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Provisions As To Merit Awards

Volume 131: debated on Wednesday 13 April 1988

The text on this page has been created from Hansard archive content, it may contain typographical errors.

'Consultants holding maximum part-time contracts, and, undertaking private work, shall not be eligible for distinction and meritorious service awards.'.— [Mr. Robin Cook.]

Brought up, and read the First time.

Order. I am reminded that the hon. Gentleman has not put his name to the new clause. Will an hon. Member whose name is on it please move it formally?

With this it will be convenient to take new clause 3—Private work by National Health Service consultants—

'A consultant holding a whole-time National Health Service contract shall not undertake private work and any consultant who undertakes private work shall be deemed to be holding a part-time contract and his remuneration be adjusted accordingly.'.

I apologise for that slight technical hitch. It is typical of the inefficiency in some hospital operating theatres.

In speaking to the clause, I do not want to be seen as making an attack on doctors and members of the medical profession, some of whom remain my good friends despite many of the things that I have said about them in the past. It is an attack on certain doctors and, in particular, on some practices in the medical profession that have been encouraged by the Government, particularly in respect of part-time consultants and the abuses of private practice.

I believe that my comments will gain all-party support. I note that even the hon. Member for Darlington (Mr. Fallon) wrote on this matter in the The Guardian of 17 February. He said:
"Porters, cooks and cleaners have been obliged to lay their jobs on the line. But in nine years of radical Thatcherism whoever heard of a consultant sacked for inefficiency?"

We shall be talking about merit awards, private practice and efficiency. Opposition Members have been talking about inefficiency for a number of years, but the Government have only recently discovered it. They have discovered it not for its benefits, but as an excuse so that they can say that the problems in the Health Service are the fault of someone else, rather than because they have underfunded the Health Service. They have been looking around for scapegoats.

I wish to speak first about merit awards. They have all-party support. The hon. Member for Surrey, South-West (Mrs. Bottomley) asked a question about merit awards. She asked:
"Does the Secretary of State agree that with more than 6,000 merit awards now being paid annually and with the top award being worth more than £27,000, thus virtually doubling a consultant's pay, it is in the interests of the public, the patients and the profession that more information should be readily available? It is time for people to know the by whom, the to whom, the how and the why of merit awards. That would end the secrecy and suspicion."—[Official Report, 10 February 1987; Vol. 110, c.144.]
Opposition Members wish to echo those sentiments and to develop them at this stage.

Merit awards go back to the inception of the Health Service and were set up as a result of the Spens committee, which argued that merit awards were required
"if the recruitment and status of specialist practice are to be maintained, specialists must be able to feel that more than ordinary ability and effort receive an adequate reward"
and that
"any satisfactory system of remuneration must involve differentiation dependent on professional distinction".
Four types of merit awards are given, in addition to the consultant's salary, which currently stands at £32,000 per annum. There is a C merit award of £5,790, a B merit award of £13,000, an A merit award of £22,750 and an A-plus merit award of £29,550, virtually doubling a consultant's salary.

About one third of all consultants receive those awards, but there are two important factors to consider in respect of their distribution. First, very few women receive them. Women are particularly discriminated against because of the nature and secrecy of the committee.

I never received a merit award either, when I was working as a consultant.

The merit awards are concentrated on the high-profile, high-tech branches. In my unit, there was a 60 per cent. uptake of merit awards. At one time, 12 out of 14 consultants had a merit award. Cardiothoracic surgery received 50 per cent. of the awards. I was disappointed that, even with my considerable distinction, the committee felt that it could not give me an award at that stage.

The problem is that, in some important specialties which do not have such a high profile, fewer people receive awards. For example, in occupational medicine, only 7 per cent. of the profession receive merit awards. There is a bias against certain specialties in favour of others, depending on the nature of the committee. That bias is inherent in the structure and it is self-perpetuating.

The structure hands out £60 million of taxpayers' money a year, yet we know very little about it. People have asked me about the merit awards system. I have been asked who gives out the awards and I have had to reply that I do not know. I have some vague idea that one or two people may be involved, but I am not sure. I have also been asked who receives the awards, and again I have had to reply that I do not know. Slight changes have been made recently and we can find out from the health board who receives the awards, but it is very difficult for the public to discover what is happening. I have also been asked why people receive the awards and what meritorious work has to be carried out. Again, I have to reply that I do not know. Therefore, £60 million of taxpayers' money is handed out by people we do not know to people we do not know for reasons that are not clear to anyone.

Reasons have been given for the granting of the awards. A statement appears in the Official Report on 4 November 1983, stating that the reasons for granting the awards include:
"direct service to patients or their general practitioners, improvement of the service, training and teaching research, medical administration, and clinical or academic distinction. Hard work and outstanding service to the NHS may alone be sufficient reason for an award, particularly at the B and C levels."—[Official Report, 4 November 1983; Vol. 47, c. 487.]

Although we may accept that numerous members of the profession who may or may not fulfil the criteria for merit awards actually receive them, we recognise that many people clearly do not deserve the awards. The reason why they have obtained awards, to which they are clearly not entitled, is that the awards are granted by a secretive system run by a small band of men. That is a form of patronage.

I remember that the system was used as a form of patronage. There was always a godfather figure in the region who controlled the system and the money. That medical godfather dispensed patronage. At the end of the day he decided whether someone received a merit award, depending on whether or not that person had been a good boy and supported the various ideas which the godfather wanted to propagate.

The merit awards are given for life. At the age of 40, on a salary of £32,000, someone may receive a top-up award of £11,000 or £12,000 for life. It does not matter whether that someone continues to fulfil the meritorious standards to retain the award. Reform must be made. How can we continue to dispense £60 million of taxpayers' money for life when there is no system of control?

I am not alone in believing that there is need for reform. Many members of the medical profession believe that there should be reform. Most members of the profession agree that the merit award system needs to be reformed, although they may not all necessarily agree on the precise need.

New clause 2 contains our proposals for reforming the merit award system. The awards should be limited to those working full-time for the National Health Service. Only those people perform meritorious work and behave with distinction sufficient to merit the awards. We want the Government to consider our proposal.

The awards were originally granted at the inception of the National Health Service to encourage members of the profession to stay within the NHS and not to practise privately. We want to return to that original reason and ensure that the merit awards are given only to full-timers in the NHS. I know that they are given pro rata to part-timers who fill in, but we want the awards to be granted only to full-timers.

I have the support of Professor David Anderson, the professor of endocrinology at the university of Manchester. He described the system as "patently indefensible". He said:
"We all know consultans who work incredibly hard for the NHS who do not have an award, or only a low-grade one, while others whose commitment is not what it was continue to enjoy higher awards."
Therefore, we are asking the Government to review the merit award system and to accept our new clause, which seeks to ensure that these awards will be made available only to full-time consultants.

9.15 pm

We would also like merit awards to be reviewed every five years. It is incredible that one can be given this large amount, often doubling one's salary, yet it never again comes up for review. It is vital that, if the awards are to be be retained, they should be reviewed every five years.

It is also important—the Minister may wish to reply to this as well—that all those considered for merit awards are told of this consideration and that, if they do not receive an award, the reason is published. If doctors are failing to improve their standards or are developing their efficiency and doing new things, that would be a useful check. At present one cannot find out whether one has been considered, other than by devious means. It would therefore be an advantage to know whether one was being considered, and, if turned down, to be given the reason why.

New clause 3 deals with the question of private practice in the National Health Service, the contract and the question of full-timers doing private practice. The contract was changed by the Government in 1980. One of the first things that they did was to take the consultant contract from what was full-time and maximum part-time—nine-elevenths—and to give the maximum part-timers ten-elevenths and allow those who worked full-time to do private practice.

We wish to reverse that. We want a full-time consultant to remain a full-time consultant and not be allowed to do private work.

The change in contract was introduced by the Government, who now complain about the amount of private practice done by consultants. Perhaps they may like to reflect on that every time they hold up the consultants as the reason for the problems in the National Health Service. When they introduced the change in 1980, the Government said that it was for the effective functioning of the hospital service that consultants should feel that they were fairly treated and that their contributions were appreciated and adequately valued. In making the offer, the Government sought to translate this into action. The Minister made what was described as "an imaginative gesture" to consultants, clearly believing that its effect upon morale could only redound to the advantage of the National Health Service and its patients.

That was the comment at the time the Government changed the system and allowed full-timers to do private practice. Opposition Members pointed out that consultants would shift their bias towards private practice, to the detriment of the National Health Service, and campaigned against the move. To counter that, the Government decided to introduce six principles—these "paper principles" that no one really believed in and no one bothered about. But we predicted that, even with the principles, the National Health Service would be damaged. No, said the Government. Yet we find that, come the end of last year, the Government once again believe what we say.

Have the Government changed their mind? I read from The Independent of 14 December:
"The Downing Street attack came as Mrs. Thatcher, who has a network of Conservative doctors"—
that would not be difficult—
"who brief her independently of official channels, was told last week that hospitals could be 15 to 20 per cent. more efficient if consultants who did private work in NHS time, or spent unnecessary time on committees … were brought to heel."
How interesting—the very thing that we were talking about in 1980 when the Government changed the contract. Suddenly we find that the Government agree with what we said then.

On 13 December there was a series of articles in The Sunday Times, planted by the Government, developing that theme. On the front page it said:
"Thatcher rounds on top doctors."
There was nothing about remunerating them well or about increased morale reflecting on the Health Service and developing it, as there had been in 1980.
"Thatcher rounds on top doctors."
It sends shivers down my spine.

At the bottom of the article, it talks of
"spending time in Harley Street, 'or wherever', while their clinics and operating lists are looked after by unsupervised junior staff."
Those are the things that Opposition Members talked about and campaigned against for many years. The Government are suddenly agreeing with us. What has happened to cause that change of heart by the Government?

Another theme that has been developed by the National Audit Office is inefficiency in the provision of services. The Sunday Times reported:
"Inefficiency played a large part in this because of the inadequate forward planning of admissions"—
"this" is the misuse, the under-use, the 50 per cent. use, of operating theatres—
"lack of coordination between hospital departments, and last-minute cancellations of operations due to the absence of medical staff."

How surprising. Those are the things that we were talking about in 1980, but we were told to go away, that our fears were silly and that such a situation would never happen because doctors could be trusted, being highly professional members of society. I remember being told to stop casting scurrilous slurs on the medical profession. However, suddenly we find:
"Thatcher rounds on top doctors."
What has suddenly happened? Perhaps the Minister will explain it.

The Public Accounts Committee has considered the report of the National Audit Office on the use of operating theatres. In one district health authority, there was 50 per cent. under-use of operating theatre time, half of which was because of cancellations by anaesthetists and consultants, not because of misallocation or mismanagement, but purely because of those people not turning up or not wishing to carry out those operations. It was suggested in Committee that a possible reason was that they were going down the road to do private work.

There is no question but that that is the reason. I have experience of many lists being cancelled, not always because of the surgeon, but because of the anaesthetist also. We must include the anaesthetist in the equation. As a junior doctor, I had experience of patients being on the operating table, anaesthetised, waiting for the surgeon to come from a private clinic. That is not unusual.

We predicted all those things when the contract was changed in 1980. We are now seeing them come to fruition, but it is interesting that the Government admit to the problem. They will be keen to accept our new clause 3 so that we can get back to the position that existed before 1980. It is the fact that surgeons perform private work that leads to poor use and inefficiency in the provision of services.

If one is a full-timer, one is always there and available to do things as they arise. One is always there to see the X-rays as they are produced, and to see the patients. One produces an efficient service by always being there, fitting into slots that become available. However, if one has a private practice commitment, certain sessions are immediately taken up and shifted aside, and it is impossible to be efficient.

Let us consider a parallel. We have a National Health Service in which we allow some doctors to work as private contractors. Let us consider what would happen if we allowed airline pilots to do the same. Let us imagine that we turn up for the British Airways shuttle at London Heathrow, only to find that it has been cancelled, just like an operation, because the pilot has decided to fly for British Midland Airways Ltd. that morning. He probably took the British Airways shuttle with him without telling anyone. That is an absolute parallel—[Interruption.] Yes, or teachers. They are the same, but they would take the blackboard with them.

The argument for allowing more private practice was that it would help to reduce waiting lists. It was said that people going into private care would help to reduce waiting lists. There was no evidence whatsoever of that, and there has been no evidence since. Indeed, waiting lists have increased. However, that was the argument. That is similar to the argument that if a large queue is waiting for a bus and a taxi comes along and someone gets in the taxi, the queue becomes smaller. However, they do not realise that there is a large queue for a bus in the first place because the person who is supposed to be driving the bus is moonlighting and driving the taxi. That is the problem that we face with private practice in the National Health Service.

I am glad that the Government see the problems that they generated when they changed the contract in the 1980s. They accept that the contract produces inefficiency and encourages absence from the NHS. I hope that they will accept new clause 2, which deals with merit awards, and new clause 3. The system must be overhauled in the interests of fairness, equity and open government.

We have had a riveting expos? of the more arcane features of the merit award system and the functioning of consultants in hospitals from one who knows, in the person of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith). I only hope, for his sake, that he is not ill in the next week or two.

I hope that my right hon. Friend will keep the matters under review in the regular discussions he has with the presidents of the royal colleges. In those discussions he should continue to consider the equally important question which impinges directly on the efficiency and effectiveness of consultants and their involvement in local management processes: that is, the question of their contracts being held at district level. The excuse that is usually given for this not being considered is that many consultants work for several districts. That is hardly an important reason, since the number of such consultants is not known by the DHSS, as I elicited through a parliamentary question not long ago.

In the regular discussions and consultations that my right hon. Friend has with the royal colleges, he should consider not only the points that were made by the hon. Member for Strathkelvin and Bearsden, but also a change in where consultants' contracts are held, because it would contribute greatly to the efficiency of the service if their accountability lay where their work is.

In responding to the debate, I can most easily indicate my general approach by saying a word first about what my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) said about the point at which consultants' contracts are held, because it will cover the generality of the thrust of my reply, which is that we are always prepared to keep these matters under review. I noted with great interest the suggestions that were made by the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) and by my hon. Friend.

I shall also take such steps as I can to ensure that the hon. Gentleman's remarks are drawn to the attention of his colleagues in the profession not in the spirit that my hon. Friend implied about what they might do to penalise him, should the occasion arise, but rather that they may reflect on those remarks.

I hope that the House will understand why I will comment on only one or two practical points rather than cover the full sweep of the hon. Gentleman's remarks. His proposed new clause 2 would exclude from the receipt of distinction awards all maxirnum part-time consultants, including those who carry out their contractual duties entirely properly and efficiently, while it would make no changes to the position of consultants holding other types of contracts. As he said, maximum part-time consultants are expected to devote substantially the whole of their professional time to their duties in the NHS and to have the same commitment to continuing patient care as whole-timers. That may include being available to give emergency cover at night and at weekends. This is more than a technicality, although I understand that it could be said to be a technicality.

If the new clause were adopted in its present form, the most likely outcome would be that most maximum part-timers would not become full-timers, but would change to nine-session part-time contracts to secure their right to be considered for distinction awards and to undertake unlimited private practice. The loser in that would almost certainly be the Health Service.

I wish to clarify the terms of the new clause. As the Minister will be aware, its purpose is to bar from awards consultants holding maximum part-time contracts and undertaking private work. It is not our intention to bar from merit awards those consultants, albeit a minority, on maximum part-time, who become maximum part-timers for other reasons than a wish to carry out private work, such as female consultants who work as maximum part-timers because of family commitments. It is important that I put that on the record; otherwise I dare not go home at the weekend.

I should not want the hon. Members for Livingston (Mr. Cook) and for Strathkelvin and Bearsden to be persecuted by every doctor in Scotland.

The comments of the hon. Member for Livingston have left me in some slight difficulty, although I do not mind that. The difficulty is that the clauses are meant to be read together for what they are—two separate and distinct propositions. Unquestionably, the interpretation that I have just given is what new clause 2 states. The hon. Gentleman's interpretation relates to what would happen if new clause 2 and new clause 3 were amalgamated. Nevertheless, it does not significantly alter the point that I sought to make. Indeed, if anything, it may strengthen it.

If the position that would be created jointly by the two new clauses were brought about, and possibly by either of them separately, the most likely outcome would be the loss of several consultants to the Health Service or a diminution of their commitment to the Health Service by moving to part-time contracts of fewer sessions than are implied by a maximum part-time contract. I doubt whether that was intended, but it was reasonable for me to make that point.

9.30 pm

I am glad that the hon. Member for Livingston made his point. The tears that the hon. Member for Strathkelvin and Bearsden wept over the plight of women in relation to merit awards appeared to be crocodile tears, in the light of the rest of his proposition, which would certainly have made it much more difficult for women to receive merit awards.

In view of the time, the desire to make progress, and the slight confusion that has been created by the way in which the clauses were presented and the way in which they were represented, it is probably not sensible for me to say more except to repeat that I shall reflect on what has been said and ensure that, by various means, it is drawn to the attention of the professions, the advisory bodies and, indeed, the review body.

Question put and negatived.