Published: 27/11/2003, Volume II3, No. 5883 Page 17
Mark Britnell is chief executive, University Hospital Birmingham trust
Until now, many NHS plan developments have been largely achieved through a cash-plus-growth formula, with modest levels of service redesign. The consultant contract, and the Agenda for Change pay negotiation, moves modernisation into a new realm and strikes at the very heart of a producer and professional-centred service.
A huge sigh of relief was heard from the Department of Health after the majority of consultants voted in favour of a new contract. Nobody should under-estimate the size of this achievement and the dedication of all parties. But many inside the NHS believe the deal has not taken into account the realities of consultants'work and has under-costed the consequences.
This could result in slower than expected clinical service development as revenue is directed towards pay - most consultant staff work in excess of 40 hours a week.
However, the British Medical Association also has a responsibility to make sure the majority of hours are properly and locally directed to service objectives and should frown on attempts to simply give consultant staff a wage increase without a revision to working practices.
Intelligent trusts have modelled job plans on previous years' appraisals and have juxtaposed this information with clinical activity data, which is often benchmarked with best practice internally and externally. In simple terms, trusts will have to spend more time maximising the clinical value and impact of the direct patient care programme activity - often by changing working practice within wider teams. All this adds up to a substantial amount of work in an impossibly short period of time. Even assuming that most trusts have enough decent clinical directors to negotiate properly with each consultant, there will be an immediate and unrecognised cost impact.
Many trusts privately recognise that, currently, the NHS has out-of-hours consultant services on the cheap but has not maximised value for money in so-called 'non-fixed' sessions with education and research. Clever trusts will trade these factors against each other so that all consultant-directed activities benefit service objectives.
More consultants than expected have expressed interest in moving to the new contract.While many acknowledge they have nothing to lose from adopting this position, a great deal expect the deal, quite rightly, to make them better off. The fundamental issue is whether consultants are prepared to have all activities directed, with some receiving a higher prioritisation than others.
Private practice outside 'core' hours, a greater focus on nonfixed sessions and more flexible service provision in the light of clinical need will be hotly discussed topics between consultants and clinical directors.
Those involved cannot have it all ways - or just their own way.
The real question is just how flexible are we all willing to be so patients can benefit?
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