08 November 2002
Incentive payments for consultants who spend most of their time working for the NHS and a scheme to elevate junior doctors to consultant level earlier in their careers could form pillars of the English Department of Health's 'plan B' following consultants' overwhelming rejection of their proposed new contract.
The deal would have extended consultants' normal working week by 90 minutes to a timetabled 40 hours, including more flexibility over evening and weekend work. It would also have given the NHS exclusive use of the first 48 hours working time in a week for seven years post-qualification. In return, consultants were offered an average 15% pay rise.
That deal now looks dead, in England and Wales at least, where only 34% of consultants backed the contract. Across the whole of the UK, the deal was rejected by 63% of senior doctors.
But in Northern Ireland 54% voted in favour, and in Scotland 59%. It is likely both countries will now press ahead with introducing the contract, although Scottish British Medical Association leaders have warned this will require further negotiations.
The restrictions on private work and doctors' perception that they would be under increasing managerial control were crucial to the rejection. Consultants feared they might, for example, be told to perform non-urgent work in order to clear waiting lists.
In England and Wales, ministers and doctors' leaders were scrambling this week to come up with an alternative formula. An embarrassed BMA, whose leadership had negotiated the contract and strongly recommended it to its members, was holding a summit meeting on the way forward on November 6.
BMA chair Ian Bogle has sought an urgent meeting with Health Secretary Alan Milburn, while the department said ministers were considering their options.
It is unlikely that the contract will be imposed on consultants in England and Wales. However, the government may encourage trusts to offer individual consultants a contract that is similar to the one that was rejected last week.
Alastair Henderson, NHS Confederation policy manager, said the government may opt for a number of initiatives rather than one national solution. He said: 'It remains unclear what wasn't liked in the proposed contract… There are a series of other options and I imagine that means a more diverse approach to how we reward people for the additional work they do.'
One option is to create a new junior consultant grade. These more generalist doctors could shoulder much of the burden of the extra work the health service must get through to meet NHS Plan targets in return for extra pay and less private practice.
The rejection of the contract by specialist registrars (the grade below consultant) would seem to be a barrier to the success of such a move but Henderson believes it could be workable. He points out that a recent review of doctor training suggested creating junior consultants. 'If it were tied to getting their CCST [consultant qualification] earlier, it could become more attractive to specialist registrars,' he said.
But Dr Paul Thorpe, chair of the BMA's junior doctors committee, threatened that consultants would leave the NHS or take industrial action if the plan were imposed.
It is thought the deal would have added around £300m a year to the consultants' wage bill.
Milburn said he was determined to use the cash to reward those who did the most NHS work. He will probably do so by replacing the consultants' distinction and merit awards schemes, which currently top up consultants' salaries.
He said: 'We set aside considerable extra resources to implement a new consultant contract. We want to use these resources to better reward NHS doctors who do the most for NHS patients, and we will bring forward plans to do so shortly. This government was elected on the basis that resources are inextricably tied to reform – and reform will go ahead.'
Milburn's comments were echoed by the prime minister in his press conference on November 4. Blair said: 'We have set aside hundreds of millions of pounds for the consultant contract and we have got to find a way of using it to incentivise performance.'
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