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In October 2003, the Department of Health (the Department) agreed a new national contract for NHS medical consultants in England. This report examines the contract negotiation; the cost implications; the effectiveness of the implementation process; and the extent to which the expected benefits for patients and the NHS had been realised. It was intended that employers would get greater control and management of their consultants' workload, and patients would benefit from a more flexible and responsive service. The Department hoped to reward consultants who made the biggest contribution to NHS work and reduce the average number of hours worked, in exchange for increased productivity. These benefits were dependent on a mandatory and rigorous process of workload planning for individual consultants (job planning). The implementation of the contract was rushed and the NHS has yet to see many of the intended benefits. Over the first three years, the Department allocated an additional £715 million to NHS trusts which was £150 million more than originally estimated. Although consultants' pay has, on average, increased by 27 per cent (from £86,746 to £109,974) and their working hours have decreased, there are no measurable improvements in productivity. The Department has succeeded in increasing the number of consultants working in the NHS, from 28,750 in October 2003 to 31,990 by September 2005, but the number of hours consultants work in private practice has neither increased nor significantly decreased. Other intended benefits have not been realised: for example the proportion of time consultants spend on direct clinical care is less than intended, and the contract has not been used to extend and develop new services for patients.
Each year general medical practices provide some 290 million consultations. The new contract (implemented in April 2004 but increased spending began in April 2003) changed the basis for commissioning primary care services. Instead of contracting with individual General Practitioners (GPs), Primary Care Trusts (PCTs) commission services from some 8,325 GP practices with around 33,000 GPs. This study examines the negotiation and implementation of the new contract and how well it is working in practice. In the first three years the PCTs spent £1.76 billion (9.4 per cent) more than the minimum committed by the Department of Health. Mostly this was due to an underestimation of the amount that GPs would earn from the pay for performance scheme, the Quality and Outcomes Framework (QOF), and the additional cost of providing out-of-hours care (most GPs have opted out of providing this service). GPs' salaries have increased by an average of 58 per cent. Practice nurses have not benefited to the same extent. While the number of consultations with patients has increased, these are not in proportion with the increase in costs, and productivity has fallen by 2.5 per cent per year. GPs are working less hours. Some progress has been made in extending the range of patient services, reduced administration, high quality care and linking pay and performance, and staff satisfaction and morale. Progress has not yet been demonstrated in productivity, and re-designing the services around patients. The contract has contributed to improved recruitment and retention of GPs. The NAO recommends that the Department develop a strategy for yearly negotiations on the QOF, which should be based more on health outcomes. PCTs should provide more services based on local need and review the number and skills of staff employed to commission and performance manage GP services with the aim of improving local commissioning.
The new contract for consultants was agreed in 2003 and widely implemented by April 2004. It was needed to increase the size and commitment of the consultant workforce if it was to deliver the NHS reform agenda and comply with the requirements of the European Working Time Directive to reduce consultants' hours. By the end of March 2006, the Department had spent £715 million on the new consultant contract (27 per cent more than the original estimate of £565 million), partly because the government had underestimated the amount of work consultants did. In September 2005, approximately 32,000 consultants worked for the NHS in England, primarily within NHS acute and mental health hospitals, accounting for £3.8 billion of expenditure in the NHS in England in 2005-06. The NAO conclude that the contract is not yet delivering the full value for money to the NHS and patients that was expected. The contract has helped to align consultants' pay levels with their contribution to the NHS, but some consultants are actually working the same if not fewer hours for more money. There is little evidence that ways of working have been changed, and few trusts have used job planning as a lever for improving participation or productivity. The contract has delivered some benefits in management of consultant time, prevention of an increase in private practice, securing extra work at plain-time and increasing participation. The contract has the capacity to provide some new levers for further enhancing management control. There is scope for the NHS trusts to make much more of the opportunity presented by the annual renegotiation of job plans to devise a set of agreed job plans that will deliver more efficient and effective services to patients.
Agenda for Change, the pay modernisation programme for 1.1 million NHS staff in England, representing a pay bill of £28 billion in 2007-08, was implemented between December 2004 and December 2006. It covered all NHS staff, except doctors, dentists and senior managers. Agenda for Change introduced a job evaluation scheme and harmonised employment terms and conditions for the multitude of jobs within the NHS. A key part of the programme is a process for encouraging staff development and improving staff performance known as the Knowledge and Skills Framework. Agenda for Change was expected to bring about new ways of working which would contribute to improved patient care and to more efficient delivery of services. Total savings of £1.3 billion over the first five years were predicted. These were to come from improvements in productivity of 1.1 to 1.5 per cent a year, reductions in equal pay claims, reduced use of agency staff and more controllable pay costs. The Department and NHS Trusts did not establish ways of measuring the effects of Agenda for Change and there is no active benefits realisation plan. The NHS pay bill for the staff covered by Agenda for Change has risen by 5.2 per cent a year on average since 2004-05 while productivity fell by 2.5 per cent a year on average between 2001 and 2005. By autumn 2008 (nearly two years after Trusts had completed transferring staff to Agenda for Change terms and conditions and pay rates) only 54 per cent of staff had had a knowledge and skills review.
The NHS has successfully transferred 1.1 million NHS employees on to a new simplified pay system. This was a substantial task which the NHS, in partnership with the trade unions, achieved in a short timescale. There are some examples of NHS trusts using Agenda for Change to help introduce new roles. But the Department of Health did not put enough emphasis on getting trusts to develop these new ways of working to secure the full benefits from the new pay system, so the programme is not yet achieving the intended value for money. Agenda for Change has reduced pay administration in the NHS, simplified pay negotiations and made it easier to estimate staff costs and monitor budgets. The NAO estimates that for 2007-08 the £28 billion NHS paybill is broadly similar to what it might have been if the programme had not been implemented. The Department predicted that Agenda for Change would save at least £1.3 billion by 2008-09 and productivity would increase, but it did not put in place any central monitoring arrangements to show what impact the new contract has had on productivity. The only productivity measure available for the NHS as a whole shows that productivity continued to fall when Agenda for Change was introduced, though the rate has since slowed. A key element of Agenda for Change, the Knowledge and Skills Framework, which defines the skills needed for a certain role and provides a tool for reviewing their use in the workplace, has not yet been fully implemented by many trusts. Effective use of the Framework is fundamental to achieving the full benefits of Agenda for Change.
The Modernisation of the Public Services and Employee Relations provides an integrated and up-to-date account of changes in work and employment in the public services. The book examines a range of different sectors focusing on core public services, especially local government, the NHS and the civil service.
This report considers how to make pay more market-facing in local areas for NHS Agenda for Change (AfC) staff and recommends market-facing pay to support recruitment and staff retention. The AfC system is perceived as fair and objective by all parties, supports stable industrial relations, and is viewed as compliant with equal pay principles. Analysis does not provide firm evidence for further investment in additional market -facing pay in the NHS at this time and further development of AfC is needed to meet the challenges and cost pressures in the NHS. AfC is considered the appropriate vehicle through which to develop market-facing pay as it already has positive features for it. The Review Body therefore specifically recommends a fundamental review of high cost area supplements, appropriate use of local recruitment and retention premia, and regular review of AfC, including its flexibilities, with any necessary negotiations brought to a conclusion at a reasonable pace
Consolidated to 12 January 2010, this book provides all regulations and Fair Work Australia Rules 2009 [Interim] for the practical operation of Australia's workplace relations system.
The Quality and Outcomes Framework has deeply divided UK general practitioners. I commend this book and applaud its determination to scrutinise every aspect of the Quality and Outcomes Framework - good and bad and in-between. - From the Foreword by Iona Heath General practice in the UK faces transformation following the introduction of the Quality & Outcomes Framework (QOF), a pay-for-performance scheme unprecedented in the NHS, and the most comprehensive scheme of its kind in the world. Champions claim the QOF advances the quality of primary care; detractors fear the end of general practice as we know it. The introduction of the QOF provides a unique opportunity for research, analysis and reflection. This book is the first comprehensive analysis of the impact of the QOF, examining the claims and counter-claims in depth through the experience of those delivering QOF, comparisons with other countries, and analysis of the wealth of research evidence emerging. Assessments of the true impact of QOF will influence the development of health services in the UK and beyond. This book is essential reading for anyone with an interest in the future of general practice and primary care, including health professionals, trainers, students, MRCGP candidates and researchers, managers, and policy-makers and shapers.
This edited collection provides an understanding of the range of learning that is enabled by trade unions, and the agendas around that learning. It comes at an important time as, in the UK, recent years have seen significant new opportunities for unions' involvement in the government's learning and skills policy. At the same time, trade unions have had to cope with declining membership and changing employment patterns, and thus have a keen interest in defining their role in contemporary employment relations and in pursuing strategies for union renewal. Therefore, in order to explore these dynamics, a strong feature of the book is its drawing together of informed, research-based contributions from the fields of training, skills and education, and of industrial relations. International and historical perspectives are included in order to better understand the contemporary issues. There are important conclusions for policy-makers, practitioners and researchers.