Government makes U turn on private practice ban
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7352.1473/a (Published 22 June 2002) Cite this as: BMJ 2002;324:1473All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
"Politics is not the art of the possible. It consists of choosing
between the disastrous and the unpalatable" wrote a former US presidential
adviser. Under these circumstances it is not surprising that both the
government and BMA would wish to put the best spin on the outcome of the
consultant contract framework negotiations. The headline "Government makes
U turn on private practice ban" and the BMA claim that "The government has
had to face the most phenomenal climb-down in medical negotiations for a
long time" are as accurate as a headline proclaiming "Consultants stuffed,
trussed, and well and truely roasted by Health Department negotiators".
The truth is probably somewhere between the two as there is still
effectively a private practice ban on part-time contract holders, who will
be largely, and from a legal point of view significantly, female.[1] For
the first seven years they would have to work an additional 24 hours or
more for the NHS to reach the 48 hour working time directive limit beyond
which they would be allowed to do private practice. This perhaps does not
fit in with the Department's Improving Working Lives initiative.
Specialist registrars should be allowed to vote on the contract proposals
for this reason alone, or is the BMA going to revert to the voting
practices of the late 1800s and early 1900s?
There are many positive aspects in the contract that will be of great
benefit to patients and enable a patient-centred service to be delivered.
Consultants will have to be more accountable for their time and be on site
more often to support junior doctors and other health service staff. The
flexibility of the contract and the option to have an annual hours based
contract makes great sense - this was not a BMA initiative and the BMA is
still selling the contract as a 10 x 4 hour sessional victory. This is
more spin rather than a clear explanation of the facts and available
options.
Juniors and seniors have raised concerns about not being paid extra
for unsocial hours but why should this happen? Senior managers, nurses,
porters, and other health service workers do not have access to huge sums
of money on offer to consultants in the form of discretionary and
distinction awards or whatever will replace these.[2] Does any consultant
really add £30 - 60,000 extra value to the NHS year after year? This does
cause resentment and not only in the ranks of consultants who have been
acknowledged by the government as frequently working beyond contract and
therefore doing something for nothing. Award holders at least have been
working on a something for something basis for some considerable time and
supported in that achievement by their consultant colleagues, juniors, and
health service teams. There should be fair pay for all within the NHS to
fit in with Labour's fair pay policy.[3]
The Agenda for Change looking at pay across the NHS has at its core
the principle of equal pay for equal work. If the Director of Facilities
leading on a trust's estates, facilities and hotel services functions is
worth an inclusive salary of £90,000, what is the value to the NHS of a
newly appointed consultant, or even an established and experienced
consultant, who is required to be part scientist, part moral philosopher,
part dextrous technician, part diplomat and part business manager?[4] If
it's the same or greater then the pay cake available to fund the
consultant contract will have to be cut in a very different manner from
that proposed. A debate free from spin is required.
1 Mather HM. Specialist registrars' plans for working part time as
consultants in medical specialties: questionnaire study. BMJ 2001;322:1578
-9.
2 Dudley N. Remuneration committees have no excuse to ignore clear
and detailed pay guidance. Health Serv J 2002;112 (5804):21.
3 Dudley N. Off limits. Health Serv J 2002;112(5800):28-32.
4 Review Body on Doctors' and Dentists' Remuneration. Twenty-Eighth
Report 1999. Chairman: CB Gough, Esq. Page 125. The Stationery Office,
1999.
Conflicts of interest: full-time consultant with a discretionary
award, no private practice, supporter of most of the red team's current
NHS policy - but this may change.
Competing interests: No competing interests
Sir
As an exercise in PR, the BMA invited consultants to pose questions
concerning the new contract with the welcoming words 'We will attempt to
answer all emails individually'. In doing so, I find the BMA 'are unable
to enter into detailed correspondence on an individual basis'.
My personal concerns relate to the preservation of Mental Health
Officer status under the new terms. After such a protracted period of
negotiation, the BMA should have placed itself in a position whereby it
could answer queries with speed and accuracy. In failing this, fear of the
unknown will surely cause us all to vote 'No'.
John Morgan
Competing interests: No competing interests
I am not a Consultant now, but hope to be someday- but not a Hospital
Consultant!
I was in hospital jobs till recently and made a move to Public Health
medicine, which is the only other branch I had any experience of, and
hence the natural choice, a few months ago. The move was in fact
precipitated by the Hospital Trust's move to stand my current contract on
its head and remodel the rotation in an unpalatable way.
It was a tricky decision and seen in poor form by some of my peers, but
after reading the ongoing discussion on Consultant Contract, I do feel
that this was the best trade off one could manage.
The issues raised by insensitive and undervalued Pay Awards to
Doctors are:
1. Loss of Market Control:
Once there is no longer any control for the Person who puts up the
"Effort" in the market, there is the very real danger of the products
being undervalued by those intersted only in Cost Control, and this is
going on in the Medical profession in a big way.
2. "Humanitarianism" vs. "business":
It is a foregone conclusion that, in this day and age, most aspects of
medical care is run as a business, except for the input by Medical &
in some cases, Nursing Professionals. Doctors who are brave enough to ask
to be valued approptriately, are subdued by the system with threats of
being branded as "inhuman". Surely there is a case for reinventing the
profession along uniform lines?
3. Loss of Progressive attainment of "Higher value" for "Less Acute
effort":
With the progression of structural modifications in training, more and
more Consultants find themselves in the position of Senior Registrars of a
Decade or so ago- constantly at the Coal Face. The easier life when the
Senior trainees would take up the bulk of responsibility for the sake of
learning experience seems to be fast receding. It is unlikely to return
for fear of a rise in the tide of litigation and general loss of trust.
Hence being On call for "a pound an hour"(!) is more likely to be the rule
rather than the exception if the profession progresses on this scale.
A clarification on Junior Doctors' pay deals as they stand now. Dr
Smith remarks that: "Junior doctors have spent years getting unsociable
hours working remunerated at above standard rate." In fact this is not the
case, as was pointed out at the beginning of the implementation itself.
They are paid 10 - 70% ADH/ banding, NOT 110- 170%. Hence it is only a
fraction of the standard rates than above-standard rates.
Competing interests: I wish to express my sincere gratitude to the
profession for making me realise the Wisdom of my decision once more.
Competing interests: No competing interests
My consultant colleagues and I, work an on-call rota described as
medium frequency under the proposed, new consultant contract. With only
junior, Senior House Officers between acute admissions and us, we are
frequently telephoned in the middle of the night, when on-call. Under the
new contract, we would get a supplement of either 2% or 5% of our basic
salary for this on-call.
I calculate that we will clear after tax between £0.57 and £1.62 for
each hour on-call, depending on seniority and the value of the supplement.
This is similar to the amount that our endoscopy unit nurses receive for
being on-call for out-of-hours gastroscopies, which occur once or twice a
month. The proposed supplement for on-call is derisory.
Competing interests: No competing interests
I went straight to my computer after clinic this afternoon to read
the latest in the BMJ on the new contract. I see no comment in it! Are the
BMA just reeling from the sustained assault following their "victory", or
have they washed their hands of the affair. Might I suggest a commissioned
article by a couple of employment law specialists ( and perhaps a Human
rights Lawyer) so that we may see how truly awful the proposed framework
is
Competing interests: No competing interests
Rapid responses so far,suggest an overwhelming rejection of the
proposed ‘Consultants Contract’ negotiated by the BMA. There is further
bad news; a survey conducted by the Hospital Doctor[1] confirms that 91%
of consultants would say “no” to this proposed contract. It cites the
Chairman of the Royal Cornwall Hospital’s medical staffing committee as
saying[1],“There was a universal call for the negotiators to resign and
for us to get new negotiators”. It must be a tough time for the BMA, and
indeed, Dr Hawker, who in fact, took part in another ‘battle’ which had
caught media attention for different reasons—the BMA being found guilty of
unlawful race discrimination, and the record damages over £800,000.00[2].
In fact, Dr Hawker was a leading witness in BMA’s abortive defence in this
case, and an among other things, the Manchester employment tribunal
found[3]:
“Even more surprisingly, Dr Hawker revealed to us late in his
evidence that the respondents had already established a Racial Equality
Working Party at this time, but he could not tell us what its terms of
reference were and we find it clearly was not involved in any of the
relevant decisions in this case”
So there are two major concerns for BMA members at the present time;
the consultants contract and the damning ‘race award’. Surely, it must be
a difficult time for Dr Hawker, and he will have to work hard to restore
BMA’s credibility.
References
[1] Hospital Doctor;News:27 June 2002
http://www.hospitaldoctor.net/hd_news/hd_news_article.asp?ID=7033&Sectio...
[2]Hospital Doctor;News:27 June 2002
http://www.hospitaldoctor.net/hd_news/hd_news_article.asp?ID=7024&Sectio...
[3] Mr Rajendra Chaudhary-v-BMA; Case No: 2401502/00 (Manchester
ET,Reserved Decision,24 September 2001, para.72)
Competing interests: No competing interests
Sir, I would be grateful for further information as to what exactly
the proposed contract offers in regards to pensions arrangements, as this
seems to be an area couched in rather vague language. Is the pension
remaining final salary, and cannot this be explicitly stated now prior to
any vote.
With reference to vague language it appears that many clauses are
preceded by should, usually and is expected. Whilst guidance notes and
recommendations can be made on interpretation, ultimately more clarity of
language would help.
This is particularly so in relation to the discussion of job plans which
appear to be able to be imposed by your employer as well as in respect of
progression up the pay scale.
I am also dissapointed both at the failure to implement any agreement back
dated to April 2002 as suggested originally. The fact that appointments
above bottom of scale will effectively be ignored and represent pay cuts
to many, especially in the already shortage specialities. I would not be
suprised to see many recently appointed consultants having to change jobs
to cope with this loss of income.
Competing interests: No competing interests
From what I have read so far, I dislike this framework agrrement. It
has removed our ability to work in a professional manner, and organise
activity for the benefit of our patients. The idea of the rigid session
where attendance in the hospital is mandatory means that no activity will
be started in future if it may overrun the end of a session, and there
will be no stimulus to be efficient and get more done, as an early end to
the session is now not rewarded. Although this flexibilty is abused by a
small minority, the vast majority use it to organise work as efficiently
as possible. Am I to be paid for my meal breaks? If not, I will have to
take them as a matter of right, as I would be a complete mug if I worked
over a lunchtime I was not paid for. The new contract rewards the 'clock
watcher' and treats the doctor who stays until the job is done as an
idiot. The only staff left on a professional contract will be the
management, and I am afraid I simply do not trust the 'we would never
interpret the contract in that way' that I have heard said so far. If it
is written down, it can be enforced.
As far as any pay rise is concerned, I do not understand why, as a
consultant of some 14 years it will take me 23 years from appointement to
reach the salary maximum, whereas a newly appointed consultant would take
19. I wrote to Douglas Bilton, acting secretary of the CCSC on this
matter, and recieved the reply that this was the best that could be done
to bring the deal in under the financial limits imposed. Not good enough.
I have no problem with new starts being awarded a decent salary, but a
whole lot with me and my colleagues being discriminated against. After all
, we were the ones who also did a large number of appalling rotas, and did
not get the salary or time off given to the present trainees. Why should
we be penalised again? If the contract needs to be phased in, then an
equitable scheme for all should be sought.
While the idea of payment for emergency work and so on out of hours
is laudable, it has always been possible to locally negotiate sessions to
cover onerous on-call committments. All that has happened so far is that
this principle is to be formalised nationally, but with the loss of
recognition of the nature of unsocial hours.
I think it's a bad deal. We can do much better and for the good of
the service we certainly ought to. The negotiationg committee should take
this framework back.
Competing interests: No competing interests
Have you taken a close look at the hard copy of the framework
agreement that dropped through your letterbox this week? The cover
depicts two prisms bending light in ways that defy the laws of optics.
There's a metaphor there somewhere...
Competing interests: No competing interests
Re: Consultant job plans
Steve George makes a series of well argued points. What has not been
addressed (and I do not seek to take him to task over this) is the
potential impact on the NHS of a de-facto ban on private practice by NHS
consultants. My experience is that the vast majority of patients treated
in the private sector are entitled to NHS treatment. If HMG succeeds in
its apparent aim, which is to severely restrict private practice by NHS
consultants, how will this affect NHS service provision? Do they feel
their policies will be largely ineffective or do they think changes will
come about; in the latter case, what do they imagine the result will be? A
large-scale exodus of consultants to the private sector would probably be
unwelcome, but how much better would it be if there were to be a sharp
reduction in private sector provision?
Competing interests: No competing interests