HC Deb 19 July 1973 vol 860 cc932-43

3.6 a.m.

Dr. Shirley Summerskill (Halifax)

I am taking this opportunity to raise the subject of merit awards, or distinction awards as they are sometimes called, for consultants in the National Health Service. Approximately £11 million of taxpayers' money is spent on these awards each year but surprisingly little parliamentary or public discussion takes place about them and this large expenditure.

The Under-Secretary will no doubt point out that these awards were started by a Labour Government, but it is now 25 years since the service was created and it seems time to reform various aspects of the service, especially as we are now reorganising it, and to look at arrangements that might have been acceptable inside or outside the medical profession at the time, but which are not necessarily acceptable 25 years later.

The awards were based on the recommendation of the Spens Committee which said that, if recruitment to and the status of specialist work were to be maintained, specialists must be able to feel that more than ordinary ability and effort received an adequate reward. I do not think that today it follows that the principle necessarily applies—that it is necessary in order to maintain the status and recruitment of specialists—as their salary scales and structures are not quite the same. One of the intentions of the merit awards at the time, certainly one of the intentions in the mind of the then Minister of Health, was to award them in order to encourage consultants to enter the service and co-operate in it. Today these aspects are different from what they were in 1948.

I have not found in the Estimates a single figure for the amount spent each year, but I have calculated—and the hon. Gentleman will confirm or deny—what appears from the annual report of the Department of Health and Social Security to be the amount.

For England and Wales the numbers of awards in payment at 31st December 1972 were as follows

A-plus awards, 100 of £7,350 each—incidentally, if a consultant gets this award it can double his salary for every year of his working life; A awards, 364 of £5,577 each; B awards, 1,053 of £3,273 each; and C awards, 2,258 of £1,392 each. That makes a total of 3,775 awards for 10,813 consultant appointments. Therefore, I calculated that £81 million a year is spent on these awards in England and Wales.

My hon. Friend the Member for Kirkcaldy Burghs (Mr. Gourlay), who cannot be here for the debate but who has taken a great interest in merit awards in Scotland, has asked me to point out that there are 579 of these awards in Scotland, which I calculate to cost another million to £2 million a year. The total amount of taxpayers' money spent on awards is therefore approximately £11 million a year.

That is spent on an arbitrary number of consultants representing 35.2 per cent. of the total. The Spens Committee originally said that these awards should be given to a significant minority. How we are to approve of giving this large sum of money to 35.2 per cent. of consultants appears to have no logic behind it. I should be interested to know the Minister's justification for maintaining this 35.2 per cent. Does he want to increase or decrease it? If neither, why does he think that this is a suitable figure?

The Review Body's report, published two days ago, recommended that merit awards should be increased by nearly 200. I should be interested to know the Government's view on the desirable number of these awards.

The main criticism of the awards—there are many criticisms—is that they are shrouded in secrecy as to whom they are given and for what reason. Who decides who shall have them is another criticism. They are awarded by medical and dental consultants to other consultants, so they are awarded by the profession to the profession. This does not seem to be the ideal way to distribute these awards.

The medical committee consists of 19 consultants and only one layman. Surely one could not imagine a similar arrangement for, say, a group of hospital matrons to get together to award other hospital matrons a large amount of taxpayers' money on grounds of merit or for a group of top civil servants to get together to award taxpayers' money to other top civil servants.

It must be difficult for members of the committee to award sums of money to their colleagues. The medical world is not such a large world and often men who are given awards must be personally known to the committee. If they were not personally known, how could they be judged? It seems most unsatisfactory.

Perhaps the major complaint, however, which the public are now beginning to appreciate, is the secrecy about who receives the awards. Parliament is never told and neither are the public. Even the doctors are now criticising the secrecy. It took some time for this to happen. Up to now this secrecy has been justified on two grounds. It was feared that patients would flock to the doctor who had the A-plus award and that if they could not see him they would go to the A award man, the B man and then the C man. All the others would be left out in the cold. It is also said that it would be unfair to name those who were getting the award if those who had just missed it were not named, their reputations being marred.

Those are not strong enough arguments to justify total secrecy about these awards. The Regional Hospital Consultants and Specialists Association has called the system mediaeval and undemocratic and last month the BMA's annual representative meeting at Folkestone asked for full disclosure of the merit awards. The BMA was asked to press for the system to be renegotiated. The medical profession therefore want the Government to look at this aspect. The BMA has just held a referendum which showed that just over half of all consultants who participated wanted an end to the secrecy.

Another element of secrecy concerns the grounds on which the awards are made. This is an arbitrary matter. How is a doctor awarded for more than ordinary ability and effort, which is one definition? is it length of service? For some arbitrary reason, a doctor who is aged 70 or more is not eligible for a merit award. Is it the type of service that counts? If so, how is it measured? We know that the committee takes advice on all these matters and that it has advisers all over the country. It discusses the doctor in question with the various bodies who know him and deal with aspects of his work. But it seems to me extremely difficult to measure ability and effort and to pay accordingly. The doctor will receive the award for the rest of his life, whatever his future effort and ability. If he deteriorates or if the standard of his work falls, he still gets his merit award.

A further unfair aspect is that 54.6 per cent. of consultants with teaching hospital appointments have a merit award, whereas of the non-teaching hospital consultants—the vast majority—only 25.3 per cent. receive merit awards.

Then there is a discrepancy with regard to specialties. Altogether, 79.8 per cent. of all awards go to thoracic surgeons. Neuro-surgeons are very high on the list. Only 21.2 per cent. of the awards go to geriatricians—and looking after old people is an increasingly essential specialty and extremely difficult and often unpleasant. So there seems to be no fairness in that respect.

Finally, I question the basic concept of having distinction or merit awards at all, even if everything else about them was fair. Should not consultants be paid a realistic salary, obviously depending on other factors? The merit awards themselves have given rise to such criticism and resentment in so many cases in the medical profession that the Government should reconsider whether the money, about £11 million, could not be spent perhaps as incentive awards. These could be used to encourage consultants, for instance, to undertake full-time work within the National Health Service.

At the moment only one-third of the consultants work full time in the National Health Service and the other two-thirds do only part-time work. Many of the latter are also, as well as getting merit awards, earning in private practice outside the service. It surely is unfair to the full-time workers in the service who do not receive merit awards to see what extra payment that other consultants might be getting.

Also, incentive awards could be designed to encourage doctors to specialise in less glamorous subjects in which there is a serious shortage, such as psychiatry or geriatrics, and they could also be designed to encourage consultants to settle and work in industrial areas where there is often a chronic shortage of consultants in various specialties.

I ask the Under-Secretary to carry out, not only at my request but at that of the BMA's annual representative meeting, an urgent review of the whole merit award system.

3.23 a.m.

The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)

It maybe for the benefit of the House if I start by outlining the distinction awards system and then say something about the aspects which the hon. Member for Halifax (Dr. Summer-skill) has mentioned.

First I shall deal with the origins of the system. Distinction awards for consultants date right back, as the hon. Lady said, to the beginning of the National Health Service and are associated with Nye Bevan. He introduced distinction awards, accepting the recommendation of the Spens Committee, which argued that If the recruitment and status of specialist practice are to be maintained, specialists must be able to feel that more than ordinary ability and effort receive an adequate reward", and that any satisfactory system of remuneration for consultants must involve differentiation dependent on professional distinction. The Pilkington Commission—the Royal Commission on Doctors' and Dentists' Remuneration—examined the system thoroughly and its report in 1960 endorsed it generally. As the Royal Commission proposed, since 1960 the number and value of awards has been determined on the recommendations of the Review Body on Doctors' and Dentists' Remuneration.

To be eligible for a distinction award a doctor or dentist must hold a consultant appointment and be under the age of 70. A consultant who holds an honourary appointment with a hospital board as a clinical teacher or research worker, and who devotes an assessable amount of time to National Health Service clinical work, is also eligible. Consultants who work part time for the hospital service are eligible to receive a distinction award on a pro rata basis.

Awards are made by the Secretaries of State of the three Health Departments on the recommendation of an independent Advisory Committee on Distinction Awards. This is predominantly professional body composed of members of the medical profession appointed by the Secretaries of State on the nomination of Royal Colleges, other medical faculties, the MRC and universities. There are currently 19 members, including the Chairman, Sir Hector MacLennan. There is a non-medical Vice-Chairman, Sir David Trench—a former important colonial Governor. Sub-committees advise the main committee on awards to Scottish consultants and dental consultants.

When the scheme was introduced the number of awards bore a fixed percentage relationship to the total number of consultants eligible. However, the Royal Commission recommended that this system should be replaced by a fixed number of awards, and that the Review Body should be responsible for suggesting any alteration in the number which might be required by conditions prevailing from time to time. The number is flexible and does not necessarily have any absolutely unvarying percentage relationship. What broadly guides the Review Body is the notion of the substantial minority which was mentioned by the hon. Lady.

The Third Report of the Halsbury Review Body, published on 5th July this year, recommended some increase in the number of distinction awards available which approximately matches the increase in numbers of eligible consultants. There are now available for distribution 119 A-plus awards value £7,350, 434 A awards, value £5,577, 1,256 B awards, value £3,273, and 2,743 C awards, value £1,392. These figures relate to Great Britain. The total possible cost of these awards comes to £11.2 million assuming that they were all paid in full, but estimated figures gives an actual cost of £9.8 million. The Review Body recommended no increase in the value of these awards on this occasion. Approximately one-third of eligible consultants hold awards at any one time, and over his career a consultant has approximately a 50 per cent. chance of obtaining some kind of award.

Awards that have become vacant through the retirement, death, etc., of award holders, and any new awards resulting from the recommendations of the Review Body, are distributed annually. The advisory committee takes the greatest care to ensure that as far as possible the claims of no consultant are overlooked, and advice is sought and received from many local and national sources. These include regional awards committees, made up of the professions' own nominees; medical committees of undergraduate and postgraduate teaching groups; ad hoc regional hospital board committees; the Royal Colleges; the Medical Research Council; the public health laboratory service, and individual consultants themselves.

The chairman has made it known that the advisory committee will consider advice from any professional quarter, and I understand that many consultants and others write in to support particular colleagues. Although there is no formal appeals procedure, the advisory committee is always prepared to receive representations from a consultant on his own behalf, and these too are considered with other advice.

In addition to the advice received in this way, the chairman and vice-chairman of the advisory committee make annual visits to each region to probe, assess and expand the recommendations and advice received. On these visits they consult the local committees which have made written recommendations and also other groups. In 1972, for example, 33 centres outside London, including of course all the main provincial centres of medical services, were visited as well as the four metropolitan regions themselves. The programme of visits is varied as much as possible for year to year.

Normally the advisory committee holds its main meeting in January each year when it has before it the information culled from the sources I have referred to. All recommendations are made by the full committee, which has before it details of all eligible consultants. The Scottish sub-committee, whose sources of advice and procedure are similar to those in England and Wales, puts forward the names of consultants in Scotland.

I should say a little about the criteria for awards. In a recent article, published in Health Trends, Sir Hector MacLennan wrote: Given the large number of specialties … the variety of circumstances in which specialist medicine is practised in the National Health Service, and the different types of contribution that a man can make to his specialty and his hospital, it would be very surprising if we could distil clear and absolute standards for use as rules of thumb to cover all cases. Certain types of cases are relatively straightforward. If, for example, a consultant clearly has international standing in medicine then he is a candidate for an A award … similarly, a consultant with a clear national standing in his specialty is a candidate for a B award … and a consultant with a clear regional pre-eminence would be strongly placed for a C award. Clinical excellence, in other words, is obviously a major consideration, but particularly conscientious teaching of junior medical staff or students or outstanding contributions to medical knowledge through research are other important aspects of a consultant's work which may qualify him for an award.

It is fundamental to the system that awards should be given for outstanding merit wherever that is found. That is right, in my view, but one result is that some specialties, for whatever reason, attract a higher proportion of gifted individuals than others. The hon. Lady fairly made that point. However, the trend in recent years has been for a reduction in the differences between the "best" and "worst" specialties.

A similar process has been going on between the proportion of awards in London, especially in the London teaching hospitals and those in the provinces. Indeed, in furtherance of its established practice the Doctors' and Dentists' Review Body in its 1973 review has regard to the advice of the chairman of the advisory committee. As a result, it recommended extra C awards to enable dedicated work under difficult circumstances to be recognised". The report made clear that the awards were intended for merit flourishing outside teaching hospitals and particularly in the regions". I am pleased to say that the Government were able to accept the recommendations for the extra awards together with the rest of the report. This is an attempt to redress the balance away from teaching hospitals towards non-teaching hospitals and away from London towards the provinces.

One aspect of the distinction awards system which has provoked a good deal of discussion from time to time, and which the hon. Lady criticised particularly, is the non-publication of the names of award holders. The matter was recently discussed again by the medical profession at its annual representative meeting. The Department, however, has not received any consequential representations from the profession on the matter as yet. They may come in due course, in which case we shall give careful consideration to them.

The advisory committee itself decided in favour of non-publication when the system was established, and this practice was unreservedly endorsed by the Royal Commission. There are two good reasons for not publishing the names, as opposed to the numbers and distribution, of award holders. The reputation of those who are worthy of an award, or a higher award, if they are unable to attain one immediately because of the restricted number of awards available, is protected by the discretion that is observed.

The practice prevents patients and members of appointments committees from forming value judgments on consultants without having the advantage of knowing all the factors which would have caused an award to be granted or not granted.

It is particularly argued that the effect upon the consultant-patient relationship of publication could only be harmful in that patients might be induced to judge the quality of treatment by the rate of remuneration of the consultant in whose charge they were placed. The Royal Commission pointed out that it is not always necessary in a public service that the remuneration of individuals should be made public, and instanced the general practitioner as an example. It might also have mentioned the dentist in general practice.

Dr. Summerskill

Will the Under-Secretary give his opinion on these conflicting views? He is quoting various authorities and says that he has not received the BMA's request. Do the Government feel that there is a case for reviewing merit awards, and particularly the secrecy aspect, because of the point of view of the taxpayer or of Parliament, or are they simply waiting for the BMA to ask them to review the secrecy aspect? Is there to be no sign of any action until the BMA asks for it?

Mr. Alison

This is very much a matter which has been determined by a coming together of a range of interests and concerns, starting with the political initiators of the service, supported by the profession with which it was mainly concerned. From the political side, I see no disadvantage to the taxpayer in the system. There would be a much greater disadvantage to the taxpayer in the hon. Lady's proposal that merit awards or higher fees should be associated with posts and not with individuals. The likely cost to the National Health Service would then be a great deal higher than is the cost of the discriminating merit award system that we have now.

On secrecy, I see nothing offensive in the present system. I see positive advantages, for the two reasons I have suggested, and no clear, overwhelming advantage to the other side that would suggest a great public gain if all the recipients of awards were named with individual connotations.

However, if the profession's view of the matter is evolving and it has misgivings about the secrecy, we shall reconsider it. We are anxious to preserve professional reputations and the efficacy of the way in which consultants can deliver their service in the context of the National Health Service. Nothing is fixed and final. If the profession wants change, there will be change over a period. But I have heard no arguments on the side of disclosure strong enough to overwhelm the advantages we derive from the tradition of discretion in the matter.

The medical and dental professions must themselves in the end give a clear expression of view on the matter. We should be prepared to consider most carefully any representations from that quarter in favour of change, but we have not yet received formal representations—or informal representations.

Although the names of individuals are not published, a good deal of important statistical and other relevant information is published annually in the Department's annual report. The 1972 annual report was published earlier this week. The report contains the names of the advisory committee and its dental sub-committee; the age groups of consultants receiving awards in the year; the number and percentage of award holders by teaching, non-teaching and joint appointments; and the distribution of awards by region and by specialty. Moreover, the chairman of the advisory committee has addressed many meetings throughout the country, open to all consultants, on the workings of the system. He has also recently published a comprehensive article in the Department's domestic journal Health Trends, which all National Health Service doctors in England and Wales receive.

I hope, therefore, that the House as a whole will agree that although, for reasons which I have explained, a degree of confidentiality necessarily attaches to the system of distinction awards, at least for the present, this long-established system has a useful place in the health service today.

The hon. Lady's initiative in raising the matter will, however, serve to bring more fully home to the public what is going on and what the issues are. If changes are desired, I am certain that in the next 25 years, as in the past 25, the system can evolve and develop to meet contemporary needs.

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