 Jan 2003 (BMA London)

The BMA's consultants' committee has given a cautious initial response to the Health Secretary's plans for incentives and additional rewards for NHS consultants. The BMA will be pursuing constructive talks with Ministers and civil servants over the next few weeks.

Responding to a letter to the BMA Chairman from the Health Secretary which explicitly recognises that "the great majority of consultants are highly committed to the NHS and to improving the quality of NHS patient care", Dr Ian Bogle says that he is encouraged to see the re-opening of a constructive dialogue on the way forward for consultants.

Dr Paul Miller, the newly elected chairman of the BMA consultants' committee says :

"I am encouraged that the door is open for talks and that the Health Secretary has recognised that we share a common agenda in wanting to improve and modernise services and in rewarding those who work hardest and most intensively for the NHS. However, the Health Secretary's plans for local incentives do seem to be very strongly tied to Government targets and consultants are very wary of having clinical care dictated by political priorities. I will be arguing strongly that preserving the national character of the NHS is best achieved by national agreement on a national contract.

"We now have a range of options for rewarding consultants which will require detailed discussion at national level. We will need to go into very careful, serious discussion on these plans but I do not believe that annual payments for meeting performance targets are the right way to reward consultants who have spent their whole careers developing patient services.

"We remain opposed to local implementation of a contract framework that was clearly rejected by consultants in England and we doubt whether it would prove a popular option for consultants. We do strongly welcome the apparent abandonment of plans for a junior consultant grade and the clear commitment to expanding the number of senior doctors in the NHS."

The Health Secretary has indicated that more than 50 Trusts have expressed their interest in offering the rejected contract locally. The BMA remains sceptical about the appetite for local implementation and will be advising its own members to look carefully at the range of alternatives available for contractual improvement. Mr Milburn's proposals include the option of additional payments for consultants who retain their existing contract.

The BMA supports the proposal for sabbaticals as a retention measure for NHS consultants.

Funding for consultant pay has been passed to primary care trusts in preparation for 1 April and the BMA understands that individual Trusts will need to submit plans to the PCTs describing how they plan to deliver incentives to their consultant workforce. The BMA believes that very clear guidance will be needed for PCTs to ensure that all hospital specialties are given a fair share of any incentive payments, not merely those associated with waiting list targets. Consultant leaders will pursue the detail with Department of Health officials over the coming weeks and listen to the views of consultants. They remain committed to a nationally agreed contract rather than ad hoc incentive solutions.

The BMA warns that consultant morale remains fragile, with many senior doctors angry at the lack of recognition in political circles of their heavy workload and their key role in leading the modernisation of patient care.

© The Stealth Anorak 2003