NHS Consultants (Hansard, 20 March 2002)

§ Ian Lucas (Wrexham)
National health service consultants are the engine that drives the hospital sector. In the deluge of reforms that has swept through the NHS in the past 20 years, it is remarkable that the contract that governs the way in which NHS consultants work has remained largely unchanged since 1948. Therefore, I very much welcome the proposals that the Government published in February 2001 for a new approach to the consultant contract.
As a former non-executive director of an NHS trust, I am well aware of the prodigious commitment of some NHS consultants to their patients. They work long hours above and beyond the call of duty to treat patients who are in pain and need the professional skills that they offer. But I am also aware that there are consultants who are employed in the NHS, especially some of those who work under part-time contracts, who spend a great deal of their time working outside the NHS in the private sector.
Danger of abuse in the health service is always at the point where private commercialism impinges on the service. Abuse occurs when an attempt is made to marry the incompatible principles of private acquisitiveness with a public service. It was Aneurin Bevan who identified that problem in "In Place of Fear" more than 50 years ago. Half a century later, that problem affects the care of NHS patients.
At the outset, it is worth noting the present pay levels of NHS consultants. Under the present contract, the basic pay scale is between £50,000 and £66,000 per annum, although discretionary points can lead to salaries in excess of £80,000 being paid. Over and above that income, NHS consultants can earn very large sums from the private sector. I commend the excellent report of the Health Committee on consultants' contracts in the previous Parliament, which revealed that from 1999, the estimated annual average private earnings of NHS consultants in plastic surgery exceeded £75,000 and in orthopaedics were almost £59,000.
There is some evidence to show that that figure is likely to have substantially increased in recent years. The pressure to reduce waiting lists means that more public money is being used to employ NHS consultants outside the NHS and some consultants are exploiting their monopoly position to increase their income.
This week, the Financial Times reported one NHS trust chairman as saying: Consultants have suddenly realised they are in short supply and that they have market power. Last year we settled at a price of around £600 a session … We are now negotiating for what we will pay them after April and their opening offer to us is £1,500. On 17 March, The Sunday Times reported that one David Taggart, a consultant surgeon at the Oxford John Radcliffe hospital, was paid £34,000 over and above his salary for operating on his own patients to reduce waiting lists.
One of the commonest complaints in my constituency surgeries is from those who have been given a waiting list appointment, but who are then made aware that if they were treated in the private sector they could secure the 410 same treatment, often from the same doctor, almost immediately. That gives consultants a perverse incentive to keep waiting lists long and to encourage trusts to use additional public funding to buy health care from them in the private sector. That boosts their private income and means that long waiting lists give financial benefits to those consultants.
To my surprise as a trust board member, I learned that boards have no idea how much the consultants they employ actually earn from the private medical sector. Even more disturbing is the fact that NHS trusts have no means of knowing how many hours consultants are working in the private sector. In the era of clinical governance, that is simply intolerable. I was the chairman of a clinical governance committee with a responsibility for assessing the quality of work carried out by consultants. How can that be done when the committee has no means of knowing how many hours a week its employees, who are often carrying out hugely complex surgery, are working?
It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.
Motion made, and Question proposed, That this House do now adjourn.—[Mr. Kemp.]

§ Ian Lucas
Until there is full disclosure by NHS consultants of the work that they do in the private sector, there will be doubt that they are fully committed to NHS work and that they are not working excessive hours in the pursuit of profit. Openness is in the best interests of doctors, the NHS and patients.
I know that the Government's proposals for a new NHS contract were greeted with howls of outrage from the British Medical Association. I admit that this is a difficult issue, but I urge the Government to stand firm on the principles laid out in their proposal for a new approach to the consultants contract in February 2001.
As someone who was part of a management team at an NHS trust hospital, I do not believe that the present contractual arrangements allow NHS managers to manage consultants, who are some of their most important employees. Floating sessions allow consultants maximum freedom to work as they wish and give managers minimum power to ensure that consultants work within the aims of the NHS trust by which they are employed. In a letter to The Daily Telegraph published on 28 February, Mr. John Hale, who worked in the NHS for 15 years, wrote: one of the biggest drains on the service was consultants with part-time contracts. They spent fewer than their contracted hours working for the NHS, concentrating on their private practices. As a consequence of their commercial activities, many consultants are late arriving at their out-patient clinics or operating sessions and frequently do not attend at all. Consultants operate on the basis of good will, not contractual obligations. In the modern NHS, in which strategic planning is of vital importance, that cannot be allowed to continue.
I welcome the fact that the BMA agrees that greater transparency should be the basis of the new contract. Consultants should know what is expected of them, managers should know what to expect from consultants, and patients should know that the generous pay levels thought to form part of the new proposed contract will fund real commitment to the NHS on the part of all consultants.
411 There is one further area of great concern. In February 2001, the Government proposed that new consultants should, for the first seven years of their contract, be prevented from engaging in similar work outside the NHS. It takes substantial public investment to train consultants; the private sector does not fund the training. It is right, in principle, that as the public sector funds the training, the public sector should benefit. However, it is not just a matter of principle. Those who manage the NHS tell me that such a change would dramatically increase the NHS work carried out by new consultants, which would help reduce waiting lists. The Government must therefore stand firm.
I suspect that the negotiations on the NHS consultants contract may come to a head soon. The key to successful reform of the hospital sector lies in a new NHS consultants' contract that harnesses the skills of consultants for the NHS. It has taken more than 50 years for this opportunity to come. Having created the chance for reform, the Government must not duck the issues.

§ The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)
I congratulate my hon. Friend the Member for Wrexham (Ian Lucas) on securing this debate on the important issue of NHS consultants' contract. I also acknowledge his expertise and experience in these matters, and his encouragement to the Government to stand firm in the negotiations that are currently going on.
My hon. Friend will know that the United Kingdom Health Departments—we are negotiating the contract on a UK basis; it is not just a matter for England—are currently working with the central consultants and specialists committee of the British Medical Association on the new contract. I hope he will understand that, while the negotiations are under way, I cannot discuss the details of what is under discussion. As he said, the negotiations are complex and difficult, but it may be helpful if I set out why we are engaged in trying to reform the consultants contract and describe the benefits that we are hoping to achieve for consultants and staff from the new arrangements.
We recognise the dedication and commitment of doctors throughout the NHS. We know that consultants do an excellent job for the NHS which patients very much appreciate. Consultants often work under real pressure and sometimes flat out to provide the best possible care for their patients. We want the new contract to provide a better framework within which we can acknowledge this commitment to the NHS and to the patients under their care.
We have delivered the largest-ever sustained increase in funding for the NHS, but resources alone will not modernise and improve the service. We need to make the whole system work better and be prepared to do things differently. We are beginning to see much of that change happening throughout the NHS, and our challenge is to make the change universal and to get good practice adopted everywhere. We need consultants to be at the forefront of this modernisation, leading clinical change and redesigning clinical services around the patient, so that we no longer have a top-down service. We want to put patients at the centre and to ensure that all the services meet their needs.
412 We must also recognise that consultants sometimes feel they are struggling against the system. They cannot always get access to theatre or out-patient slots and sometimes the equipment that they want is already being used. Too often consultants feel that they do not get rewards for their service—6 per cent. of all women consultants hold a distinction award compared with 5 per cent. for all ethnic minority consultants and 17 per cent. for all white male consultants. Clearly those issues need to be addressed.
We need to tackle the issue of private practice. We all know that the majority of consultants work extremely hard for the NHS, working long hours and showing outstanding commitment. We need to tackle head on any suggestion that there could be conflicts of interest between NHS work and private work by NHS consultants. The time has come to be transparent, open and straight with people about such issues. The place to do that is in the contract negotiations.
Many factors affect waiting lists and waiting times in the NHS, and not all of them relate to the availability of individual consultants, but they have a key role to play in making sure that waiting lists and waiting times go down. We need to be to able to reassure patients that there is no conflict between consultants' work in the private sector and their work in the NHS.
We want to develop a contract that sets out clearly arid unambiguously what is expected of consultants, that allows the NHS to make the most effective use of their time and that properly rewards consultants for their commitment to and performance in the NHS. That involves changing the way the system works to make it better for patients and consultants. We hope to do that through partnership in the negotiations that are currently taking place.
The NHS plan set out our plans to overhaul the contract and to work with doctors' representatives to try to achieve a mutually agreeable conclusion to the negotiations. We set out our proposals to develop the system of medical care in hospitals so that it becomes a more consultant-delivered service, with much more direct patient care being delivered by consultants. The NHS plan also set out proposals for an unprecedented increase in consultant numbers—equivalent to an increase of more than 30 per cent. since 1999. The Government have shown a real commitment to increase the number of consultants in the NHS so that patients can be seen more quickly and more effectively by very senior members of staff who can provide excellent quality care.
To make the best use of the increased number of consultants, we must have a clear contract that sets out the commitment of consultants to the NHS. The Government published detailed proposals on the consultants' contract in February 2001, building on the commitments set out in the NHS plan. These proposals, and the British Medical Association's proposals, form the basis of the negotiations currently taking place.
Our specific aims are to develop a system that gives better rewards to those who do most for the NHS, that gives proper recognition for the intensity of different working patterns, that makes better use of consultant time and effort, and that offers incentives and rewards to those who make a long-term commitment to the NHS.
The key elements of our proposals are a higher starting salary of £60,000, compared with the current salary of £51,000; additional pay thresholds that will take the basic 413 salary up to £80,000, depending on satisfactory performance; immediate access to a new and much more transparent awards scheme—replacing the current system of distinction awards and discretionary points—that will offer awards of up to £65,000 in addition to the basic salary; a new concept of phased careers, involving an initial phase of maximum patient contact and high-intensity working when people are at the beginning of their careers and have lots of energy, drive and enthusiasm; the scope to reduce work load intensity for more experienced consultants who might want to do other work or change their working patterns; and a new system of mandatory job planning, with annual job plan reviews. My hon. Friend made the important point that often NHS managers do not have available full information on what consultants are doing, and where, when and for whom they are doing it. A job planning system will make the process much more transparent.
A crucial part of the plan is an initial period of perhaps seven years during which newly appointed consultants would be restricted to working exclusively in the NHS. Following that initial period, there will be a choice of contractual arrangements, based on time and service commitments to the NHS. For NHS employers, such a contract will provide greater direct management of how a consultant's time is organised, and enable working together to design job plans. All activities will be programmed into that job plan, and an increased proportion of programmed consultant time will be devoted to direct clinical care. A clear restriction will be imposed on carrying out work for other organisations in NHS time, and the opportunity will exist to offer greater rewards for NHS service and good performance.
For consultants, the proposals offer a significant increase in pay and rewards, and better planning of their time. We recognise consultants' concerns about inability to plan work loads—particularly emergency work loads—into their job patterns. Indeed, the profession itself wants clarity in terms of its commitments. As I said, we want to ensure proper rewards and incentives in the system.
For new consultants, our proposals would provide 15 per cent. higher lifetime earnings than the current arrangements. After 12 years, the majority of existing consultants would be between 15 and 20 per cent. better off than under the current arrangements. The proposals offer a real incentive for maximising commitment to the national health service. For patients, better planning of consultant time will allow better use of staff, equipment and facilities, greater opportunity to plan the working day and shorter waiting times.
414 An intensive programme of negotiations is under way. They deal with job planning, organisation and timetabling of the working week, core working hours, the possibility of extended patient services, on-call and emergency work, starting salary, consultants' progression up the pay hierarchy, disciplinary arrangements and links to private practice.
I am pleased to say that good progress has been made, but some difficult issues still need to be resolved. We need to ensure that trusts and consultants work together to deliver the new contract and benefits for patients. Implementation has to be led by a strong programme of support and guidance, and we are working with the BMA to ensure that implementation can proceed smoothly, so that there are no disruptions to patients or staff.
This is the first fundamental overhaul of the consultants' contract since 1948, and we should not underestimate the work to be done. It is crucial that we get it right. We published our initial proposals in February 2001, and we have been working with the BMA since then to develop detailed proposals. Some tricky issues are involved, but we remain committed to seeing the negotiations through and improving the system.
Consultants throughout the NHS work very hard, and I understand that only 15 per cent. are on part-time contracts. Some choose such contracts for domestic reasons, and in order to have flexibility in their careers. We recognise that the vast majority of consultants work extremely hard for the NHS.
The current contract, largely unchanged for more than 50 years, is outdated. We are developing a new contract that will recognise consultants' contribution and also commitment to the NHS. We want to have a system in the future that is designed around the needs of patients, that recognises the skills that consultants bring to the service and that makes patients the driving force. That is not an easy task.
We are prepared to make a substantial investment in the right contract, and I have outlined the increases in pay and rewards that will be on offer for those who want to devote their time to working for the NHS. I am confident that we will have a package that will be seen as a major improvement on the current system and that will deliver the significant benefits we want to see for patients in the NHS. I am delighted that my hon. Friend the Member for Wrexham raised this important subject this evening and I welcome his support for the Government's proposals in the negotiations.