The Hospital Consultants and Specialists Association
submission to the Doctors’ and Dentists’ Review Body on the
special remit letter from Dr Dan Poulter, Parliamentary Under
Secretary of State for Health dated 30th October 2014
The Hospital Consultants & Specialists Association (HCSA) is a professional
association and trade union which represents and advises hospital
consultants, staff and associate specialist doctors and specialist/specialty
(not core trainees) registrars in the UK, both in the NHS and Private Sectors.
Formed in 1948, when it was identified that consultants needed a
membership body that would speak for them in the early years of the NHS,
that need has never abated, and 66 years later we have a stronger, larger
association with a track record of supporting its members. The HCSA
represents thousands of consultants and specialists in the NHS, participates
in the national and local partnership forums, has an observer’s seat on the
NHS Staff Council, and is affiliated to the Trades Union Congress.
Whilst we have trade union recognition in a number of NHS Trusts and work
side by side with our fellow trade unions and professional bodies on many
issues, we do not as yet enjoy national trade union recognition. This is of
great concern to us and our members. As a consequence therefore we have
not been party to last 18 months of negotiation between the Government and
the BMA, and have little information on the detail of those negotiations. We
do however have our own views on the issues under consideration and this
document sets out those views.
The HCSA is pleased therefore to have this opportunity to participate and
make a contribution. The special remit letter asks the Doctors’ and Dentists’
Review Body (DDRB) to:
“Make observations based on information and data presented on pay related
proposals for reforming the consultants contract to better facilitate the
delivery of health care services seven days a week in a financially sustainable
way i.e. without increasing the existing spend.”
The letter goes on to say:
“The DDRB should also consider the following, including work already
completed by the parties to the negotiations:

The work by the DDRB on the payment of clinical excellence awards
(CEAs) and the Government’s response to that

Proposals
for
pay
progression
linked
to
responsibility
performance; and

Arrangements in other sectors which provide seven day services.”
and
Seven Day Services
It is the HCSA’s policy to encourage and work with any properly focused
initiatives to eliminate the variation in survival rates and wellbeing which has
been shown to exist for acute and emergency hospital admissions in the
evenings and at weekends. As we have not been party to these negotiations
we would need to have a clearer understanding of what the current
proposals involve. Whether proposals are aimed at just emergency services
or whether they are intended to cover elective medicine as well. It is
important to note that preventative medicine is a key driver in reducing
patients presenting acutely as well as improving out of hours and weekend
staffing numbers/seniority.
There is already an established consensus in a number of specialties that the
presence in hospital of consultant/SAS medical staff during out of
hours/extended day periods and weekends is essential to provide good
quality medical care. Some hospital departments already have consultants
and senior doctors present during on call periods, for example, Radiology,
Obstetrics, Paediatrics and Paediatric Surgery.
There are other specialties which regularly see consultants undertaking
weekend ward rounds and operating lists when they are on call at weekends.
For most hospital doctors, working over 7 days for some part of their
rostered working lives is normal.
The HCSA supports the aims of 7 day services for patients, but this must be
achieved by properly planned change and adequately resourced
developments in hospital staffing, working patterns and clinical facilities. It
must be ensured that the increase in ‘consultant presence’ as recommended
by the Royal College of Physicians and others, which is intended to
adequately treat acute emergencies, does not simply drift into undertaking
additional routine clinics at weekends etc.
Principles and safeguards for seven day services
The policy of the HCSA towards these changes in working arrangements is
supportive where the work arrangements are balanced and:

are agreed by all the doctors involved

do not demand long periods of continuous working

maintain adequate rest periods and full adherence to the EWTD

do not compromise opportunities for family friendly work
patterns/work life balance

provide time off in lieu to guarantee the protection of the health and
wellbeing of the doctors concerned

there should be a maximum number of weekends that consultants
should work in a year
Our membership surveys have found that our members hold the above
principles to be very important. It is also important to recognise the growing
numbers of both single working parents and those families where both
parents work full time, the extended working life caused by higher pension
age, and take this into account in further deliberations and negotiations.
Needs and opportunities for seven day services
Whilst fresh patterns of working by senior medical staff would reduce the
additional manpower required to support 7 day provision of service by
hospitals, extra medical staff will still be needed and this in turn will lead to
increased costs. It is vital that this is properly recognised and delivered from
the outset.
The HCSA recognises that fresh patterns of working present opportunities for
part time and shift working, which can be attractive to some existing hospital
doctors and those appointed in the future.
There are already some opportunities for innovation with existing levels of
medical staff, which can bring fresh working arrangements into play now,
delivering benefits and with adherence to the principles and safeguards
mentioned earlier.
Where existing numbers of consultants and specialists in a department are
adequate, the introduction of fresh patterns of working over 7 days can be
achieved by an imaginative application of compensatory rest and innovative
work patterning. This can eliminate the need for additional hours of work by
members of the team and contain the impact of additional resourcing. This
outcome was achieved by the Radiology Department at the Worcestershire
Acute Hospitals Trust, which sought HCSA advice on the best way to
approach such a change.
There is no “one size fits all” solution. What may well fit a large specialist
regional centre would not fit a small district service. There is a need to look
at staffing in general, the numbers of hospital beds available both at
weekends and during the week. Cleaning and maintenance needs are
important and must not be compromised.
Extension of work into a seven day pattern must also be supported by a full
complement of clinical and non-clinical support staff, nurses, AHP’s admin,
estate and managerial services on site. It is not reasonable or sensible to
expect the medical workforce to work more closely to normal weekday
patterns without the same support as they currently do on a weekday. If a
member of staff becomes sick during the out of hours period, staff must be
available to solve that issue rather than leaving it to a doctor to add to their
existing work and stress but without the resources that HR staff have.
The HCSA believes that Schedule 3 paragraph 6 of the current contract
should only be surrendered once full agreement and safeguards above are in
place but should be replaced with a protection clause based on recognition
of certain criteria (such as those protected under law against discrimination
such as faith). This clause should also give clear guidance about age limits,
especially taking into account the expected longer working life with later
retirement. Royal colleges already recognise that certain groups such as
surgeons and obstetricians should not contribute to out of hours after a
certain age, such as 55 for obstetricians.
The HCSA has worked in partnership with a number of Trusts and examples
exist of increased consultant presence being introduced successfully within
the frame work of the existing contractual provisions.
Pay Progression
The HCSA starts from a principle of unease around the whole idea of
performance related pay when it comes to the care of patients. The principles
we stand by, are that of providing patients with quality care and excellent
outcomes. However we understand the need for innovation and for clear and
agreed objectives that both benefit patient care and experience and at the
same time reward consultants and specialists who have achieved their agreed
objectives. Such objectives have to be realistic with appropriate opportunities
to keep up to date, undertake research where necessary, and utilise SPA time
to the full.
At this point it is worthwhile mentioning that the HCSA has and continues to
embark, with other health service unions, on a programme of Action Short Of
Strike (ASOS) over the decision of the Government not to implement the
recommendations of the DDRB in relation to the 2014/15 pay round. This
has angered many of our members at a time when pension contributions
have risen inextricably. We mention this as incremental progression is seen
by many as a journey to knowledge and experience that make progression a
key component of the remuneration package.
The current consultant’s pay scale has 8 thresholds and takes 19 years to
reach the top pay point. This is the longest scale by far of any NHS worker
and is seen as an acceptance that to obtain the levels of skill, knowledge and
experience takes a significant length of time. The HCSA is of the view that
any proposals to reform pay progression must be accompanied by a system
of pay protection that ensures consultants do not lose out both in terms of
future pay and pension. The notion that a resultant reform could lead to
consultants working more unsocial hours for less pay is one that our
members would find unpalatable. We already know that many consultants
have and continue to seek work overseas and any reform that had weak
transition and protection would see this trend continue. Likewise the
potential for consultants to opt to retire earlier than had been anticipated
would be a real risk if this element of reform was out of touch with
expectations.
Out of Hours
Out of hour’s provision and payment has to cater for all, those with
intensive out of hour’s demands and those without such demands.
However there has still to be some element for simple “availability”.
Availability is not just being available but does carry with it a significant
restriction to freedom. Being available, constrains where (usually within 30
minutes return to work) and what one can do so this significant restriction
of freedom certainly has a value to it. As a consequence this should be
closely based on frequency, duration and intensity of work and should be
annually reviewed based on job planning. There must be pay recognition
that work such as operating / anaesthesia / obstetrics / ITU / neonatology
etc. have a different intensity to other work. This needs regular review as
work patterns change and must be based on a diary process, preferably
continuous. Similar safeguards should apply as set out above so
consultants are not tired, but fit to work providing safe care to patients.
This must include ensuring that adequate rest periods are taken in
accordance with the EWTD.
CEAs
The issue of CEAs is one that generates a wide range of views. Some feel the
system has benefits and some see it as having disadvantages. Some feel the
system should focus more directly on delivery of clinical services. In general
it is felt that the system should continue to reward hard work and innovation.
It also serves as an incentive for high achievers.
Any thoughts about abolishing CEAs would be counterproductive and could
impact on the willingness of consultants to volunteer for additional activity.
Conclusion
We know that morale amongst our members is at a low point, maybe the
lowest it has ever been. We hope that the outcome of the DDRB’s
observations will signal the rebuilding of morale and generate better
engagement. Whilst the HCSA has not been party to any of the negotiations
over the past 18 months or so, our members have been keen to participate
and have a voice. We were disappointed that negotiations stalled in particular
as we had no direct influence over the direction that these negotiations
would take. It surely has to make sense that the voice of thousands of
consultants and specialists should be heard on the important issues that
affect them. None more so than their contracts of employment. Finally we
would request that the HCSA contribute to the oral hearing to give further
evidence and expand on this submission.
Eddie Saville
Chief Executive/General Secretary
Hospital Consultants and Specialists Association
1 Kingsclere Road
Overton
Basingstoke
Hampshire
RG25 3JA
31th December 2014