The Advisory Committee on Distinction Awards is to lose its in-built medical majority, although some doubt this goes far enough to justify the system, reports Mark Crail

If anyone belies the image of the civil servant as cautious bureaucrat it is Sir William Reid. He made a memorable health service commissioner. Now he looks set to bring his own brand of radicalism to doctors' distinction awards.

Backed by ministers angry at the system which allowed Bristol heart surgeon James Wisheart to hold on to his 'merit' money, and by the apparent biases in how the cash is handed out, he has launched a series of bold reforms.

Last week, Sir William announced that the Advisory Committee on Distinction Awards, which he has chaired since August, would no longer have an in- built medical majority, and threw open its doors to further change.

In a bid to tackle the widespread view that the whole system is based on a cosy closed shop of cronyism, consultants will in future be able to nominate themselves for a distinction award.

Any consultant who has not received an award within 10 years will have their case reviewed to ensure they have not been 'overlooked', as will any consultant whose award has not been upgraded in the same period.

And, post-Bristol, consultants who fall foul of the General Medical Council, the courts or their employer's disciplinary proceedings, or whose professional or personal behaviour might undermine the system, could lose their award.

There has been a considerable shake-up in the committee's membership. In place of the old 33-member ACDA, the Reid reforms bring in a relatively slim-line 14-member body shorn of many of the medical glitterati.

For the first time, doctors will be in a minority, with patient representatives gaining two seats (an innovation) alongside the NHS chief executive and his Welsh counterpart, two NHS employers and a regional chair.

Doctors will find their interests represented by the chief medical officer, the chair and a vice-chair of the Academy of Medical Royal Colleges, one representative of academic and research interests, and a solitary consultant.

Recognising the realities of devolution, from 1999 there will be a Scottish Advisory Committee on Distinction Awards. For 50 years the UK-wide body has had the final say on a Scottish sub-committee's recommendations.

The Scottish ACDA, announced this week, will be chaired by North Ayrshire and Arran trust chair William Ritchie; its vice-chair will be Professor Alistair Spence. Each held the same post in the previous sub-committee.

Andrew Foster, chair of the NHS Confederation's human resources committee, greets the reforms as 'a move in the right direction'.

He says: 'This moves away from the haggling shop between the specialties, and that's good. There probably never was as much cronyism in the system as people thought, but perceptions are everything. We need transparency.'

He says the guidance given to the new 14-member committee on how they should allocate awards is crucial. 'I would like to see a greater emphasis on rewarding hard work - recognising that some people work harder than others,' he adds. The guide talks about contribution to service goals, but I would like to see that emphasised more.'

A critic of the system, Professor Alan Maynard says: 'Fundamentally, the question remains, what is the purpose of all this?'

He asks: 'Are distinction awards supposed to compensate people who don't do much private practice, or to reward excellence? If so, what is the scope of excellence - is it the practice of medicine or the management of medicine?'

The answer to that, he suggests, might come out of a broader review of the criteria on which awards are made. But he is gloomy about the prospect of using the distinction awards system to effect real change.

'If you are going to move to a better and fairer system, it is going to cost you. But it won't necessarily lead to any great improvements in patient care.'

He also warns that with reforms to the distinction awards system, Whitehall rumours of a big shake-up for the doctors' pay system, and a sweeping clinical governance agenda, ministers are running a risk of instability.

'It is like taking bricks out of a wall,' he says. 'If you're not careful, the whole thing comes crashing down on you.'

The TUC-affiliated Hospital Consultants and Specialists Association is rethinking its position on the awards. Its long-standing policy has been to replace the system with a set of seniority payments.

HCSA chief executive Stephen Charkham says the organisation is concerned at the high rate of early retirement among senior doctors, and suggests the money could help address that problem.

The Reid reforms are 'all pretty sensible stuff', he says. But he has strong reservations about giving lay people a decisive say in distinction awards. 'I don't want to sound patronising, but how are these people going to judge?' he asks. 'There will be experts on the committee, but what are the lay people going to contribute?'

Guide to the NHS Consultants' Distinction Awards Scheme: 1999 awards round. HSC 1998/187.