I draw everyone's attention to the job in hand. I am pleased to welcome one of our regular attendees, Dr Kevin Woods, and his team. In today's session, we will ask questions about the Auditor General's recent report, "Implementing the NHS consultant contract in Scotland", with particular focus on the negotiation and planning of the contract, the impact of the contract to date and the plans to use the contract to improve care for patients. With Dr Woods are several former members of the Executive team who have made some effort to be here, for which I thank them. I ask Dr Woods to introduce his team formally and to make his opening statement.
As you say, convener, I am joined by colleagues who have moved to other jobs. On my left is Mike Palmer, who was formerly the assistant director in our human resources directorate and who played an important role in the consultant contract. On Mike's left is Julie Burgess, who is currently the chief executive of the Birmingham Women's Healthcare NHS Trust but, prior to that appointment, was responsible for the consultant contract as director of pay modernisation. I am grateful to Mike and Julie for returning to assist the committee today. On my right is Tim Davison, who is the chief executive of NHS Lanarkshire and who, as chair of the pan-Scotland NHS employers reference group, played an important role in the implementation of the contract. On his right is Dr Charles Swainson, the medical director of NHS Lothian. I am grateful to them all for coming along in support.
Thank you, Dr Woods. Your statement has helped to shape the context for us. Thank you for the guidance material that you said you will make available to the committee. Our clerks will no doubt receive that from you.
Yes. I have no reason to believe that anything in the material or in what I have said this morning was not made available to Audit Scotland. All of the material is in the public domain. I brought it to committee simply to demonstrate the scale of advice that we offer to NHS Scotland.
Okay. We move to questions from committee members, which will cover the negotiations on, planning for and impact of the contract. Susan Deacon will open our questioning on the subject of the negotiations.
Thank you for that helpful introduction, which helped to remind us of the background to this complex issue. I will explore in particular the recurrent question of the extent to which the contract reflects distinctive Scottish needs. The question has arisen both at committee and in the Audit Scotland report. In your opening remarks, you noted the general recognition that there is good reason for having a UK framework for pay in the NHS, both for consultants and other staff groupings. That is worth noting; indeed, we stated that explicitly in a previous report.
I agree very much about the benefits of addressing the issues on a UK basis. We needed to do that to recognise the mobility of labour. It would not have been advantageous for a market to develop across the UK; that would only have caused people to try to outbid each other on pay and conditions. For a long time, having a UK basis for the contract has been a central plank of ministerial policy.
I am happy to comment. I was present at the negotiations in London that led to the framework agreement in 2002. There was direct input from all four health departments into the negotiations, and ministers in all four countries were kept abreast of progress.
That is helpful. I have a final question about the negotiation process before we move on to consider its outcome. After the negotiations at UK level, was there a mechanism—a parallel process or grouping, for example—for considering how the emergent ideas and proposals could be shared and road tested with stakeholders in Scotland?
The NHS Scotland management representatives who took part in the UK negotiations kept NHS trusts and boards in Scotland abreast of developments. There is a wee caveat around that, because confidentiality rules were placed around some of the more sensitive areas of negotiation. Given that negotiations were continuing, we did not want those elements to be in the public domain and, for tactical reasons, not all the details could be divulged. However, the main elements—such as the thrust towards job planning, a more transparent organisation and better management of consultants' time—were communicated to the trust and board chief executives regularly. The feedback that we got from the service in Scotland was that the proposals were useful because they would create and provide us with the management information that we need if we are to start managing consultants' time more effectively.
I presume that, as part of that process, there was a relationship with the BMA here in Scotland. One of the interesting factors is that, in the vote on the contract in 2002, the medical workforce in Scotland voted differently from people in other parts of the UK. Is it fair to deduce from that—or simply to record—that the BMA in Scotland was involved in a parallel dialogue with its membership and the department?
Yes. The relationship between us and the BMA was constructive and positive throughout the period. There was an open door to communication between us and there was a lot of communication. I contrast that with some of the relationships with the BMA in England, where the two parties were slightly more polarised. That might reflect the fact that England is a much bigger country and it is more difficult to get people around the table to communicate things regularly. In Scotland, regular dialogue was maintained between us and the BMA. It is clear that the BMA was at pains to keep its members abreast of developments.
Thank you. I will resist the temptation to explore that even further, fascinating though it is.
I do not believe that the contract contains any special provisions on remote and rural areas, but one factor that is integral to the contract is an acknowledgement of consultants' travelling time, which might have had a cost impact in remote and rural areas even though only a comparatively small number of consultants work in those places.
On the waiting time initiative payments, I stress that the triple-time payments are only for ad hoc waiting time initiatives. We were careful in writing that into the contract. As Dr Woods has said, the thrust of the contract is to enable boards to programme ahead, on a regular basis, extra sessions that consultants can take in order to meet waiting times targets without those being classified as ad hoc sessions, which would attract triple-time payments. We are definitely seeking to reduce the amount of triple-time payments as we move towards a more programmable and programmed approach to meeting those targets. As Dr Woods says, the evidence is beginning to show that, through the falling level of payments across a number of boards.
I am sorry to interrupt, but it would be useful to clarify this point before you move on. The Audit Scotland report expressly states:
Yes. I do not know how a diagram can be recorded for the Official Report, but although we acknowledge that the payments went up, they are now firmly on the way down and are now well below 1 per cent of the current consultant pay deal.
Okay. I appreciate the fact that, in relative terms, the payments are marginal to some of the wider costs, but it is important that you have highlighted something that is markedly different from what is in the Audit Scotland report.
I need to refresh my memory of what the report says. The suggestion is that all boards are paying triple time rather than using time off in lieu, although I do not know what NHS Lothian is currently doing. Perhaps Charles Swainson can update the committee on NHS Lothian's practice in relation to that, bearing in mind the fact that we are trying to get rid of the payments altogether.
I have taken the view that such work is additional, ad hoc work above the 48-hour working limit that the contract proposed, so it would be wrong to pay consultants triple time for it and to expect them not to have appropriate rests. NHS Lothian is prepared to pay up to double time and expects the additional component to be taken as extra rest, which ensures that consultants are fit to work for the NHS when they return to their normal duties. The work is additional and the extra payment is for work outside the normal contract. The result of our policy is the lower payments that we have made in Lothian.
Although the payments are tailing off, as Charles Swainson said, boards have often decided that they were a significantly cheaper and more efficient alternative to sourcing extra activity in the private sector. We often calculated the cost of using ad hoc payments in-house—even triple-time payments—and compared that with ad hoc sourcing of activity from the private sector. Often, such payments were a much more efficient use of NHS resources, so they were helpful at times, although we all acknowledge that we would not want to sustain them in the long term.
I will give members some data for NHS Lanarkshire and NHS Lothian, to provide them with a sense of the size of such payments. In the six months to the end of December, Lothian's expenditure was £137,000 and Lanarkshire's expenditure was £175,000. That gives members an idea of the contribution of such payments, although they are at the margins.
That is helpful. I have a question about use of the private sector, which Tim Davison touched on. We know that the private sector in Scotland has traditionally been much smaller than that in England. I do not know whether trends are changing, but it is clear that the NHS in England is making substantial use of the private sector in a host of ways. You draw to our attention the fact that the comparison that you made was of NHS costs with NHS costs as distinct from what the cost in the private sector might be. In relation to the Audit Scotland report or to the wider debate about new arrangements for the consultant contract, do wider issues of which we ought to be aware arise that are a function of the different sizes of the private sector north and south of the border?
I do not think that any material issues are not already in the public domain. The contract gives us a much more structured way of managing the extent to which consultants engage in private sector work and it gives us a much more formalised and explicit framework for ensuring that we know where our consultants are and that we can audit that. It also makes when consultants will undertake private sector work an explicit part of the job planning agreement. Although the market is much smaller in Scotland, and even more so outside the cities in Scotland, we have a much more structured way of managing the interface. That construct has been really helpful.
First, I declare an interest in that I am still a member of the British Medical Association.
Do you mean the data that we had back in 2000?
Yes.
Very little information was held centrally in comparison with what was held locally, but even that was not as complete as was necessary to cost the contract.
At what stage in the process did you feel that you had enough data to make a costing?
The survey that was undertaken throughout the UK with the BMA was important in that respect. I do not know the precise dates on which the survey was conducted. It happened between 2000 and 2002—perhaps Mike Palmer can say precisely when. The survey was intended to fill the gap. Mike Palmer might wish to add a little to this, but my understanding is that the survey was, when it was conducted, regarded as being a reasonable basis on which to carry the contract forward to its next stage. As the Audit Scotland report shows in retrospect, a number of underestimations in the survey became clear.
I do not have with me information on exactly when the survey was undertaken—it was in 2001. I am sure that we could furnish the committee with more precise dates for the survey, but it would have been carried out just prior to the opening of the framework negotiations, which took place around the middle of 2001. About 300 consultants were surveyed and were asked to draw up diaries of their working patterns. The survey was conducted jointly with the BMA and was endorsed by the profession.
Was that the survey that informed the first national cost estimate in March 2003?
Yes. There were cost estimates prior to March 2003, which would also have been informed by the survey.
Why did the first national cost estimate underestimate the cost of the contract by £171 million?
First of all, the figure of £171 million is a cumulative figure over three years. 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. The principal reason why the cost was underestimated was that the survey indicated that it would be necessary to buy about one third of a programmed activity beyond the 10 programmed activities in the contract; in fact, by the time of the contract's implementation, further work had shown that it would be necessary to buy an extra 1.4 programmed activities. In the course of the first year of the contract's implementation, that actually turned out to be 1.5 programmed activities, as opposed to 1.4. That trend was observed throughout the UK. In other words, the survey underestimated the amount of programmed activity that would have to be bought over and above the 10 programmed activities in the contract.
Has analysis been done of why the survey underestimated that? Was it because of what the surveyed 300 consultants put down or was it to do with the interpretation of the survey?
Mike Palmer might wish to elaborate on this, but I will say that there were a number of individual components to on-call duties that added up to additional programmed activities.
Our analysis of why the survey underestimated the original costs shows that some cost assumptions that were made as a result of the survey information turned out to be overoptimistic. For example, it was assumed that a large element of the extra on-call costs could be offset against the notional additional half days that were given to some consultants under the old contract in recognition of on-call duties. The number of notional additional half days that were assumed to be in the system, and which was put into the costing model, was higher than what turned out to be the case. Therefore, the savings that we could get from offsetting the extra costs against the notional additional half days were proportionally less. That was one fairly significant factor that led to the initial estimate's being lower than it should have been.
Dr Woods mentioned the need for consistency across the UK, but there was not complete consistency—some areas were left to local negotiation. Can you say what those areas were and why they were left to local negotiation?
The general point is that those areas were very much at the margins and probably represent less than 5 per cent of the total contract. Issues around the contract were left to local negotiation. Mike Palmer will set out what they were.
As Dr Woods said, the areas that were left to local negotiation were very much at the margins. The key elements that drive the working patterns and the costs for the contract are all consistent, and the terms and conditions lay out plainly which are the elements around job planning, on-call supplements and out-of-hours payments. The marginal elements that were left to local negotiation included, first, a specific issue about recognition for covering on-call rotas for absent colleagues. Secondly, they included discussions about the meaning of the phrase "minimal disruption" in relation to payment of fees, because we put into the contract a caveat that said that if a piece of potentially fee-paying work caused only minimal disruption and if that was agreed with the manager, the fee could be retained by the consultant. There was clearly a need to define specifically what that meant, so that was left to local negotiation.
You have touched on the guidance that was issued to boards. How much of it—by volume, if you like—was issued after implementation of the contract?
I am not sure what the measuring rod is for the volume of guidance. A lot of guidance was produced. Mike Palmer has described the period prior to the framework's being introduced. Discussions were held immediately on publication of the framework and letters were issued to the service in July 2002, July 2003 and subsequently. However, that does not really do justice to the number of discussions that took place. Tim Davison will elaborate on some of the work that the pan-Scotland NHS employers reference group, which met fortnightly, undertook. Residential events were held to brief chief executives and medical directors. Guidance and advice were issued before the contract was implemented and discussions took place. We continue to issue guidance in response to any situations that arise, so that has been a continuous process. I am not sure that there was any absence of paperwork.
The contract has been implemented 3,500 times—it is important to stress that the contracts are with individual members of staff and involved individual negotiations and discussions over about a year. Although there was a date from which the contract applied, it was implemented on an individual basis over a period of months. Most of the guidance was issued before and during contract negotiations with individual consultants. It took us several months to get every consultant, or the vast majority of consultants, on to the new contract. Job planning discussions were often straightforward, but they were sometimes extremely complex and took place over a number of months.
I will clarify the situation a little more. The consultant contract was a negotiated set of terms and conditions and so it was, in effect, the rule book. Boards had to apply for a variation if they wanted to move away from the negotiated terms and conditions. Over the 18 months to two years in which I was involved in the project, there were only about half a dozen requests for variations, which related to specific circumstances. As health boards started to go through the job planning process, they had the rule book, which on first reading appeared clear, but as they started to apply it to individual circumstances, they needed further clarification. We sent out a number of documents in the following months to clarify how to handle particular circumstances.
Such a major exercise must have taken up a huge amount of management time. Apart from sending out letters, which would add to the stress rather than relieve it, what supports did you make available to boards during the implementation process?
I will invite my colleagues to say a little more on this matter in a moment. I have looked at the record and, put simply, those matters were standing agenda items in our regular meetings with chief executives and medical directors. As I have said, a number of residential events were held to allow people to immerse themselves in the detail.
I will explain the process a little more, and perhaps Dr Swainson will describe the detailed discussions that took place at health board level.
Before we go on, I want to clarify the relationship between trusts and boards. The contract was implemented in 2004 and backdated to 2003. When did responsibility for employing consultants transfer from trusts to boards?
Although trusts were dissolved on 1 April 2004, the contract itself was agreed at the end of 2003, which gave us an important window of opportunity to get our act together on implementation. As the majority of consultants were employed in the 28 trusts, the trusts assumed responsibility for co-ordinating implementation—although, as Dr Woods has pointed out, health boards were also heavily involved in the process. From 1 April 2004, all NHS consultants came under the employment of NHS boards, and the majority of contracts were signed from then on.
Given that trusts had been brought under the auspices of boards before then, to what extent did trusts and boards operate separately? I presume that the boards were co-ordinating what was happening in trusts.
Although health boards employed, for example, public health consultants, the trusts, which were statutorily independent organisations, employed the vast majority of consultants and were therefore responsible for implementing the contract.
Forgive me, but either it was a material factor or it was not. The evidence that we are getting is that a significant contract, which was not a stand-alone contract because other contracts were being considered at the same time, was introduced at a time of reorganisation for the health service. Is the message that reorganisation of the health service contributed to the problems that we are discussing today? Was that a large factor?
I do not believe so. Scotland is a small place where it is easier to work in single systems. It was a great strength that I could, as chair of the implementation group, get every trust chief executive, medical director and HR director into the same room three or four times to talk about how we were overseeing the implementation of the contract.
That is helpful.
I felt that plenty of guidance was available. The contract was not published in its final form for us all to look at until relatively late in 2003. As Julie Burgess said, we were offered a set of terms and conditions, which we used to figure out how to implement the contract. Employers in boards and trusts were considering at an early stage what was different about the new contract and how they could use it to gain benefits for employers and, by implication, for patients.
Members have no further questions on that subject, so I invite Margaret Jamieson to take us on to questions about the impact of the contract.
We have spoken a lot about the impact of the contract on boards and individual consultants. I believe that boards and the Health Department decided very late in the day to consider what the improvements in patient care would be. Will you explain why that change came so late in the day? What specific performance indicators and monitoring systems have been introduced?
You are referring to the fact that the HDL on the benefits realisation from pay modernisation was not issued until July 2005. That reflects the sheer scale of the implementation process that people were working their way through. People believed that the first year of effort needed to involve such a process, for the reasons upon which my colleagues have elaborated. We fully accept that we needed to be clear about the improvements for patients that we wanted to result from the consultant contract and from the other pay modernisation contracts that we have been discussing. That is why the HDL that was issued in July 2005 addressed all strands of pay modernisation.
Certainly, although we should be relatively brief so that we can ask our remaining questions in our allotted time.
I reiterate that getting the 3,500 consultants on to the new contract was a massive task for the first year. It was necessarily a big issue. In the past year, it became increasingly clear to managers—I speak from personal experience—that having a requirement to agree service objectives with consultants was a key tool. As they entered the job planning process in the implementation phase, a number of organisations began to see the power in using service objectives to maximise how much they got from each consultant. They started to appreciate how that would help them to deliver organisational benefits and improve patient care. During the implementation, there was a dawning among a number of organisations that were flagging up issues that, over time, they would be able to demonstrate real improvements in patient care. However, to reinforce the point, it was always agreed that the first year would be implementation—that we would get the basics right and then build on a solid base to deliver the benefits.
I will take orthopaedics as an example, because NHS organisations in Scotland have found it the most difficult specialty in which to get waiting times down. Under the old contract, consultants spent a lot of their time seeing routine out-patient referrals. Those patients often waited more than a year to be seen as out-patients before potentially being listed for procedures.
I will give some practical examples. In the first year of the contract, one of the major benefits that we saw for patients in NHS Lothian was a reduction in cancellations of theatre sessions. Cancellations by the surgeon dropped by more than 40 per cent and they have remained at low levels ever since. In the second year, across a range of elective specialties, we saw productivity increases of 6 per cent—that is an average across the elective specialties for which we are counting waiting times. By the end of 2005-06, we saw productivity improvements of more than 10 per cent—measured in additional procedures and new out-patients—for the same number of consultants across individual specialties. That was achieved solely through the application of good job planning and good service redesign.
Audit Scotland advises us that when the report was published, in certain areas, including mine, around 6 per cent of consultants had opted for the new contract but had not yet signed it. What is the figure now?
I believe that about 99 per cent of consultants have accepted the new contract.
Is that being monitored?
I do not have the information centrally, but I have seen the figure in the briefing that I have. I could confirm it for you.
You could check it and get back to us.
The important point is that we now have absolute clarity about the key objectives and targets that we expect NHS boards to deliver, which include some of the indicators to which you referred. The data are captured through the work of our delivery group in monitoring local delivery plans. We expect boards to ensure that the connection between the targets and job plans is put in place.
Speaking as a constituency member, it would be helpful for us to see how that approach impacts in each of our areas. We might find that some of the effects are vastly different. It would be good to be able to measure the impact of the consultant contract in different board areas. The minister might well consider that when he visits each board in the summer. The primary issue that we are considering is that your department has not established a specific timescale for when the benefits will be achieved under the new consultant contract.
In a sense, that is because we will continue to pursue benefits every year. We have asked for six-monthly progress reports on pay modernisation plans. That is how we are tracking them. It is not a case of having a particular set of benefits by a particular date. We will want new benefits as we proceed, which will reflect ministerial, departmental and local priorities, connected by service objectives and job planning.
Is that not a significant change to the way in which negotiations for pay, terms and conditions have previously been undertaken in the health service? There was always a goal that management was trying to achieve in the end.
It does constitute a significant change, in the sense that we are making things much more explicit. Many things used to be implicit, and a lot of management effort went into making it all work. The significant change that is being brought about is one of the benefits of the contract.
I will now ask you some questions on how consultants feel about the contract. According to the Audit Scotland survey, 7 per cent of consultants believed that the new contract had led to improvements for patients. That figure is worryingly low, would you not agree?
We have spent quite a bit of time trying to understand what that could mean. It is hard to know what connections consultants might have been making in their own minds when they were asked that question. Perhaps I could invite Dr Swainson to comment on this subject. We may be talking about an issue of attribution. By that I mean that we have a new contract and quality improvements, but it is not clear whether we are putting them together and thinking in the most effective way. I invite Charles Swainson to elaborate.
I have spoken to a number of colleagues about the question, how they might have interpreted it and the significance of that very low value. Most people took the question as asking what relationship their benefit from the contract had to the way in which they looked after patients. Most of them felt that the contract that they worked under bore no relationship at all to the way in which they personally looked after patients, that is, what and how they were paid did not particularly affect their individual care of patients. The people with whom I spoke did not think of that question in the same way that we have been discussing it for the past 10 minutes, with regard to benefits realisation for the wider system.
That is interesting. I turn to the issues relating to the reduction in consultants' working hours and the number of them who have still not signed a waiver under the European working time directive. I note that 98 per cent of them continue to work more than 48 hours without that waiver. Where are we with respect to eradicating that practice?
There is a clear obligation on employers under health and safety at work legislation to address that issue, and that is what we expect them to do. That involves securing waivers in cases where consultants work beyond 48 hours. What has been reported is something that we have known about in relation to many people who work in public services. They have a strong sense of vocation and commitment to the work that they do and to the people whom they serve. In Scotland, the vast majority of consultants are very committed and hard working and they want to go the extra mile for their patients. I suspect that that, as much as anything, is what the survey is reporting. Again, colleagues might want to comment on the matter.
It is difficult to know what 3,500 people thought when they filled in a survey.
What monitoring process have you asked boards to put in place to ensure that the contract complies with working time legislation and how is that reported centrally?
Although we do not intend to monitor compliance centrally, we expect boards to do so locally through the discussions that individual consultants have with their managers, who are usually clinical directors.
Because we review job plans at least annually, we know whether consultants are working more hours than are specified in the contract. For example, for many years there were only two thoracic surgery consultants in Lanarkshire. However, a one-in-two rota is simply unsustainable in the longer term, and the surgeons' job plans show that they work significantly more than 48 hours a week. Of course, we are not blind to the situation. We have recruited an additional consultant, although I have to say that a one-in-three rota is still very tight. Moreover, we have signed up to the west of Scotland cardiothoracic in-patient concentration at the Golden Jubilee national hospital, which will resolve the intense on-call situation by bringing together all thoracic and cardiac surgeons.
I should also point out that the solution is not always to increase the medical workforce. That is where the connection to redesign becomes important, although I will not go over issues that we have covered before, such as workforce capabilities and extended roles.
Your comments suggest that the redesign is more focused on consultants. Do you agree that, in the past, some consultants did not really sign up to that process when it was suggested for certain specific areas?
I am not sure that I entirely recognise your comments about the past. The other week, I attended the launch of our diagnostics collaborative, which is intended to help us to improve access to important diagnostic services, and was struck by the number—and, indeed, the enthusiasm—of senior clinicians leading this work on our behalf. The extent to which the contract supports that work is very important. That said, I have always been impressed by the readiness of some of our consultant leaders to embrace change.
We now have a far more structured and explicit means of designing and describing that relationship. For example, until recently, gynaecological in-patient services in Lanarkshire were spread over the three main general hospitals. However, the vast majority of gynaecological interventions and treatments are carried out in out-patients departments as day cases, so we concentrated our in-patient services on just one site, which meant that we had a much bigger pool of consultants and were able to provide specialist in-patient services, rather than gynaecology patients being in general surgical wards. Through the job plan, we were able to describe a much better out-of-hours arrangement for staff, who had only one site to cover from a bigger team, while still having the vast majority of patient contacts on the three sites. We were therefore able to use the job plans to agree with consultants the out-patient sessions and the day-case sessions that they would have on the three sites, as well as their in-patient sessions on the one site. That is the kind of thing that brings the exercise to life. It is not that we did not do such things in the past. We did reorganise services in the past, but the job planning and the new contract arrangement makes the negotiation far more explicit and transparent.
The job-planning process and the new contract give us the ability to agree with consultants the changes needed in their working patterns during the process of redesign, as we have already done with nurses, therapists, secretaries and managers, and—as has been the case for some time—for doctors in training. The last leg of the stool gives us all the tools that we require not only to engage people in redesign but to support it contractually.
A positive opportunity that comes out of it, and which cannot be understated, is that the job planning year on year gives employers and consultants the chance to refocus on organisational priorities, so if an organisation wishes to change its services or portfolio or to redesign its service it has the opportunity every year to renegotiate the job plan. That is quite a different situation from the one that we had in the past. Also, the new contract can specify that, if someone is working a 40-hour week, 75 per cent of that time should be focused on direct clinical care. The flexibility and focus on the amount of time being spent on direct clinical care present us with real opportunities that we did not have under the old contract.
I see that Mary Mulligan and Eleanor Scott have further questions, but I would like to finish our questions on managing costs.
That is the point that I was making earlier. The indications are that those figures are now much lower; I gave examples from Lanarkshire and Lothian. We are tracking that and we want that out of the system. We want the work done within the capacity of the new contract, and we now believe that those payments are way below 1 per cent of the consultant pay bill. I cannot recall the figures without looking them up again in my notes, but I think that the figure was about £175,000 in Lanarkshire over the six-month period to the end of December, with a similar figure—I think that it was £137,000—in Lothian for the same period. That gives an indication of the fact that those costs are at the margin. We are determined to meet our waiting times targets through the provisions of the contract and through various measures that I have described to the committee previously. The good news is that we are hitting those waiting times targets; the data published last week show that we have the best waiting times we have ever had in NHS Scotland, and the provisions in the contract will help us to maintain that.
You talk about tracking, but we understand that most NHS boards are not monitoring all aspects of the contract costs. I stress the word all. Will that not make it difficult for boards to identify areas for improvement and savings on which you will be able to gather national information?
I must confess that I was not entirely sure what it was that they were not monitoring, so I am really not able to answer your question.
Do you believe that boards are monitoring all aspects of the contract costs?
My expectation is that they will. It is very much in their interests to ensure that they make the best possible use of the resources that they have.
I would like to follow up on the contract issue. I understand the need for flexibility, but was it really necessary to have almost individual contracts for consultants?
Yes, I think so. Although someone may be described as a general surgeon, what they do in their role as a general surgeon will vary quite a bit, because often they will have a special interest. That means that they will have to devote a proportion of their time to a particular kind of surgery, so the contract had to be sensitive to those specific circumstances.
It is extremely important to have individual contracts, because job planning is moving into a new era. We currently employ team job planning as the first step, which enables us to agree the overall objectives for a department, the volume of activity that staff will be required to undertake and the resources that they will use. We also want to include the amount of teaching that consultants will undertake with medical undergraduates and nursing students, and the number of postgraduates that they will train, what they will train them in and how many sessions or resources that will take.
Absolutely. Having convinced me that it was necessary to have 3,500 individual contracts, can you tell me how you monitor that throughout Scotland?
It is the responsibility of the individual employers, but there is a danger when it comes to considering some of the things that we mentioned earlier. It comes down to the process of annual appraisal, annual review of the job plan and asking questions about whether the objectives have been met and what the new objectives for the forthcoming year should be. That work will, in general, be led by individual clinical directors, in the process that Charles Swainson was trying to describe.
So the individual clinical directors in each health board will continue to ensure that they are doing what is necessary to fit what is needed in their local areas. How do you then benchmark that between somebody in Shetland and somebody in Glasgow? How do we ensure that we are getting the right balance and that we do not end up in the sort of competitive situation that you said should be avoided?
On benchmarking, we would be wary of trying to make too many direct comparisons about the content of individual job plans, for all the reasons that we have just described. We are interested in the product of all that activity in terms of benefits, and that is why we are currently analysing the pay modernisation plans that we have received. Of course, the work that we are doing specifically in relation to productivity—on the 1 per cent objective and the balanced score card—will give us some indicators, because it will use data that are generated through the information and statistics division to enable us to see that picture.
Are you confident that that will ensure that patients get the best service, regardless of where they might be or who the clinician might be?
Yes. We are very clear that that is what the contract is about. It is a means to an end and part of a range of other pay modernisation activities that we are undertaking. 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.
The contract might not be benchmarking, but it is sense checking. A consultant's work in Shetland differs greatly from that in Glasgow because the health service differs greatly. The job plan under the contract allows for negotiation with the individual consultant. That might lead to a consultant who works in a small team in a big rural area having more time in their job plan for on-call duties—first because they are on call more frequently because there are fewer consultants, and secondly because they have more travel time because they go from Oban to Fort William to Inverness rather than around the city of Glasgow—and doing less teaching, training and research and development. On the other hand, a consultant in a big teaching centre, where there are much bigger teams and consultants are less frequently on call, might have a job plan with less travel and less out-of-hours work but more time spent teaching, training and doing research.
I, too, have a question about monitoring. Through job planning and appraisal, we will now know the hours that consultants are actually working. More than half of the respondents to the survey that is referred to in the report said that their contracts did not match their working hours, and a significant number were working over the European working time directive's limits. We should know that. What central monitoring of that is being done with a view to workforce planning for the future?
We have information on that, which I am trying to locate. I was keen to see what the average working hours were in different specialties and different places. I am not sure that I will be able to locate the data on that quickly enough for you, but we are happy to provide a note on that.
I was not asking for the data; I merely wanted to be reassured that it was being monitored centrally, not being left to individual boards.
It is being monitored centrally. I seem to recall that the average working hours are about 44 or 45 hours per week.
Consultants' working hours have peaks and troughs, as do all our working hours. That would become clear if I asked MSPs how many hours they worked on average and then compared it with the hours that they worked each day. We have consultants and managers who work well in excess of 48 hours some weeks and less other weeks. The contract is based on an annualised approach, in which we take the totality of the work and divide it by the number of weeks worked. It is inevitable that there will be peaks and troughs for busy professionals who work in a demand-led service.
I was more concerned to confirm that there was some central monitoring of the overall, collective need for consultant hours in Scotland.
Yes, there is.
We might not have time to get into this, but the important connection to make is that the monitoring needs to inform workforce planning. I have outlined to the committee on previous occasions the reforms that we have put in place in that regard.
With regard to the information on individual work plans and job plans, the Audit Scotland survey contains evidence that the notion of "service as usual" exists in the minds of some consultants. There seems to be a different approach with respect to the job plans, or a variation in their quality. To what extent can you reassure the committee that their quality will be consistent between health boards?
I cannot give a categorical assurance that the job plans will be as good everywhere as they are in the best cases. I can, however, tell the committee that we are confident that the medical directors group, which has a key role in leading the work, is working together to ensure that the consistency that you are describing is achieved. There will always be some variability. As I have been pointing out, it cannot be completely removed. It is probably not desirable to remove it entirely, given the different circumstances that will apply. We are confident that we have a group of people who are leading the process in the way that we would want.
I am obviously not talking about the variation in what the job plan actually says.
I understand that.
I am focusing on the variation in the quality of the job plan, and in our being confident that the plan will do what it says it will do.
In practice, there will always be some variability in an organisation as large as NHS Scotland. As Mike Palmer indicated, we are currently in the third year of the contract. We are accumulating experience, and need to learn from it and share it. That is where the medical directors group becomes critically important.
As Dr Woods has just said, we are in the third year of what has been a very steep learning curve for some people. Essentially, the detail of job planning depends on the quality of the training and support that is given to clinical directors. They are a group of doctors who fulfil a management role part time, and the individuals change, so there is a constant refreshing of the group, with newcomers requiring to be trained and supported. There will always be some variability, but there is a floor to it. The consultant contract says that if someone has not made a reasonable effort to attain their objectives, if they have not completed a proper job plan, or if they have not had an appraisal, they cannot go forward for pay progression. That is a pretty good floor to use when measuring the system.
Thank you. That is useful. It is 12.28 and we still have quite a bit of our agenda to go. Please excuse me if I now call this evidence-taking session to a halt. It has been highly instructive for us. Thank you, Dr Woods, for coming here today and bringing your team with you, particularly all those who made so much effort. There will be a number of areas that we will wish to tidy up. Your answers have provoked questions in our minds, so we may seek some further information that time limits us from obtaining today. I am sure, therefore, that we will get back to you in writing. I thank you for your time. Your evidence has been very helpful.
Thank you all very much.
Agenda items 5, 6 and 7 are in private.
Meeting suspended until 12:31 and thereafter continued in private until 12:51.