Professor Alan Maynard discusses the need for efficient systems to address poorly-performing consultants and redundant managers.

The Department of Health management team are increasing their carbon footprint by touring the country and encouraging SHAs and PCTs to lead the revolution outlined in the Darzi report.

Whilst greater attention to outcome measurement and the reduction of unacceptable clinical practice variations is most welcome albeit very late, some fundamental issues are being ignored - in particular, job tenure of clinicians and senior managers.

Most consultants provide good or at least adequate patient care, as far as our current weak performance management systems can detect. However if a hospital has one or two less-than-proficient practitioners, they have major problems.

If the often slow and cumbersome hospital governance procedures identify a poor surgeon, what happens? She or he can be tutored in-house, in the hope that their practice can be improved. If this fails, they can be sent externally to renew their trade crafts. If problems continue, the Royal College or a national regulator can be called in, usually to give a bland report of limited use to local management anxious to increase patient safety.

The high cost of gardening
If during this process, the surgeon is doing no or less work, the impact on the hospital’s activity and achievement of national targets can be a significant problem. If the consultant is suspended, they usually take “gardening leave” on full pay; and the hiring of a locum, if available, increases wage expenditure. “Gardening leave” can go on for years, wasting taxpayers’ resources.

The processes of correcting the performance of a poor consultant is thus costly and time-consuming, absorbing large inputs of scarce management time. If the Government really want to reform the NHS, these issues should be a focus of immediate attention. Why is this not happening?

The top-loaded risk sink
If practitioners are dangerous for patients, a hospital should be able to dismiss them. Furthermore the process of review and dismissal should be short and efficient, rather than costly and inefficient. Compensation should be modest: if a practitioner cannot provide demonstrably safe and efficient care, why should the NHS have to keep them in the style to which they are accustomed?

If the performance of nurses and porters are problematic, they can be dismissed. It is anachronistic that doctors who cannot deliver good patient care should be treated differently.

The same argument applies to NHS managers. The 2006 mergers of SHAs and PCTs led to large numbers of redundancies. Perfectly competent senior managers in their fifties took early retirement. All had their pension funds augmented; some at the cost to the taxpayer of several millions of pounds.

This is a quite ridiculous policy, consuming resources which should fund patient care rather than the generous early retirement of staff. These folk are generally competent and should be slotted into NHS posts even at lower level of pay and with less seniority if necessary. Members of Unison and the Royal College of Nurses who are made redundant do not get “golden handshakes”. Why should well-paid senior managers be paid differently?

’Government is too cowardly to deal with the issue of dismissing inadequate consultants and the subsidisation of the early retirement of senior NHS managers’

The discussion of consultants and managers in these positions is below the public radar. Yet government continues to emphasise that it wishes to incentivise change in the NHS. It has introduced new methods of paying GPS (the quality outcomes framework or QOF), and is using payment by results and fines for C.Diff to induce change.

Sadly, government is too cowardly to deal with the issue of dismissing inadequate consultants and the subsidisation of the early retirement of senior NHS managers. Many low-paid workers in the NHS have a more normal contract of employment and resent strongly the unfair ways in which different groups of colleagues are treated.

Why did Darzi ignore these issues? He has promised the review of the system of “performance-related pay” for consultants”, known as clinical excellence awards. Instead of nibbling at the edges of contracts of expensive employees, government should take a wider remit so that staff can be deployed more flexibly e.g. consultant programmed activities for weekend, evening and night work would be most useful as juniors disappear due to our adherence to the rules of the European Working Time Directive.

Can Whitehall village be induced to be radical rather than ignore fundamental inefficiencies and inequities in NHS workforce practices? Let’s hope so, but don’t hold your breath. These problems have been ignored for years.