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6th Report, 2006 (Session 2)

Implementing the NHS Consultant Contract in Scotland

CONTENTS

REMIT AND MEMBERSHIP

THE REPORT

ANNEXE A – EXTRACTS FROM THE MINUTES

Extract from the Minutes – 4th Meeting 2006 (Session 2)
Extract from the Minutes – 8th Meeting 2006 (Session 2)
Extract from the Minutes – 9th Meeting 2006 (Session 2)
Extract from the Minutes – 13th Meeting 2006 (Session 2)
Extract from the Minutes – 14th Meeting 2006 (Session 2)
Extract from the Minutes – 15th Meeting 2006 (Session 2)

ANNEXE B – ORAL EVIDENCE AND ASSOCIATED WRITTEN EVIDENCE

9th Meeting 2006 (Session 2), 30 May 2006

ORAL EVIDENCE

Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland
Mike Palmer, (former Assistant Director, SEHD HR Director), Head of Division, Social Inclusion SEDD
Julie Burgess (former Pay Modernisation Director for the Consultant Contract), Chief Executive, Birmingham Women's Healthcare Trust
Tim Davison, Chief Executive, NHS Lanarkshire and Dr Charles Swainson, Medical Director, NHS Lothian.

SUPPLEMENTARY WRITTEN EVIDENCE

Letter from Dr Kevin Woods, Head of Scottish Executive Health Department and Chief Executive of the NHS in Scotland to the Clerk

ANNEXE C – OTHER WRITTEN EVIDENCE

The following unpublished evidence is available from the Clerk:

Health Board Benefits Realisation Progress Reports for all Health Boards
Draft framework produced by UK health departments, June 2002

Remit and membership

Remit:

1. The remit of the Audit Committee is to consider and report on-

(a) any accounts laid before the Parliament;

(b) any report laid before or made to the Parliament by the Auditor General for Scotland; and

(c) any other document laid before the Parliament concerning financial control, accounting and auditing in relation to public expenditure.

2. No member of the Scottish Executive or junior Scottish Minister may be a member of the Committee and no member who represents a political party which is represented in the Scottish Executive may be convener of the Committee.

(Standing Orders of the Scottish Parliament, Rule 6.7)

Membership:

Mr Brian Monteith (Convener)
Susan Deacon
Robin Harper
Margaret Jamieson
Mrs Mary Mulligan
Margaret Smith
Mr Andrew Welsh (Deputy Convener)

Committee Clerking Team:

Clerk to the Committee
Shelagh McKinlay

Senior Assistant Clerk
Joanna Hardy

Assistant Clerk
Clare O'Neill

Implementing the NHS Consultant Contract in Scotland

The Committee reports to the Parliament as follows—

INTRODUCTION

  1. This report sets out the Committee’s findings in relation to the Auditor General for Scotland’s (AGS) report entitled “Implementing the NHS Consultant Contract in Scotland” (AGS/2006/3).

EVIDENCE

  1. The Committee held one oral evidence session on Tuesday 30 May 2006. The following witnesses gave evidence to the inquiry:

  1. Dr Kevin Woods, Head of the Scottish Executive Health Department and Chief Executive of NHSScotland, Mike Palmer, (former Assistant Director, SEHD HR Director), Head of Division, Social Inclusion SEDD, Julie Burgess (former Pay Modernisation Director for the Consultant Contract), Chief Executive, Birmingham Women's Healthcare Trust, Tim Davison, Chief Executive, NHS Lanarkshire and Dr Charles Swainson, Medical Director, NHS Lothian.

FINDINGS AND RECOMMENDATIONS

  1. The Committee’s main findings and recommendations are set out at Appendix A.

SUMMARY

  1. In July 2000 the English Department of Health announced UK wide pay modernisation schemes affecting most NHS staff. The four UK health departments produced a draft framework in June 2002 and the contract was finally agreed in 2003 and implemented in 2004.1

  1. The contract represents a “major cultural change within the NHS” 2 and is the single biggest change to the way in which consultants work since the previous contract for consultants was agreed in 1948.3

  1. The contract also represents a very significant investment. The AGS report estimates the cumulative additional cost of the contract in Scotland over the first three years as £235m.4

  1. Over the past two and a half years the Committee has devoted considerable time and energy to scrutinising the implementation of the consultant contract. In two successive overview reports on NHS performance (published in July 2004 and June 20055) the Committee expressed concern about issues such as inaccurate cost estimates, lack of information, lack of clarity about the benefits to patients and the contract’s failure to properly reflect Scotland’s needs.6

  1. Having now considered the AGS report on the implementation of the contract in Scotland these concerns remain. Conclusion: Specifically in relation to the way in which the contract was implemented the Committee considers that :

    • Poor information led to inaccurate cost estimates and undermined the effectiveness of negotiations;

    • The negotiation process did not give sufficient weight to the needs and priorities of the service in Scotland; and

    • The contract does not fully take into account the differing characteristics of and challenges facing the NHS in Scotland.

  1. The current operation of the contract also falls short of what is required to ensure that its objectives are met. For example, the quality of consultant job planning is patchy. Action is needed to improve the quality of job planning if the contract is to lead to better services for patients.
  1. Conclusion: Most importantly, the patient benefits which were to flow from the considerable investment in the consultant contract are not being demonstrated.

  1. Conclusion: The contract has the potential to both fairly remunerate consultants and deliver change and improvement - but it is not being used to best effect. It is therefore important that the impact and effectiveness of the contract are kept under review to ensure that the expected patient benefits are delivered in future.

INFORMATION

  1. The Committee took evidence on the information available to the Scottish Executive Health Department (SEHD or “the Department”) in negotiating and planning for the introduction of the contract. Only very limited information specific to Scotland was available7, including data on the proportion of staff working on maximum part-time contracts and average salary levels. (Col 1648) There was no Scotland-wide data on consultant activity. 8

  1. A survey was undertaken in 2001 when about 300 consultants were asked to draw up diaries of their working patterns. This survey looked at the activity of consultants in England. It was not considered necessary to do a separate survey in Scotland. 9 (Cols 1648 and 1654)

  1. Conclusion: The Committee is extremely critical of the decision not to collect information on consultant working patterns in Scotland. More could and should have been done to gain a better understanding of consultant activity in Scotland.

  1. This lack of information undermined the Department’s ability to:

  • Negotiate a contract which would effectively meet Scotland’s needs;

  • Adequately estimate the costs of implementing the contract; and

  • Ensure that the contract delivered maximum benefit for patients.

  1. Recommendation: The Committee recommends that SEHD ensure that future discussion on terms and conditions for staff groups are:

  • fully informed by data relating to Scotland; and

  • take into account Scotland’s specific needs and circumstances.

MEETING SCOTLAND’S NEEDS AND THE NEGOTIATION PROCESS

  1. The negotiations on the contract were conducted on a UK basis, involving SEHD representatives. In June 2003 SEHD was able to negotiate the contract for Scotland, although most aspects of the contract were agreed across the UK.10

  1. The Department gave evidence that, while the core of the proposals was developed from ideas that were generated at UK level, NHS Trusts and Boards in Scotland were kept abreast of developments and the proposals were analysed from a Scottish perspective. (Cols 1648 and 1649)

  1. Conclusion: However, the evidence does not persuade the Committee that this has translated into a contract which fully takes into account the differing characteristics of and challenges facing the service in Scotland such as; higher staffing levels; greater remoteness and a smaller independent health care sector.11

  1. The Committee’s concern that negotiations did not adequately address differing needs in Scotland is starkly illustrated by the disproportionate financial impact of the contract in Scotland’s island health boards, where the pay bill has risen by as much as 90 per cent following introduction of the contract.12 The Committee has seen no evidence that this impact was planned for or expected.

  1. There are powerful arguments in favour of negotiating contracts for NHS staff on a UK basis. For example, a significant disparity in terms and conditions for staff in different parts of the UK would be likely to result in recruitment and retention difficulties for some areas.

  1. However, the UK negotiating framework must enable each Department to ensure that the distinctive needs and priorities of the service in its area are to the fore during discussions. The Committee is not persuaded that this happened in practice in relation to the consultant contract.

  1. Rather, the impression is of a process where the core elements of the contract were determined in response to the concerns of the service in England. SEHD’s capacity to ensure that the aspirations of the service in Scotland really shaped the negotiations appears to have been limited.

  1. Conclusion: The Committee believes that, the negotiation process for the consultant contract did not enable the needs of the service in Scotland to be given sufficient weight and priority.

  1. Recommendation: The framework for UK negotiations must ensure that each Department involved has an opportunity to shape core proposals. SEHD must ensure that in future core proposals for UK negotiations are fully informed from the outset, by Scottish data, needs and priorities.

Local Negotiation

  1. The Committee considered evidence on issues which were left to local determination and the reasons for this.13 The Department stated that these issues, with the exception of recognition for covering on-call rotas, were left to local negotiation because it was felt that it was most appropriate for these decisions to be taken locally. (Col 1656) These decisions were taken either during or after the negotiations.14

  1. However, in evidence to the Committee Julie Burgess commented that health boards subsequently asked for a “united line” on certain issues that had been left to local determination. (Col 1658) 15 The fact that a centrally agreed line was required to enable Boards to implement these elements of the contract is not consistent with the Department’s assertion that these issues were more appropriately dealt with locally.

  1. In addressing areas left to local determination the AGS report states that “Although these areas do not account for major costs under the new contract, they have often been difficult to agree locally, involved a lot of management time and have delayed implementation.”16 In addition, it is likely that the capacity of Boards to deal with these issues locally will have varied widely.

  1. Conclusion: In the Committee’s view SEHD have not demonstrated that there was always a planned approach to this issue, agreed in advance with Boards. Rather the evidence points to local negotiation coming into play because SEHD and the BMA were unable to reach agreement centrally.

  1. Conclusion: The Committee considers that the management effort required to resolve these issues locally is likely to have diverted attention from key issues such as planning for patient benefits.

  1. Recommendation: The Committee recommends that in future, a more planned approach should be taken to identifying issues which are to be determined locally.

COSTS

  1. SEHD originally underestimated the cost of the contract for the first three years by £171 million.17 The principal reason for underestimating the cost was that it was necessary to buy more additional sessions of consultant time, (or extra programmed activities) than anticipated. (Col 1654) 18

  1. Mr Palmer stated “In the first estimate it was believed that costs would increase by about 8.6 per cent. Once NHS Boards did more detailed work in the period that followed that estimate – in other words when we had more data from boards and consultants in Scotland – it became apparent that that was an underestimation of the likely additional cost.” (Col 1654)

  1. Conclusion: Therefore, because good quality information was not available when planning for the contract, the costs were underestimated significantly. Consequently, financial assumptions underpinning negotiations were unreliable.

  1. SEHD emphasised that the costing model was long-term and looked at an outturn over a 20 – 30 year timeline (or the working life of a consultant) arguing that in these early stages of the contract’s life, up-front costs were being seen without yet being able to judge the savings that might be made in the longer term. (Col 1655)

  1. While the Committee accepts that the contract may lead to more efficient and effective working practices, no evidence has been presented on the long term costing model, nor of the projected savings and efficiencies to be delivered over this period.

  1. Recommendation: The Committee recommends that:

  • SEHD ensure that future cost estimates for changes to public service staff contracts are underpinned by accurate and comprehensive Scottish information and fully take into account Scottish needs and circumstances;

  • Where initial investment is expected to yield efficiencies or savings in the longer term that this anticipated benefit be explicitly stated and quantified in the costing model.

Waiting Times Payments

  1. The Committee took evidence on the cost of waiting times payments since the introduction of the contract. The AGS report records that SEHD expected to save £2m annually in waiting times payments but that in 2003/04 the payments increased by 34 per cent to £3.4m.19

  1. In oral and written evidence SEHD stated that these payments were now reducing and that the intention was to stop them altogether. (Col 1651) In its written submission the Department provided evidence showing a decrease in higher level payments for most Boards.20

  1. It is reasonable to assume that a public £2m savings target would be supported by clear plans, and subsequently action, on the part of both the Department and Boards to achieve that target. However, the Committee has seen no evidence of this.

  1. Conclusion: The Committee considers that arrangements to achieve the stated target of saving £2m annually in waiting times payments were not in place as they should have been. However, the Committee welcomes the progress that has been made in reducing the payments and recognises that SEHD and Boards are taking action to address the issue.

IMPLEMENTATION: SUPPORT AND GUIDANCE FOR BOARDS

  1. The AGS report sets out the support and guidance available to Boards in implementing the contract. This included the Pan Scotland NHS Employers Reference Group; the National Partnership Steering Group and the Consultant Contract Team at SEHD which was set up in January 2004 three months before implementation took place. A significant amount of written guidance, and amendments to the contract were also issued – much of it after implementation.21

  1. Tim Davison stated that most of the guidance was issued in sufficient time to inform contract negotiations with individual consultants (Cols 1657-1659) and Julie Burgess set out the support offered by the Department to help Boards clarify how the “rule book” would be applied in individual circumstances. (Col 1657)

  1. The Committee accepts that a significant amount of guidance was issued and that efforts were made to supplement this written guidance through events and other ongoing support.

  1. Conclusion: However, the Committee considers that some guidance was issued too late and that the process for supporting implementation of the contract was piecemeal.

  1. Recommendation: Comprehensive and clear guidance and other support mechanisms to help Boards through the implementation process should in future be made available earlier. Such support should also take into account the varying capacity of Boards to implement a change of this magnitude.

PLANNING FOR BENEFITS

  1. Prior to agreement of the contract SEHD set out the intended benefits of the new contract.22 It is reasonable to expect therefore that clear plans to achieve these benefits should have been an integral part of the implementation process from the outset.

  1. However, the AGS report found that few boards were able to provide evidence of having integrated implementation of the contract with local priorities for services and changing the way services are delivered.23

  1. In addition, the health department letter on benefits realisation from pay modernisation was not issued until July 2005. Dr Woods stressed that the letter addressed all the strands of pay modernisation, not just the consultant contract and also emphasised the sheer scale of the implementation process,(Col 1661) commenting that “For a time implementing the contract might have become almost an end in itself but it was always intended to enable the NHS to progress.” (Col 1672)

  1. The Committee recognises the effort required to implement the contract, given that it required individual discussion with all of Scotland’s consultants. However, it was incumbent on both SEHD and Boards to ensure that these individual discussions were set in the context of improvements to patient services and the achievement of higher level benefits.

  1. Julie Burgess stated that, as time went on, it “became increasingly clear” to managers how agreeing service objectives with consultants would help to deliver organisational benefits and improve patient care. This was described as a “dawning” that, over time, Boards would be able to demonstrate real improvements in patient care. (Col 1662)

  1. In the Committee’s view this evidence supports the AGS finding that most boards did not plan how they would achieve benefits from the contract until after implementation.24

  1. Conclusion: In the main, SEHD and Boards did not ensure that discussions with consultants were properly linked to wider service change for the benefit of patients.

  1. Recommendation: The SEHD and Boards should ensure that future contract agreements are used to drive improvements for patients from the outset.

Benefits from Job Planning

  1. A number of witnesses spoke about the potential for the job planning process to provide significant patient benefits. (Col 1669) The Department considers that the intended benefits from the job planning process have been achieved.25

  1. Job plans are clearly central to achieving the benefits of the new contract and the quality and detail of these plans is therefore vital. However, the AGS report found that the quality of job plans varied widely.26 Evidence from the consultant survey also indicated that work done by some consultants has continued much as before, regardless of job planning discussions.27

  1. Dr Woods referred in evidence to work being undertaken by the medical directors’ group to ensure that consistency is achieved (Col 1674) and the Scottish Association of Medical Directors group has also recommended that a national process for job plan reviews be put in place in 2006/07. 28

  1. However, In response to the Committee’s request for further information, the Department did not provide evidence of work being undertaken centrally to monitor the quality of job plans. 29 SEHD also did not offer evidence of specific support being given to medical directors to help improve the standard of job planning.

  1. Conclusion; Not enough attention is being paid to ensuring that the quality of job plans improves and that good practice is shared.

  1. Recommendation: In responding to this report SEHD should set out:

  • how the quality of job planning is to be improved and maintained across Scotland;

  • how job planning is being used systematically to redesign and improve services for patients; and

  • what improvements to the job planning process have taken place since publication of the AGS report.

  1. The consultant survey showed that only 7 per cent of consultants felt the new contract had led to improvements for patients30. The Committee is not inclined to disregard this finding despite Dr Swainson’s suggestion that consultants have wrongly interpreted the intention of the question. (Cols 1666 -1667)

  1. SEHD, Boards and consultants themselves have a responsibility to ensure that the contract results in better services for patients. At the very least the finding may indicate that consultants are not aware of the wider impact of the contract - which they should be if job planning discussions are addressing the needs of the service as well as the needs of individual consultants. (Col 1667)

  1. Conclusion: The fact that only 7 per cent of consultants surveyed felt that the new service had led to improvements is a cause for concern and indicates that job planning discussions are not being used as a lever for change in the way that was envisaged.

MONITORING ARRANGEMENTS

  1. The total cumulative additional cost of the contract over the three years to 2005/06 is £235m.31 This is a very substantial amount of public money. Yet, a key finding from the AGS report was that there is little evidence to assess whether the contract has improved patient care. In its written submission SEHD give an assessment of the progress made in achieving the stated intended benefits of the contract.32 The Committee also received copies of Health Boards’ Pay Modernisation Benefits Realisation Progress Reports.

  1. The benefits realisation reports do provide evidence of developments at individual service level and the Committee welcomes the service improvements described – but it is not always clear how they link to the contract. While the plans afford an opportunity to showcase areas of good practice and positive developments, the Committee is not convinced that they are an effective monitoring tool. The reports do not give a picture across Scotland for key areas of the contract such as working hours, use of consultants’ time or private practice.

  1. Conclusion: The Committee is of the view that current monitoring arrangements are not sufficient, particularly given the very substantial amount of public money involved. Currently it is not possible to demonstrate whether intended benefits from the contract are being met.

  1. Without better monitoring of the impact of the contract it will not be possible to identify whether benefits are being delivered and how investment should be directed in the future.

  1. Recommendation: The Department should ensure that monitoring provides information on whether anticipated benefits, such as the impact on private practice work, are being achieved across boards and across services, rather than providing specific examples of good practice.

CONSULTANTS’ WORKING WEEK AND EXTRA CONSULTANT ACTIVITY

  1. One of the stated objectives of the contract was to address excessive working hours and have less tired doctors.33 A cap of a 48 hour working week was put in place by the Pan Scotland Employers Reference Group (PSERG), in line with the European Working Time Directive (EWTD) to ensure that wherever possible consultants are not working in excess of 48 hours per week. Where hours are in excess of this limit, there is a legal requirement to sign a EWTD waiver.

  1. However, over half of the consultants who responded to the Audit Scotland survey said that they worked over 48 hours per week; 93 per cent of these respondents said they had not signed a EWTD waiver. In addition, 51 per cent said that their job plan did not reflect their working hours.34

  1. In response SEHD pointed to the fact that, in relation to information gathered on Extra Programmed Activities, (EPAs) only a minority of consultants have declared working above 48 hours. However, actual hours worked by consultants are not monitored centrally.35

  1. The Committee acknowledges that consultants often wish to “go the extra mile” for their patients (Col 1667) and many consultants’ willingness to work longer hours to ensure the quality and continuity of patient care is to be commended.

  1. However, the Committee remains concerned about the hours worked by consultants. Indications from the Audit Scotland survey are that the objective of consultants not working over 48 hours per week is not being met. In evidence to the Committee SEHD refer repeatedly to figures for consultants’ contracted hours, despite the Audit Scotland survey finding that actual hours worked often do not match contracted hours.36 The Committee is concerned that this reliance on data relating to contracted hours will continue to “mask” the actual hours worked by consultants. If this persists then SEHD will again lack accurate information on consultants’ work commitments.

  1. Furthermore, the evidence presented to the Committee has not addressed how the 48 hour limit or the signing of EWTD waivers will be monitored or addressed.

  1. Conclusion: Not enough is being done at board level to ascertain the extent to which consultants are working in excess of 48 hours per week.

  1. The problems caused by a lack of accurate information on consultant working have been examined earlier in this report. In fact this is an issue which the Committee has examined in earlier inquiries. In its 5th report of 2005 on the financial performance of the NHS in Scotland the Committee specifically highlighted the danger that the contract might not result in consultants having more time for direct patient contact – given that it was not known how many hours of clinical activity consultants in Scotland were already undertaking.37

  1. The Committee’s concerns have been proven to be well founded. In its written submission SEHD confirm that the intended benefit of securing extra consultant activity more cost efficiently has not been achieved38. In fact extra programmed activities are being used to sustain existing services – because the extent of consultants’ commitments was not known.

  1. Recommendation: The Committee recommends that steps be taken to collect a more accurate national picture of consultant activity.

PAY STRUCTURE

  1. The Committee recognises the professionalism, expertise and commitment of NHS Scotland staff, including consultants. The work undertaken by all NHS staff should be properly recognised. The contract addresses this by explicitly recognising on-call duties and out of hours work performed by a consultant which was not recognised before.

  1. The Committee notes that improved recruitment and retention of consultants was one of the intended benefits of the contract. It is to be hoped that the contract’s more explicit recognition of all duties undertaken by consultants will have a positive effect on recruitment and retention. The Committee notes and welcomes the increase in consultant numbers in Scotland – although at the time of writing it is not clear whether the target of an additional 600 consultants by September 2006 will be met.39 Recommendation: The Committee recommends that in responding to this report the Executive confirm whether consultant recruitment and retention targets have been met. The Committee would be grateful if this response could particularly highlight and give information for those specialities where targets are not being met and where vacancies persist.

THE FUTURE OF THE CONTRACT

  1. The Committee supports the Department’s efforts to ensure that all NHS Scotland staff are properly recognised for the work that they do. However this must go hand in hand with clear plans to ensure that pay modernisation investment is translated into tangible improvements for patient services.

  1. The Committee notes the potential of the contract to both fairly remunerate consultants and deliver change and improvement – however at the moment it is not being used to best effect.

  1. Conclusion: The anticipated wider service benefits from the considerable investment in the consultant contract are not being demonstrated.

  1. Recommendation: SEHD and Boards must take steps to ensure that the stated benefits of the contract are both achieved and demonstrated more effectively.

  1. The NHS will continue to change in line with advances in technology and social change. For example the increasing numbers of women graduating from medical school may have a significant influence on the working patterns and priorities of the consultant profession.

  1. Conclusion: It is important therefore that the impact and effectiveness of the contract is kept under review.

  1. SEHD and Boards need to ensure that the contract is being used to maximum effect. Recommendation: In the short to medium term SEHD and Boards, in partnership with the profession. should monitor and review the contract’s fitness for purpose and ability to deliver greater benefits to patients and staff.

Appendix A

FINDINGS AND RECOMMENDATIONS

SUMMARY

  • Conclusion: Specifically in relation to the way in which the contract was implemented the Committee considers that:

    • Poor information led to inaccurate cost estimates and undermined the effectiveness of negotiations; 

    • The negotiation process did not give sufficient weight to the needs and priorities of the service in Scotland; and

    • The contract does not fully take into account the differing characteristics of and challenges facing the NHS in Scotland.  (para 9)

  • Conclusion: Most importantly, the patient benefits which were to flow from the considerable investment in the consultant contract are not being demonstrated. (para 11)

  • Conclusion: The contract has the potential to both fairly remunerate consultants and deliver change and improvement - but it is not being used to best effect. It is therefore important that the impact and effectiveness of the contract are kept under review to ensure that the expected patient benefits are delivered in future. (para 12)

INFORMATION

  • Conclusion: The Committee is extremely critical of the decision not to collect information on consultant working patterns in Scotland. More could and should have been done to gain a better understanding of consultant activity in Scotland.  (para 15)

  • Recommendation: The Committee recommends that SEHD ensure that future discussion on terms and conditions for staff groups are:

    • fully informed by data relating to Scotland; and

    • take into account Scotland’s specific needs and circumstances. (para 17)

MEETING SCOTLAND’S NEEDS AND THE NEGOTIATION PROCESS

  • Conclusion: The evidence does not persuade the Committee that the contract fully takes into account the differing characteristics of and challenges facing the service in Scotland such as; higher staffing levels; greater remoteness and a smaller independent health care sector.  (para 20)

  • Conclusion: The Committee believes that, the negotiation process for the consultant contract did not enable the needs of the service in Scotland to be given sufficient weight and priority. (para 25)

  • Recommendation: The framework for UK negotiations must ensure that each Department involved has an opportunity to shape core proposals. SEHD must ensure that in future core proposals for UK negotiations are fully informed from the outset, by Scottish data, needs and priorities. (para 26)

Local Negotiation

  • Conclusion: In the Committee’s view SEHD have not demonstrated that there was always a planned approach to this issue, agreed in advance with Boards.  Rather the evidence points to local negotiation coming into play because SEHD and the BMA were unable to reach agreement centrally. (para 30)

  • Conclusion: The Committee considers that the management effort required to resolve these issues locally is likely to have diverted attention from key issues such as planning for patient benefits. (para 31)

  • Recommendation: The Committee recommends that in future, a more planned approach should be taken to identifying issues which are to be determined locally. (para 32)

COSTS

  • Conclusion: Because good quality information was not available when planning for the contract, the costs were underestimated significantly. Consequently, financial assumptions underpinning negotiations were unreliable. (para 35)

  • Recommendation: The Committee recommends that:

    • SEHD ensure that future cost estimates for changes to public service staff contracts are underpinned by accurate and comprehensive Scottish information and fully take into account Scottish needs and circumstances;

    • Where initial investment is expected to yield efficiencies or savings in the longer term that this anticipated benefit be explicitly stated and quantified in the costing model. (para 38)

Waiting Times Payments

  • Conclusion: The Committee considers that arrangements to achieve the stated target of saving £2m annually in waiting times payments were not in place as they  should have been.  However, the Committee welcomes the progress that has been made in reducing the payments and recognises that SEHD and Boards are taking action to address the issue. (para 42)

IMPLEMENTATION: SUPPORT AND GUIDANCE FOR BOARDS

  • Conclusion: The Committee considers that some guidance was issued too late and that the process for supporting implementation of the contract was piecemeal. (para 46)

  • Recommendation: Comprehensive and clear guidance and other support mechanisms to help Boards through the implementation process should in future be made available earlier. Such support should also take into account the varying capacity of Boards to implement a change of this magnitude. (para 47)

PLANNING FOR BENEFITS

  • Conclusion: In the main, SEHD and Boards did not ensure that discussions with consultants were properly linked to wider service change for the benefit of patients. (para 54)

  • Recommendation: The SEHD and Boards should ensure that future contract agreements are used to drive improvements for patients from the outset. (para 55)

Benefits from Job Planning

  • Conclusion: Not enough attention is being paid to ensuring that the quality of job plans improves and that good practice is shared. (para 60)

  • Recommendation: In responding to this report SEHD should set out:

    • how the quality of job planning is to be improved and maintained across Scotland;

    • how job planning is being used systematically to redesign and improve services for patients;

    • what improvements to the job planning process have taken place since publication of the AGS report.  (para 61) 

  • Conclusion: The fact that only 7 per cent of consultants surveyed felt that the new service had led to improvements is a cause for concern and indicates that job planning discussions are not being used as a lever for change in the way that was envisaged. (para 64)

MONITORING ARRANGMENTS

  • Conclusion: The Committee is of the view that current monitoring arrangements are not sufficient, particularly given the very substantial amount of public money involved.  Currently it is not possible to demonstrate whether intended benefits from the contract are being met. (para 67)

  • Recommendation:  The Department should ensure that monitoring provides information on whether anticipated benefits, such as the impact on private practice work, are being achieved across boards and across services, rather than providing specific examples of good practice. (para 69)

CONSULTANTS’ WORKING WEEK AND EXTRA CONSULTANT ACTIVITY

  • Conclusion:  Not enough is being done at board level to ascertain the extent to which consultants are working in excess of 48 hours per week. (para 76)

  • Recommendation: The Committee recommends that steps be taken to collect a more accurate national picture of consultant activity. (para 79)

PAY STRUCTURE

  • Recommendation; The Committee recommends that in responding to this report the Executive confirm whether consultant recruitment and retention targets have been met. (para 81)

THE FUTURE OF THE CONTRACT

  • Conclusion: The anticipated wider service benefits from the considerable investment in the consultant contract are not being demonstrated. (para 84)

  • Recommendation; SEHD and Boards must take steps to ensure that the stated benefits of the contract are both achieved and demonstrated more effectively. (para 85)

  • Conclusion: It is important therefore that the impact and effectiveness of the contract is kept under review. (para 87)

  • Recommendation: In the short to medium term SEHD and Boards, in partnership with the profession. should monitor and review the contract’s fitness for purpose and ability to deliver greater benefits to patients and staff. (para 88)

Footnotes:

1 AGS report, “Implementing the NHS Consultant Contract in Scotland” (AGS/2006/3), pages 4 and 5, paras 5, 11 and 15

2 AGS report, page 4, key finding

3 AGS, report, page 4, para 7

4 AGS report, page 10, para 22

5 Audit Committee, 8th report 2004, “Overview of the National Health Service in Scotland 2002/03” and 5th Report 2005,”Overview of the Financial Performance of the NHS in Scotland 2003/04”

6 Audit Committee 8th report 2004, paras 10, 13, 17, 50 – 59, 82 – 87 and 5th report 2005 paras 7,8, 38-56, 72-73

7 AGS report, page 10, para 20 and SEHD submission page 1, para 1

8 AGS report, page 10, para 20

9 SEHD submission page 1, para 1

10 AGS report page 5, paras 11 - 15

11 The Committee raised this concern in its 5th Report of 2005, “Overview of the Financial Performance of the NHS in Scotland 2003/04”, page 8, para 46

12 AGS report page 20 Exhibit 6

13 SEHD submission page 2, para 3. The Department also state in the submission that there was prior consultation with Board representatives and the BMA in all cases.

14 SEHD submission, page 2, para 3

15 Dr Swainson also referred to the need for central guidance on the issue of “minimal disruption” in relation to payment of fees – despite the fact that this had been judged appropriate for local determination. (Cols 1660 and 1661)

16 AGS report, page 16, para 41

17 AGS report page 10, para 22

18 According to the Department, this underestimate of the number of additional extra programmed activities required was a trend observed throughout the UK (Col 1654)

19 AGS report, page 22 paras 66 – 71

20 SEHD submission, page 9, paras 14 and 15 and Annex A

21 AGS report, page 12 paras 34 to 38

22 AGS report, Appendix 5, page 40

23 AGS report, page 16, paras 43 and 44

24 AGS report, page 9, Key findings

25 SEHD submission, page 4, para 6

26 AGS report, page 30 para 106

27 AGS report page 30, para 107

28 AGS report, page 31, para 112

29 SEHD submission page 3, para 4

30 AGS report, page 29, para 98

31 AGS report, Summary, page 3; The cumulative additional cost rises to £273m when inflation and on-costs are included.

32 SEHD submission, pages 3-5, para 6

33 AGS report page 31, para 113

34 AGS report, page 31, paras 113-117

35 SEHD submission, page 6, para 9

36 SEHD submission, page 6, para 9

37 Audit Committee 5th Report of 2005, “Overview of the Financial Performance of the NHS in Scotland 2003/04”, paras 51-53

38 SEHD submission, page 5, para 6

39 SEHD submission, pages 4-5, para 6

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