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8 Changes for NHS doctors

  • expansion of medical students, specialist registrars, consultants and GPs
  • further expansion to follow
  • move to new quality-based contracts for GPs
  • new arrangements for single-handed practices
  • new contract for consultants
  • extra rewards for consultants tied to NHS service

Introduction

8.1 Doctors working in primary care and in hospitals work hard for their patients. Both their commitment and skill is highly valued. We have some of the finest doctors in the world. The NHS has to value its doctors by investing more in their skills and their efforts for patients. But the contractual arrangements for GPs and consultants stem from 1948. They are based on arrangements that in important respects are not relevant to today's world. In partnership with doctors and their representatives now is the time to make changes to help deliver the improvements in this Plan.

Family doctors

8.2 Our family doctors are a real source of strength for the NHS. As a result of the changes in this Plan we will have strengthened GP services still further:

  • there will be 2,000 more GPs and 450 more GPs in training by 2004. This will just be a start - faster growth of the number of GPs will need to continue beyond 2004
  • there will be a bigger role for GPs in shaping local services, as more become specialist GPs, as PCTs become universal and as new care trusts (see chapter 7), incorporating social services as well as health services, come on stream
  • pressure on GP services will be eased as nurses and other community staff (see chapter 9) together with a new generation of graduate primary care mental health workers (see chapter 14) take on more tasks 74 Changes for NHS doctors
  • up to 3,000 family doctors' premises including 500 new primary care centres will benefit from a £1 billion investment programme by 2004
  • GPs will be helped with their continuing professional development through earmarked funds
  • NHS occupational health services will be extended to cover family doctors.

8.3 The development of primary care services is key to the modernisation of the NHS. However, we need to modernise the relationship between the NHS and GPs, building on what is already good. The current GP contract - the 'red book' - has often worked well, but it gives greater emphasis to the number of patients on a GP's list and the quantity of services provided rather than the quality of them. Too often it has been an obstacle to GPs who have wanted to develop services tailored to the needs of their own local population.

8.4 Family doctors are also looking for better and more flexible ways of working. For example, some GPs want to spend at least part of their career as salaried doctors rather than independent contractors. A significant number want to restructure their practices, perhaps to develop new services by using their staff in new ways or co-operating with other practices in offering care across a local community.

8.5 Since 1998 an increasing number of GPs have been working to a different type of contract - the Personal Medical Services (PMS) contract - instead of working to a standard national contract. Personal Medical Services pays GPs on the basis of meeting set quality standards and the particular needs of their local population. For example, if an area had a particularly high level of heart disease the PMS contract could set targets for ensuring that local people at risk were identified and prescribed appropriate treatment.

8.6 In some Personal Medical Services schemes all members of the healthcare team - doctors, nurses and other health professionals - work on a similar contract instead of the traditional arrangement where staff work for a self-employed GP. Personal Medical Services also allows GPs, if they choose, to work on a salaried part-time or full-time basis.

8.7 This approach has brought a wide range of benefits. It has been used to develop new services for specific populations, such as ethnic minority communities, to attract doctors and nurses into deprived areas and to improve services for patients.

Case study of a PMS scheme in an area of deprivation

Until recently, the Pennywell area of Sunderland could not attract any GP practices to serve a population of approximately 13,500 people. Under PMS, the local NHS trust now employs a GP and fully integrated primary healthcare team to work in partnership with the community and other local agencies. People in this area of high need now have fast access to a wide range of primary care services. These include minor operations, drop in sessions, health promotion, asthma control and breast screening clinics. Some services require no appointment. In others, appointments take place on the same day of asking and the average wait for an appointment is just one day. This shift to managed healthcare means a move away from reliance on emergency care. Some 2,300 accident and emergency attendances by patients registered with the Pennywell pilot took place in the year before it went into operation. That number has now fallen by 40%.

8.8 We will encourage a major expansion of Personal Medical Services contracts. All the current pilot schemes that are successful will become permanent. By April 2002 we expect nearly a third of all GPs to be working to Personal Medical Services contracts. And we expect the number to grow steadily over the next four years to form a majority of GPs. Salaried GPs will come to form a growing number of family doctors providing that is what they choose to do. We will make it easier to switch to a Personal Medical Services contract by introducing a standard core contract to help cut bureaucracy. New entrants will, in the future, be able to make a more automatic switch into Personal Medical Services without a lengthy pilot phase. The core contract will ensure basic consistency on delivering key objectives such as access to primary care, national service framework standards, quality and clinical governance.

8.9 As we develop the core Personal Medical Services contract we will work with GPs and their representatives to amend the national 'red book' contract. The revised national contract should reflect the emphasis on quality and improved outcomes inherent in the Personal Medical Services approach. By 2004 both local Personal Medical Services and national arrangements are set to operate within a single contractual framework that will meet the key principles and requirements of a modern NHS. This will be the most significant change to the way GPs work for the NHS since 1948.

Single-handed practices

8.10 It is particularly important to be able to confirm that single-handed practices are offering high standards, because although most single-handed GPs work hard and are committed to their patients, they tend to operate in relative clinical isolation. They do not have the ready support from colleagues enjoyed by GPs in larger practices. The current 'red book' contract is a particularly poor mechanism for protecting quality standards in these practices.

8.11 For this reason, new contractual quality standards will be introduced for singlehanded practices.This will either be done through a negotiated change to the 'red book', or if this proves not to be possible, a new national Personal Medical Services contract will be introduced into which all single-handed practices will be transferred by 2004. The role of primary care groups and primary care trusts in promoting and auditing clinical governance will also help reduce isolation and encourage co-operation between GPs.

Hospital doctors

8.12 Hospital doctors do a brilliant job for the NHS. Consultants are specialists whose expertise is highly valued by patients. As a result of the changes in this Plan by 2004 consultants working in the NHS will be benefiting from:

  • a major investment in equipment, information technology and facilities described in chapter 4
  • a 30% expansion in consultant numbers with further increases in the pipeline as a result of expansion in medical school places and specialist registrar posts. In the first instance this will help end single-handed consultants in hard pressed specialties.

8.13 But we intend to go further. As part of the Government's in principle commitment to major expansion of the consultant grade there will need to be a significant increase in the numbers of specialist registrars. One of the reasons that this has not happened in the past is that local NHS trusts have had to contribute part of the cost of specialist registrar posts. As a result there has been a large gap between the number of specialist registrar posts that have been planned for nationally and the number of posts that have actually been created locally. This will now change. From 2002 the Government will centrally fund all specialist registrar posts provided that agreement can be reached with the medical Royal Colleges and other bodies on curricula and criteria for training recognition.

8.14 In addition, as well as ensuring the creation of specialist registrar posts, the Department of Health will take action to help ensure that the appropriate number of consultant posts are established in NHS trusts across the country. Drawing on national service frameworks, workforce plans will match the new standards of care with the numbers of staff required to implement them. NHS trusts will be performance managed against these standards.

8.15 So there will be a guarantee of more consultants and more future consultants too. There will also be a greater role for consultants in shaping local health services:

  • hospital consultants will play a central role in the new local taskforces and modernisation boards that will advise on and oversee the implementation of this NHS Plan in all parts of the country
  • strengthened forms of commissioning will draw more directly on the expertise of hospital consultants particularly when it comes to the regional commissioning of specialised tertiary services and in developing long-term service agreements with primary care groups and trusts
  • radical new forms of clinically-led care will be piloted. In the first instance, pilots will be established to commission cancer services from the new cancer networks which span a number of individual NHS trusts.

8.16 Over the next decade there will be an unprecedented expansion in the number of consultants working in the NHS. It will be vital to ensure the NHS is getting the maximum contribution possible from both existing and new consultants.

8.17 Expansion on this scale also creates the opportunity to ensure that there is a clear career path for all senior doctors. We have examined two options here. The first would involve expanding the number of non consultant career grade doctors, often on trust specific contracts. This option would allow the NHS to get more fixed clinical sessions from senior doctors without competing with private practice, and it will be kept under review.

8.18 The second option is to make hospital care a consultant delivered service, where there is a clear career structure so that doctors have certainty about how they will progress and where contractual obligations to the NHS are unambiguous. It is this option that both the professions and the Government support in principle. Its implementation, however, will depend upon a new consultants' contract.

 8.19 The national consultant contract is largely unchanged since 1948. Most consultants work very hard for the NHS and with tremendous commitment to the NHS. Many are working beyond their contractual commitments. But the way consultants are managed on the ground through their current contract is far from satisfactory. For instance, too few have proper job plans setting out their key objectives, tasks and responsibilities and when they are expected to carry out these duties. Even fewer have their performance regularly reviewed. The issue of consultants' private practice has remained a legacy of the 1948 settlement.

8.20 Consultants who make the biggest commitment to the NHS do not get the right rewards. In consultation with doctors and their representatives, we will, therefore, fundamentally overhaul the contract to reward and incentivise those who do most for the NHS.

8.21 As we have already agreed in principle with the British Medical Association, the new contract will make annual appraisal and effective job plans mandatory for all consultants. This process will enable the professional and clinical needs of consultants to be identified and support clinical governance and revalidation. It must also ensure that NHS employers are able to manage the consultant workforce effectively in order to ensure the best use of their time and of the resources of the trust. Royal Colleges will be able to advise NHS trusts on, but not veto, the content of job descriptions for consultant posts. All consultants will have job plans specified by the employer linked to annual appraisal of their work.

8.22 Consideration has been given to 'buying out' the bulk of existing private practice nationally. However, careful analysis suggests this would be unlikely to work in practice: it would probably cost at least £700 million; the NHS would have to enter a bidding war with the private sector; it would seriously distort incentives; and it would be insensitive to local requirements. A different approach will therefore be taken.

8.23 At present, the consultants' contract requires them to work an ambiguous 'five to seven' fixed sessions a week. In future, existing consultants will, by default, be required contractually to undertake seven fixed sessions a week pro rata. Trusts will be able to fund extra, fixed consultant sessions on an as-needed basis, as at present. Assuming this condition and other aspects of the reformed consultant contract are being met, existing consultants will continue to be able to undertake private practice in their own time.

8.24 A move to a consultant-delivered service means that in future, newly qualified consultants will be contracted to work exclusively for the NHS for perhaps the first seven years of their career, providing eight fixed sessions, and more of the service delivery out of hours. In return we plan to increase the financial rewards to newly qualified consultants. Beyond this, the right to undertake private practice will depend on fulfilling job plan and NHS service requirements, including satisfactory appraisals. If agreement cannot be secured to these changes the Government will look to introduce a new specialist grade for newly qualified hospital specialists to secure similar objectives.

8.25 Over time we want to make clearer the advantages of making a long-term commitment to the NHS, particularly for those who will become consultants in the future. First, doctors - as well as nurses and other staff - who are working hardest for the NHS and improving services for patients, will have access to bonus payments from the National Performance Fund. Second, we will reform the existing distinction awards and discretionary points schemes. Together they provided £170 million last year in superannuable bonus payments - ranging from £2,500 to £60,460 - to consultants. But they are not sufficiently related to the NHS work these doctors undertake. They will be merged into a single, more graduated scheme with increased funding: to enable more awards to be made; to ensure that the bulk of any new awards go to consultants who are making the biggest contribution to delivery and improving local health services; and to ensure that bigger rewards go to consultants who make a long-term commitment to the NHS:

  • following consultation with doctors and their representatives, we will publish explicit new criteria for the new single scheme by the end of the year. The new arrangements will come into force by April 2001
  • by 2004 we will aim to increase the number of consultants in receipt of a superannuable bonus from under one half of all consultants at present to around two-thirds and to double the proportion of consultants who receive annual bonuses of £5,000 or more
  • the new scheme will be weighted so that consultants who are contracted exclusively to the NHS have accelerated access to proportionately bigger bonuses
  • there will still be special provision for clinical academics (and for the first time academic GPs) and those consultants of national and international renown.

8.26 The new consultant contract will make clear that in the early and middle part of their careers, consultants will be expected to devote the bulk of their time to direct clinical care. It will also stipulate, however, that towards the end of their careers, consultants will have the flexibility to reduce their fixed clinical sessions without detriment to their pensions. We envisage a greater role for mentoring, training and leadership, for example.

Medical education

8.27 We will modernise the Senior House Officer grade, with the aim of providing better and broader educational experience and a reduction in inappropriate workload. New arrangements will be introduced progressively from September 2001. Junior doctors' hours will continue to fall.

8.28 We will rationalise the complex arrangement for medical education. As a first step we will establish a new body - the Medical Education Standards Board - to provide a coherent, robust and accountable approach to postgraduate medical education, replacing the separate bodies for general practice (the Joint Committee for Postgraduate Training in General Practice) and hospital specialties (the Specialist Training Authority). The Board will ensure that patient interests and the service needs of the NHS are fully aligned with the development of the curriculum and approval of training programmes. Membership of the new body will be drawn from the medical profession, the NHS and the public. It will accredit NHS organisations as training providers. We will wish to see consideration of options for overseeing medical undergraduate curricula considered as part of the radical review of the role of the General Medical Council, together with proposals for shortening the medical undergraduate course to three years for existing graduates and four years for others.

Clinical governance

8.29 The overwhelming majority of doctors provide safe, high quality care for patients. Medicine, however, is not an exact science. Mistakes do and will sometimes happen. The NHS has a responsibility to ensure that it has the right systems in place to keep mistakes to a minimum and to learn from them when they happen. That is why the Government has put a new focus on improving service quality. Patients have the right to expect assurances about the quality of care that they receive wherever they receive it in the NHS. There are new national standards, new systems of quality improvement and, for the first time, a statutory duty of quality on all NHS organisations. The new system of clinical governance is being introduced into all parts of the NHS. There will be extra targeted investment in doctors continuing professional development to ensure that all doctors can meet the highest quality standards and requirements of clinical governance and revalidation, coupled with new regulatory safeguards (see chapter 10).

Conclusion

8.30 The health service has much to be proud of in terms of the quality and reputation of its doctors. By 2004 there will be more doctors in the NHS with better rewards. They will be working in new ways to new contracts. Their ability to deliver redesigned services for patients, however, is partly dependent on developing new roles for nurses and other NHS staff.

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