NHS consultant contract falls short of securing intended benefits

In December 2003 an amended consultant contract was introduced in the NHS in Wales with a number of intended benefits for both consultants and the wider NHS. Between 2004 and 2011 some £35m was spent implementing the new contract which sought to improve consultants' working environment, enhance recruitment and retention, and encourage co-operation between health managers and consultants to provide a better service for patients. Effective job planning for consultants was central to securing these benefits.

Positively, consultant recruitment and retention have improved since the amended contract was introduced, with the number of full-time consultants increasing by 37 per cent between 2004 and 2011, and vacant posts falling by 6.3 per cent over the same period. In addition, the average length of a consultant's working week has reduced as a result of the amended contract. However, some consultants are still working excessively long hours. The audit found around one in six are working at least 46.5 hours and often exceeding the 48-hour European Working Time Directive limit.

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Since its introduction in 2003, significant sums of money have been spent implementing an amended NHS consultant contract in Wales. Despite this, the intended benefits for the health service are not being fully realised, largely because of weaknesses in consultants' job planning arrangements. Those are the conclusions of a report published today by the Auditor General for Wales.

In December 2003 an amended consultant contract was introduced in the NHS in Wales with a number of intended benefits for both consultants and the wider NHS. Between 2004 and 2011 some £35m was spent implementing the new contract which sought to improve consultants' working environment, enhance recruitment and retention, and encourage co-operation between health managers and consultants to provide a better service for patients. Effective job planning for consultants was central to securing these benefits.

Positively, consultant recruitment and retention have improved since the amended contract was introduced, with the number of full-time consultants increasing by 37 per cent between 2004 and 2011, and vacant posts falling by 6.3 per cent over the same period. In addition, the average length of a consultant's working week has reduced as a result of the amended contract. However, some consultants are still working excessively long hours. The audit found around one in six are working at least 46.5 hours and often exceeding the 48-hour European Working Time Directive limit.

Disappointingly, the amended contract has not driven service modernisation in the way originally envisaged. Less than half the consultants who responded to a survey during the audit felt the amended contract and job planning had led to better clinical practice, and even fewer of them thought it had improved patient care and consultants' working methods.

Whilst there was a clear focus on consultant job planning when the contract was first launched, this has diminished over time, such that current job planning arrangements in most health boards and NHS trusts are not sufficiently robust. The audit found only 61 per cent of consultants in Wales had an annual job plan. Where job plans exist, their contents vary widely, few have measurable outcomes and more needs to be done to promote consistency between and within NHS bodies in Wales.

Furthermore, only 20 per cent of consultants said their job plan identified the resources and support they needed to do their jobs. Worryingly, the audit found managers were often not part of the job reviews, which contradicts a key aim of the contract, which was co-operation between consultants and NHS managers to improve services for patients.

Typically, job planning is compromised by a lack of meaningful information to aid discussion on planned activities and desired outcomes. In 2005 the Welsh Government launched an initiative costing £1.9 million to develop a set of Consultant Outcome Indicators (COIs) to support job planning and consultant appraisal. However, by 2009 the project was abandoned because of concerns over the quality of the data underpinning the indicators. Without meaningful outcome information, job planning will inevitably concentrate on timetabling consultants' schedules rather than how consultants can enhance the services they offer.

The Auditor General, Huw Vaughan Thomas, said today:

The amended Consultant Contract has increased the number of consultants and the majority of them now have a shorter average working week. However, I am concerned that fewer than half the consultants questioned in the audit felt the contract has helped modernise the services they offer to patients, especially as this was one of its principal aims.

My report emphasises that effective job planning for consultants is essential if the contract is to secure its intended benefits. I hope the Welsh Government and NHS bodies adopt the clear recommendations in the report.

The report makes a number of recommendations which include the following:

• NHS bodies need to agree on clear objectives and outcomes in all consultants' job plans.
• It is important to ensure that clinicians and managers involved in setting these objectives and outcomes receive appropriate training and support to do this job.
• NHS bodies can help by developing an information 'framework' for each consultant specialty.
• Consultant job plans should be annually reviewed, ensuring they reflect clinical priorities and consultants' professional development, and include input from general managers.
• The Welsh Government needs to promote consistency in consultants' job plans at all NHS bodies by updating the all-Wales guidance published in 2003.
• The Welsh Government and NHS bodies need to state clearly what supporting professional activity (SPA) work consultants will do, and ensure it focuses on positive results for patients and consultants rather than quantity.
• The Welsh Government should evaluate why the COI project failed and how any lessons learned from it could help to identify new benchmarks for consultants' job plans.
• More needs to be done to identify fair and meaningful measures of consultant productivity to enable a clearer assessment of the value for money that is being achieved from pay modernisation.

ENDS

Notes to Editors:

• This report tracks the progress of the amended consultant contract for the NHS in Wales since its introduction in 2003, and is not linked to the National Audit Office report Managing Hospital Consultants which covers the NHS in England and was published on 6 February 2013.
• The first NHS consultant contract dates from 1948, when the NHS was founded, and essentially remained unchanged until the amended contract was introduced in Wales in 2003.
• The contract is a legal requirement for all consultants in Wales.
• The audit team sent a web-based questionnaire to all consultants at participating health boards and trusts in Wales in September 2010. There were 580 responses - an average response rate of 25 per cent.
• Consultants' job plans record their work under four main categories: Direct Clinical Care (DCC), Supporting Professional Activity (SPA), management sessions, and other activities.
• The Wales Audit Office's mission is to promote improvement, so that people in Wales benefit from accountable, well-managed public services that offer the best possible value for money. It is also committed to identifying and spreading good practice across the Welsh public sector.