The Academy of Medical Royal Colleges recently submitted its views on clinical excellence awards to the Review Body on Doctors’ and Dentists’ Remuneration, which is currently reviewing the awards system for the government. It is due to report this summer and the following is a summary of the AMRC’s conclusions:
Purpose of national awards
In the white paper Liberating the NHS the government has clearly stated its commitment to the concept of an NHS free at the point of use and available to everyone based on need, not ability to pay. Whilst the government envisages greater autonomy for individual healthcare providers it sees them operating within a national framework and a national set of principles that are currently defined by the NHS Constitution.
In a system with greater local organisational autonomy the question of how to reward and incentivise contributions to the wider NHS becomes more, not less, pertinent.
The AMRC strongly believes that national level awards must be there to recognise exceptional contributions to the wider NHS and reward doctors for their input into the development of the health system in the UK as a whole beyond the level of the provision of care and services at a local level.
Recognition of such work is essential to: reward excellence in achievement for the wider NHS; incentivise involvement and continuation in activity contributing to improvement of the wider NHS; and, support the retention of national/international expertise within the UK health service.
Reward
As the scheme states, its purpose is to “reward individuals who achieve over and above the standard expected of a consultant or academic GP in their post”. Contributions to the wider NHS will, almost by definition, be beyond the scope of what is expected by a consultant in his or her post.
At present, 11% of consultants receive national awards recognising their contribution to the wider NHS beyond their local employer level. This proportion of senior doctors recognised for high quality contributions to the wider health system seems neither unreasonable nor unexpected.
The level of national awards is, of course, not insignificant. But they are possibly misleadingly high as they incorporate employer level awards. ACCEA reports that over 80% of those receiving a bronze award for the first time were already in receipt of local awards at level 5 or above which in effect reduces the size of the national “reward” by about £20,000 on average. Seen in this context the Academy does not believe that the reward for national or international medical excellence of between £15,000 and £55,000 is excessive.
Incentive
The AMRC also believes that national CEAs provide an important incentive for doctors initially to become involved, and as important, to remain involved in work for the wider NHS.
NHS and UK medicine depends on the participation and contribution of doctors to the wider NHS, beyond their own trust, not only for its development but also for its practical functioning. For example, the roles of senior doctors in the development of NICE guidelines, developing and updating the 58 specialty curricula, setting and applying professional standards through College exams, setting clinical standards or reviewing and conducting clinical research all underpin the day to day operation of the NHS. Such work is vital to the future of healthcare in England but would not be regarded as a priority by all trusts.
Without the contribution of medical, and other, staff, beyond the bounds of their local employer, the NHS would cease to function effectively.
Successive governments have stressed the importance of clinical engagement and leadership. The CEA scheme recognition of the importance of non-clinical roles in leadership, education and health policy making and planning is important for medical involvement in these areas.
Academic medicine
The AMRC believes it is essential to maintain and improve recruitment into academic medicine and problems in this area are well known. Clinical academics are discouraged from private practice as it distracts from and competes with time for research/teaching. Therefore, awards provide an incentive for talented trainees to choose academic careers.
Retention
It is important that the NHS keeps its highest calibre medical staff and that the UK health system retains doctors who are world class clinicians, leaders, researchers and teachers.
Medicine is, without doubt, a global employment market. It acknowledges that UK doctors fare well in comparison to their European counterparts. However, in the key English-speaking health markets of the USA and Australia the potential remains for UK doctors to obtain significantly higher earnings.
In Australia, doctors current basic earnings range from £91-182,000, with expected overtime from £109-212,000 and with complete packages from £121-242,000.
In the USA, median earnings range from £118,000 in geriatric medicine to £434,000 in spinal orthopaedic surgery. Within this range are, for example, Psychiatry at £135,000, Emergency Care at £168,000, Anaesthetics at £233,000, Cardiology at £253,000, Vascular Surgery at £261,000, Interventional Diagnostic Radiology at £301,000 and Neurological Surgery at £372,000.
In all cases US earnings are above the top point of the UK consultant pay scale salary.
It is important that the UK health system recognises the potential for the loss of national expertise and is seen to acknowledge and address the issue in practical terms. CEAs seek to address this issue.
Employer level awards
The academy believes that some but not all of the same arguments apply to employer level awards - which are given to 43% of all consultants.
It is right that there is the opportunity to acknowledge and reward exceptional contribution by consultants and that this contribution must relate to the objectives of the local organisation. Domains 1-3 covering the delivery, development and leadership of a high quality services rightly focus on services for patients. The academy also strongly believes that Domains 4 and 5 covering research and education and training are equally important. These activities do need to be recognised by employers as a vital component of maintaining and improving the quality of care at a local level.
It is also vital that medicine remains an attractive and rewarding career option for young people making their university choices particularly with the likelihood of significantly increased costs for undergraduate medical education.
Operation of the system
One of the strengths of the system is that it does encompass all possible aspects of medical practice such as education, research, leadership and contribution to policy making and therefore incorporates the whole profession including those who do not have a primarily clinical focus. The AMRC therefore supports the criteria set out for the scheme and believes the five domains are correct.
There has been a vast improvement in the operation and application of the system at local and national level over recent years and welcomes this change.
Criticisms that the scheme is divisive, besides being self-evident, miss the point. Any scheme rewarding excellence on a competitive rather than a universal basis creates a division between those with and those without the reward. Equally, if the scheme is genuinely intended to reward excellence “over and above the standard expected” all doctors are not going to meet this criteria.
Accepting the concept of a scheme based on merit and competition it is, however, obviously important to ensure that it operates fairly. Whilst historically it may not always have been the case, the system currently operates in an extremely fair and efficient manner.
We believe the criteria for awards are right and that at local and national level great efforts are made to follow these and operate the system effectively.
Two of the key principles for the 2003 scheme were that it should be: transparent, fair and based on clear evidence; and, open and accessible to all eligible consultants.
The AMRC believes that these have generally been met. The useful analyses undertaken by ACCEA of the gender and ethnic distribution of awards seem to show there is no statistically significant gender bias nor any real difference in the ratio of applications to awards between black and minority ethnic and white applicants (except in the case of Gold Awards).
Awards should be reviewed on a regular basis and that recipients should have to demonstrate that they continue to meet the criteria for receiving the award. Equally the standards for approving the continuation of an award should be no less rigorous than those applied for giving the award in the first instance.
Conclusion
The AMRC strongly believes that awards for excellence for consultants continue to be relevant and justifiable at both local and national level.
“The Academy of Medical Royal Colleges” - what exactly does it actually do (apart from trying to defend the opaque, unfair and secrecy shrouded cea system)? anything that actually benefits patient care? please - someone enlighten me …