Not long after the distinction awards scheme for NHS consultants was launched criticisms were levelled at the administration of the awards in the press from members of the Houses of Parliament and the medical profession.
Criticisms were based on the secrecy of the scheme, demanded by the BMA to protect the private practice of non-recipients of awards, discrepancy between awards granted to specialties, geographical differences and greater recognition of the teaching hospitals and the major DGH hospitals were also exposed.
Though the DOH and the awards committee assured the profession of the fair administration and distribution of awards, gender distribution of awards were in fact not recorded and figures for the ethnic distribution were not available in 2003 at the time of the publication of the paper on gender and ethnic distribution of awards (Esmail et. al. BMJ 2003;326:687-688).
This publication and the investigation carried out by the Commission for Racial Equality (now the Equality and Human Rights Commission) provided a major trigger for the politicians to institute a review of scheme culminating in the Clinical Excellence Awards.
Progress has been achieved but the perceived ethnic and gender discrimination, and advantages for the academics and consultants in the larger institutions and specialties had not been subjected to strict statistical scrutiny.
What is fascinating if not intriguing is the implicit admission of guilt with little effort to investigate any possible explanation for these discrepancies. A DDRB report in 2012 also implies an unfair advantage in the scheme for the academics.
Is there a credible explanation? I raised the possibility of indirect discrimination due to the use of criteria that the ethnic minorities could not satisfy due to more ethnic minority consultants working in the smaller DGHs where there are limited opportunities. The CRE agreed that there was no evidence of direct discrimination and that indirect discrimination could possibly contribute to fewer ethnic minorities holding awards. (Racial discrimination in distinction awards BMJ 316; 27 June 1998).
A guiding principle of the scheme is that it ‘reflects achievement over and above what is normally expected contractually’ (ACCEA annual report 2014). Is this quantitative or qualitative? Could justifiable comparisons be made over the entire range of specialities? There is little evidence of verification of this firmly held tenet.
Claimed to create a level playing field over a vast range of specialties in my opinion it provides a misguided rationality in the scheme. Is the ‘over and above’ achievements in more demanding specialties comparable to achievements in specialities in undoubtedly less demanding.
Under-representation of some specialities is inevitable within the prevailing scheme.
A better basis for the awards is stated in the BMA’s submission to the DDRB: The essential rationale of the schemes has remained the same, namely to recognise and reward the exceptional contribution of NHS consultants. This would include performances over and above and those achievements of significance in the wider medical field – Distinction and Meritorious Service Awards (DAMSA).
The term clinical excellence as applicable to the range of medical specialities was never satisfactorily defined to justify renaming the scheme: reminiscent of the emperor’s clothes.
The criteria employed to judge performance of excellence or distinction have come in for criticism. Up to 1990 it was even held that ‘there are no formal criteria for awards’. Subsequent requirement of work of national or international significance was abandoned following the intervention of the CRE. The domains adopted currently is recognised as favouring the academic and teaching hospital consultants. It appears the DOH has resisted changes.
A persistent criticism of the award scheme is that it fails to achieve parity in the distribution of awards in all the subgroups such as ethnicity, gender, speciality, academic and service based consultants. Any discrepancy is condemned to be unfair. The wide range of opportunities and abilities is ignored.
If the teaching hospitals and the smaller DGHs are to be catered within a unified scheme the advantages that the larger teaching consultants receive should be recognised. These posts were competitively merited by consultants seeking greater opportunities. It would be unfair to pay less significance to their contributions.
It was not until 2004 under the chairmanship of Elizabeth Valence that a study published in the BMJ appeared to deny claims of discrimination made by Esmail and others (BMJ 2003).
The report concluded that ‘historical under-representation in award holding by women and doctors from ethnic minorities was partly explained by time spent as consultants’. Recent awards showed no appreciable under-representation of ethnic minorities or women consultants based on single factors or following ‘multivariate adjustment of the historical database’.
It is a matter for serious concern that the DOH and the advisory committees have over the years not conducted any meaningful statistical analysis of the figures and even appeared to admit guilt.
It is therefore time to learn the lessons and awaken to reality. Drifting into a philosophical mood I even see Darwinism in action. Survival of the fittest encouraged by recommendations from elite stakeholders and nominations by specialist associations. These certainly distort the nominations in favour of the elite specialities.
Awards meant to be rewards over time have come to be been seen as remuneration or even worse as a bonus. I would strongly urge any future awards scheme to be based on the honours scheme and reward those who:
– provide dedicated service and commitment to the NHS;
– making outstanding contributions to the NHS and to the broader field of medicine at a national or international level.
The above criteria would adequately cover local and national services. More importantly it would permit exceptional services performed at a local level to be recognised for national awards. The farcical and impractical concept of seamless transition from local to national awards should be discarded.
The mistake in the past is to include work of national and international significance as criteria. Rewards however cannot be labelled indirect discrimination.
The basic tenets of the scheme should be revisited and reflect the real world. At the time of the creation of the awards, Spens’ intentions were to allow the best possible recruits to be attracted to specialist practice and to be leaders in the field of medicine: ‘to maintain the position of British medicine in a competitive market’ with innovators whose contributions bring about changes in medical practice.
Mea culpa needs to be acknowledged by several advisory committees, Department of Health and NHS officials. The BMA’s role is conspicuous by its failure. I therefore hope we have learnt the lessons to recapture the spirit of the awards scheme to reward the dedication, hard work and the outstanding achievements of the consultants.