Published: 14/02/2002, Volume II2, No. 5792 Page 26 27
A review of consultants' distinction awards is underway and a revised scheme is due to take effect in April next year. But how many of the concerns about this long-established feature of the NHS, estimated to cost£105m last year, will be addressed?
Distinction awards are part of the consultant pay structure and are paid with salary as pensionable additions to the standard consultant salary scale.
The purpose of the scheme, instituted at the inception of the NHS, was to reward individual consultants for outstanding work. Cynics would say it was a carrot held out to the consultants who refused to join the NHS in 1948.
Awards were graded A, B and C. In 1960 an A-plus award, which is worth 95 per cent of the maximum of a consultant's salary, was introduced. Regional awards committees were responsible for making the recommendations to a central committee - the advisory committee on distinction awards (ACDA) - responsible for granting awards.
Recently, C awards have been replaced with a discretionary points scheme, administered at trust level. Of the eligible consultants, 8 per cent hold a B award, 3.5 per cent hold an A award and 1 per cent hold an A-plus award. There are around 11,350 distinction awards and discretionary points.
Despite two royal commissions and reviews by specially appointed committees, the scheme has remained fundamentally unchanged.
Over the years, it has been severely criticised.
It operated under strict secrecy - curiously, the British Medical Association demanded that the names of award holders should not be divulged. Secrecy was not relaxed until 1979, and individual consultants were permitted to inspect lists of award holders.
More recently, however, the information entered the public domain and was even published in the press. Other criticisms were the disproportionate number of awards held by members of some specialties and the fact that only 6 per cent of female consultants held awards. Seventeen per cent of white male consultants, and 5 per cent of ethnic minority consultants, hold an award. Academic and honorary consultants predominate.While only 9 per cent of consultants hold honorary appointments, 39 per cent are in receipt of awards.
Of the other consultants, 10 per cent hold awards.
Twenty-one per cent of honorary contract holders receive A or A-plus awards, as opposed to 3 per cent of other consultants.
The scheme was administered in the past by committees comprised largely of consultants, and the discrepancies are attributed to prejudicial practices and discrimination. To the best of my knowledge, no investigations have been carried out to exclude other possible contributory factors.
The scheme is operated on criteria issued by the Department of Health, which does not enter into any form of negotiation with either the ACDA or representatives of the profession.
The criteria demand national and international recognition for the higher awards and this has worked against consultants in district general hospitals.Over the years, attempts have been made to address these discrepancies. Some success has been achieved in improving the lot of female and ethnic-minority consultants, while considerable strides have been made in making the system more transparent - though not necessarily more accountable.And appeal procedures are still inadequate.
The consultation document Rewarding Commitment and Excellence in the NHS, published in February 2001, proposed far-reaching change:
the awards to be re-named clinical excellence awards;
the number of consultants with an award to increase to two-thirds;
local awards to be made at£2,500 intervals, up to£30,000;
higher awards to be made regionally and nationally at£5,000 intervals, up to£65,000;
a single set of entry criteria;
membership of regional awards committees to include primary care and patient representatives;
awards to be reviewable at five-year intervals;
awards to cease on retirement.
The document stated that while the importance of research would be recognised, 'the majority of new awards will go to those who make the biggest contribution to delivery and improving local health services'. Greater recognition for service to the NHS after all these years is welcome, but reforms that might create an unfair bias should be equally condemned. The new scheme does not address the issue of rewarding clinical academics.
Under the current scheme, consultants are expected to devote 21 hours a week to clinical work to justify the full award. This is an impossible situation, at odds with academic and teaching commitments demanded by medical schools.Many academic and honorary consultants fail to meet this target but receive full awards - and the chief executives, in making their review citations, turn a blind eye.
This requirement should be rescinded. Academic consultants should instead be judged on the level of achievement in teaching and research, just as whole-time NHS consultants should be assessed on their contribution to service and patient care, and to a lesser extent on research and publications.
The concept of a continuum proposed between local discretionary points, locally decided, and the higher awards, decided nationally, is a good one.
The continuum concept would mean that services to the NHS on a wider basis and contributions to national bodies could be rewarded before the maximum number of discretionary points or trust awards are reached. Exceptional contributions to the trust and contributions to service and patient care could be rewarded with higher awards.
This might also help eliminate past perceptions oflower awards for hands-on patient care and higher ones for national contributions for less direct patient care.
Decisions made at regional level should continue to play an important role, since members of the regional committees are likely to be more familiar with local consultants.The consultation document suggests a reduction in the number of consultant members of the regional committees, to be replaced with administrative and lay representatives.This may be a popular development politically, but will dramatically reduce the input of information.
Even with the present committee structure, it is difficult to obtain information about consultants in less popular specialties.
Hardly anyone would challenge the argument that present methods of assessment are too subjective, though a scoring system is used in some regions.A satisfactory scoring system may prove elusive. But if successfully devised and implemented, it would allow greater uniformity between regions. It is probably true that consultants in regions with fewer teaching and larger district general hospitals have an easier passage for awards.More objective assessments may help to level the playing field.The design of curriculum vitae questionnaires should make assessment easier.The onus must be on the consultant to make the case.
Trusts should strictly adhere to award procedures and issue guidelines on the membership of the trust committees.A very wide variation currently exists in the structure of these committees and the procedures adopted.
At present, awards are not granted beyond the age of 62.This was introduced to stop claims that awards were being granted to boost pensions.Awards are a reward for contributions already made and this age restriction would result in failure to recognise contributions made from age 60 or even earlier.
The new scheme proposes that the awards should be stopped on retirement or partial retirement. But the justice of this is questionable if the awards are seen as rewards for service already given.
A radical overhaul of the awards system is underway. In spite of attempts to improve the system, many problems still exist.Discrepancies in the greater number of awards for academic consultants, fewer awards for female and ethnic minority consultants and the less glamorous specialties must be addressed. It is vital that the causes of these discrepancies are identified.
Prejudicial practices may not be the sole explanation.Abuses in the past must not undermine the recognition of outstanding contributions.
Awards should remain a reward and not a carrot.
Key points
The distinction awards pay scheme for consultants has been the subject of controversy since its introduction in 1948.
It has lacked transparency and has been criticised for being inequitable.
Many academic consultants receive awards without fulfilling the required service commitment.Chief executives are turning a blind eye to this.
Proposals for a revised scheme, due to take effect in April 2003, only address some of the shortcomings.
Dr Anton Joseph is a retired consultant radiologist, and a former member of a regional advisory committee on distinction awards.He still does ultrasound sessions.
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