Nye Bevan, founder of the NHS, famously said that in order to persuade hospital consultants to join the nascent organisation, he had ‘stuffed their mouths with gold’. Nearly 60 years on from its foundation, the relationship between the UK’s health service and its consultant body, while at times still uneasy, has changed almost beyond all recognition.
At the heart of this shift is the new consultants’ contract, introduced in 2003. Prior to the contract, high-profile scandals such as the Wisheart affair at Bristol Royal Infirmary over the treatment of premature babies, the actions of gynaecologist Rodney Ledward towards his patients and to a lesser extent, those of mass murderer Harold Shipman, had left many consultants feeling disillusioned and defensive.
There was also a distinct sense, at least in the early days of Tony Blair’s Labour administration, that this was a government that thought negatively of consultants. Constant low-level mutterings within Whitehall about how consultants disappeared off to their private practices or to the golf course all the time left many feeling that their contribution to the NHS, and the hours and effort they put into the service, were going unrecognised.
The new contract was supposed to rectify this, in particular giving managers (and consultants themselves) a much clearer idea of their workloads and how much time they were and should be devoting to the NHS.
Under the terms of this contract, new working hours were set, with the option of additional sums being paid for things such as clinical excellence awards and on-call availability. But in return for larger financial rewards, the contract gave managers greater control in planning consultants’ work, with all consultants having to agree to a formal job plan with their trust. Further restrictions were put on the level of private work they could carry out, particularly early on in their
CONSULTANT MANAGEMENT WORLDWIDE
This may be uncharted territory for the NHS, but in the US such linking of pay to performance, as well as monitoring performance and looking at the notion of value-based purchasing, is relatively old news. Earlier this year, for instance, the US Congress offered physicians a 1.5% bonus if they chose to participate in a voluntary Physician Quality Reporting Initiative.
The initiative, which is run by the Centers for Medicare and Medicaid Services, outlines 74 quality measures that physicians can report on. The bonus, a lump sum set to be paid out in the middle of 2008, is 1.5% of total allowed charges for covered Medicare physician fee schedule services.
It is awarded to those who achieve an 80% success rate for patients with a disease / diagnosis in the quality measure they have selected and attain that success rate for at least three quality measures.
In France, a programme to promote professional development among physicians, with a focus on performance in practice, was introduced in 1998. Physicians in private practice were allowed to join it on a voluntary basis. Such was its success that the programme, regulated by the same body that accredits hospitals in the country, became mandatory for all physicians from 2005.
THE HR VIEW
For the British HR professional, the first challenge of working within this new framework is that consultants are unlike almost any other body of employees. Ann MacIntyre, director of HR at the Healthcare People Management Association and director of HR at Barts and the London NHS Trust, shares this viewpoint. "They are professionals," she says.
"Ever since the NHS was founded, consultants have had fluid leadership structures and a fairly autonomous relationship with management, and ensuring this is a challenge. Consultants are intelligent people and it can be uncomfortable asking such people what they do with their time. Measuring performance in this way is something that has often been quite alien to them."
What job planning means in practice is a consultant sitting down with their clinical manager to decide on their job purpose, service objectives and personal objectives. At the same time, agreement can be reached on what resources they need to meet their job plan, where they will be working and their timetable.
Another key change has been the development of team-based job planning. Rather than a consultant looking at what they are achieving as an individual, the clinical activity of the whole team is projected. For instance, a histopathology team job plan would outline the key weekly work patterns (large specimens, biopsies or post-mortems), diary exercises for individual consultants, the team’s duties when it comes to direct clinical care, any supporting professional activities and a
projection of future workload. An examination of the team’s objectives and resources would also be required.
"What it does is give people a greater level of flexibility and autonomy," argues MacIntyre. "So if someone is going to be away, it is much easier to plan for someone else to take over their work." There is also a benefit in that team planning encourages better peer and team review. "If there is, say, a renegade within the team, there is nothing better than the consultant, rather than a manager, identifying that themselves and pulling them back in, " she points out. "There is a pride within consultants, so it is about harnessing that and making them part of a better clinical unit."
While some organisations have taken a crude ‘command and control’ approach to consultant job planning, others have focused much on encouraging ‘earned autonomy’. Rewards for high performers offer an incentive for improvement elsewhere in the NHS. This could mean a doctor being granted income for research after wider agreement with the hospital. Then, being allowed to invest the proceeds from the research back into their unit as they see fit, rather than it simply being swallowed up within the wider hospital pot.
"It just underlines that there is a sense of pride and that people do like to manage their own resources," says MacIntyre. "Doctors do not like being told what to do and they do not like being closely managed. So managing them is about how you give them discretion and autonomy."
RESULTS OF THE FRAMEWORK
But has any of this worked? Are consultants now offering better quality care in a more effective way? A report by the UK Government’s spending watchdog, the National Audit Office, in April 2007 was ambivalent, suggesting that, while clear benefits had been achieved, there was still a long way to go. Many consultants were still less enthusiastic about the benefits achieved than were NHS managers.
Shortcomings of the contract included a failure by the Department of Health to collect sufficient evidence on the actual numbers of hours worked by consultants in the NHS. As a result, workloads were underestimated and the ability to judge the costs of the new contract undermined. Too few trusts set cost boundaries when negotiating consultant job plans under the new contract. This leads to trusts agreeing to more hours than they had budgeted for, resulting in cost overruns.
MacIntyre agrees that in an organisation as huge as the NHS, the way in which consultants are managed as a result of the new contract is still evolving. But from an HR perspective, one of the biggest successes is simply the fact that consultants have mostly accepted and embraced the use of profiling and job plans, leading to much more transparency and a greater sense of partnership.
"Both sides have been going through a cultural shift since the new contract," she adds. "The NHS is changing, and what is expected of consultants is changing too. They are now increasingly expected to be business partners, rather than just service deliverers."
Measuring performance among consultants is a sensitive issue, but tackling it as a way of boosting departmental funding, organising workloads and allowing greater interaction between doctors and managers has so far had a positive global effect. A continually evolving system hopefully means that the UK will follow in the management footsteps of the US and Europe.