Published: 07/11/2002, Volume II2, No. 5830 Page 6 7

The government is considering putting the£300m earmarked to fund the new consultant contract into the clinical excellence awards scheme that is set to replace distinction awards for individual consultants.

Government sources say the incentivisation of individual doctors could be linked to the way the new financial flows system will reward trusts for their activity.

Prime minister Tony Blair told HSJ the money set aside to fund the contract would be used to provide 'very considerable leverage in the system one way or the other, for managers to manage more effectively'.

The suggestion followed last week's two-to-one rejection of the new contract by consultants in England and Wales in the British Medical Association ballot.

Plans to replace consultants' distinction awards and discretionary points with a new scheme have been largely dormant since a consultation document on a new clinical excellence award scheme was launched in February 2001.

The consultant contract framework document put to BMA members included an outline of the scheme and noted that 'talks on the new scheme should be concluded as soon as possible, with the aim of having arrangements agreed before the new contract is implemented'.

But the scheme, with its stated aims to 'better reward those consultants who contribute most to the NHS' and 'better reward those consultants who contribute most to service delivery and patient care' - phrases health secretary Alan Milburn has echoed in the wake of the BMA vote - could now replace the new contract entirely.

The new scheme would see the end of both the discretionary points system and distinction awards, which have long been criticised on equity grounds, with women and ethnic minority doctors receiving proportionately fewer awards than their white male counterparts.

Distribution across specialties is also uneven, with 40 per cent of consultants in clinical pharmacology receiving awards, compared with just 7 per cent of those in orthopaedic surgery.

The combined budget for the two schemes is around£165m a year, but the 2001 consultation document pledges to increase the number of consultants holding the award from under half of all consultants to two-thirds.

Another option under discussion is for individual trusts to implement the new consultant contract themselves.

And the government may press on with proposals floated in the NHS plan to introduce a sub-consultant grade between specialist registrars and consultants, which have been long opposed by junior doctors who would automatically be placed on new contracts.

Speaking immediately after the ballot result came through, Mr Milburn stressed: 'I was always clear this was the only deal on offer.

'There can be no question of renegotiation. There can be no more resources. There can be no veto on reform.'

The government had set aside 'quite considerable resources' to 'better reward NHS doctors who do most for NHS patients'.

Mr Milburn suggested that imposing the contract across England was unlikely. 'I think, personally, It is quite difficult to impose it.' It was 'right to take stock now about how we approach this', he said. 'We need to consider how best to deploy those resources to achieve that end [rewarding doctors who contribute most].'

There might be 'a differential approach across the UK', he said.

And he added: 'In some hospitals in England, managers and consultants may come to an agreement that they want the contract operating in their hospital.'

Mr Milburn suggested three reasons for the size of the 'no' vote: consultants' concern about private practice, concerns about managers and worries about working unsocial hours. But he said concerns about consultants being 'required' to work evenings and weekends were 'based on a misunderstanding'. But he also said: 'It is a 24/7 world. The NHS has got to be part of that world.'

At its own press conference, the BMA hit back, with consultants and specialists committee acting chair Derek Machin speaking for the consultants following the resignation of chair Peter Hawker.

'Mr Milburn has completely missed the point, ' he said.

'Rejection of the contract has nothing to do with money. It is to do with the perception consultants would be forced to do extra work at evenings and weekends and [subjected to] managerial control.'

This perception had not come from measures to pay plain-time rates for evening and weekend work laid out in the contract, but had been 'produced by the sort of statements coming from the Department of Health', he said, citing in particular a slide produced by NHS human resources director Andrew Foster at a presentation in July (see story, right).

Mr Machin added, with reference to Scotland and Northern Ireland: 'The further away from Whitehall, the greater the 'yes' vote. The problem in England is the perception of targets being forced on consultants by managers under the lash from Whitehall.'

This was not because of antagonism towards managers - 'there was a lot of sympathy' for them, but they were 'subject to all sorts of political pressure, the threat of being dismissed by whoever'.

And he stressed: 'We oppose any piecemeal introduction of this contract. It would be very unwise for the government to go down this road. Consultants are angry.'