Published: 27/05/2004, Volume II4, No. 5907 Page 34 35

Job plans for consultants have highlighted organisational weaknesses that need solving before modernisation can happen, says Mark Davies

The new consultant contract was designed to help modernise NHS services by introducing more effective ways of managing consultants' workloads, and introducing a more explicit system of performance management.

As a performance development company working with the NHS, Res Consortium has been involved in the delivery of jobplan training and implementation of the new contract in over 100 acute, mental health and primary care trusts nationally.

The idea of job planning is that individual objectives should be aligned with organisational objectives through a process of task definition and agreement.

The plan then provides a core for defining roles and responsibilities, offers a standard for the performance management of that individual, and provides a framework for skill development and quality control.

When applied to the NHS, successful job planning means success in implementing the process along with a realisation of benefits.Our understanding of 'benefits'means that consultants and ultimately services being more productive, giving greater value in terms of the standards and quantity of healthcare delivered for given levels of NHS funding.Achieving these benefits depends on certain key factors being present that are consistent with best practice in general and human resource management across the public and private sectors.

So has job planning been successful so far and have benefits been realised? The ongoing disagreements at national level between the Modernisation Agency and the British Medical Association over job planning and programming caused a prolonged period of confusion as trusts struggled to develop local policies while national negotiations dragged on. A lack of clarity over funding for the new contract has also raised tensions. At trust level, much of the debate focused on numbers of programmed activities, with a persistent widespread misunderstanding that job plans should be a reflection of retrospective activity rather than a prospectively negotiated plan.

This was partly symptomatic of the complexity of the process.

However, perhaps the most fundamental difficulty has been the inability to focus negotiations on the alignment of individual and organisational objectives.

Agreeing objectives for service delivery should have formed the central focus for all other activities, including scheduling and agreeing programmed activities, performance management, and related processes, including appraisal and clinical excellence awards.

Instead, resources have been diverted into trying to agree continuation of existing service commitments without actually modernising anything. Key problems that trusts have encountered include:

an ingrained culture of poor relations between consultants and trust management, caused by inadequate communication, making local negotiations difficult;

strategic objectives were either not meaningful at a directorate/locality or specialtylevel, and that had not been clearly communicated to consultants.We found that consultants rarely had a strong sense of the overall goals of their organisations, and how these related to their own job plans.

medical managers, including medical, associate medical and clinical directors, were often illprepared, which meant they were being asked to job-plan with consultants without clear objectives themselves, or lacking competence in vital areas such as negotiation skills.

the interfaces between medical, HR and general management were often ill defined because of weak basic processes and structures.

there was an unwillingness to address productivity improvement issues has meant loss of service in some areas, leading to difficulties with commissioning organisations, and a tendency for some consultants to continue to work over contract despite not being EU working-time directive compliant.

funding concerns has led to reluctance in some trusts to devolve authority to medical managers to sign off job plans. In some cases this has meant an ongoing process of re-negotiation as the job plan draft bounces between consultant, medical manager and executive team.

The cracks revealed by this process provide valuable lessons for future performance improvement. First, NHS initiatives must be thought through and communicated more effectively from the centre, with a much greater understanding of the pressures trusts encounter when trying to implement these policies.

Strategic health authorities and workforce development confederations' existing support to trusts in training and project management could be improved by better communications and consultation with trusts about effective policy implementation.

Trusts need to realise that a strategy must inform the whole of an organisation of future goals, and the principles involved in achieving these goals. They must therefore work harder to develop meaningful objectives for staff and other stakeholders that can inform, in the case of consultants, job planning, appraisal and all other related activities.

Consultants must also take responsibility for ensuring success by striving to engage more effectively with management and recognising that teams, not just individuals, deliver services. This in turn means acquiring the necessary skills through management training and a willingness to learn from trust managers.

At a more operational level, the roles of key players in trusts must be clearly defined. Ensuring that key processes, such as general, HR and medical management, are themselves aligned is critical to support both communication and performance improvement.

This means ensuring that people in these roles have the skills to perform them.

For example, medical managers have usually received far less management training and experience than general or HR managers, and therefore require additional support and development. In our experience most medical managers have been keen to take part in the management process, but have lacked the skills and conceptual understanding to be effective.

In trusts where relations between consultants and managers have been poor, with no active dialogue, medical managers have been particularly concerned about being 'caught in the crossfire'. Trusts that have had more effort invested by both groups in building this dialogue report that job planning has been more successful.

With annual repetition of job planning to look forward to, trusts must work hard to understand where the real value and benefits from this process are likely to be found.

A central focus on the alignment of individual and trust objectives is vital, with this forming the foundation for the development of an effective performance-management system.

In turn this will mean acting on the lessons learnt from the first phase of job planning, including a more informed process of policy development, a far greater emphasis on effective communication, clearer role definitions and creation of appropriate skills and competencies.Only then will service performance be improved and benefits actually realised.

Dr Mark Davies is a director of Res Consortium.