Feature

A tale of two incomes

Proposals that new consultants work exclusively in the NHS for a fixed period are long overdue, says Peter Fisher

The consultant contract has been a matter of recurring controversy since the beginning of the NHS. From 1948 there was a whole-time contract, with those wishing to undertake private practice taking a maximum part-time variation, dropping 2/11ths of their salary.

The profession’s leaders were unhappy with that and in 1980 succeeded in negotiating the differential down to 1/11th, effectively a pay rise of 9 per cent for those consultants.

Others on whole-time contracts were given instead the right to limited private practice (up to 10 per cent of NHS earnings) which many neither wanted nor could use.

For several years now the BMA has been trying to get rid of the remaining differential. Matters have come to a head with the publication of The NHS Plan and its proposal that newly appointed consultants should work solely for the NHS for their first few years, receiving extra remuneration (amount unspecified) in recompense.

Doctors’ leaders have reacted angrily and there are reports of some trainee surgeons threatening mass emigration. But although the length of time may be negotiable, the government appears determined on the principle, as prime minister Tony Blair confirmed in his speech to the Labour Party conference.

So the stage looks set for confrontation. But is this inevitable or should there be a re-examination of the principles involved?

In 1948 the right to private practice was an eleventh hour concession to persuade the consultants of the day to drop their opposition to the NHS. As some had taken up medicine when a publicly funded health service was unheard of, perhaps there was some justification.

But those consultants have all long since retired. Does a concession made over 50 years ago have to be honoured for ever? Today’s doctors have all been brought up with the NHS and most actively support or at least accept it.

We are told that the opportunity to work in the private sector is necessary to achieve an appropriate income, yet I have never heard a convincing explanation of why it is essential that consultants in one specialty, say orthopaedics, should have a higher standard of living than those in another, say paediatrics.

Is it not possible that without the private sector, and the general assumption that we all earn heavily in it, our NHS salary might be higher?

Much is made of the ‘freedom to use my spare time as I wish’ argument. But is it really sensible to make no distinction between genuine recreation, like golf or gardening, and doing more of the same demanding and responsible work? We are constantly claiming, with justification, that our workload is excessive and we all do more than 50 hours a week for the NHS, so is it wise, let alone safe, to demand the right to take on yet more work?

Seen in this context the proposals in The NHS Plan look rather modest. There is no change in private practice rights for most of a consultant’s career. Even if the initial ‘NHS only’ phase were seven years, that would still leave more than 20 for consultants to supplement their NHS income privately.

There is a case for newly appointed consultants having the freedom to settle into their new posts and have some time spare for the young family which many will have, without the added stresses of embarking on a private practice. But they would need some financial compensation for not doing so. Before 1980, when such a contract was on offer, half of us chose it – not just for a few years but for the whole of our careers.

The NHS Consultants’ Association (NHSCA) has always argued for a contractual system that made exclusive commitment to the NHS a viable – and attractive – option. We would say that it should be the norm against which variations might be negotiated.

One way of doing this would be to ensure that time spent in the NHS and time spent privately are added together to calculate a safe work load. Those wishing to undertake private work would need to agree reductions in their NHS sessions (and salaries) accordingly. This is surely inevitable under any rational interpretation of the European working time directive.

The idea of newly appointed consultants being committed exclusively to the NHS in their early years was first floated (as far as we are aware) in an NHSCA pamphlet published shortly before The NHS Plan. Although health ministers were among the recipients we were surprised, but far from dismayed, to find the concept firmly incorporated in the plan.

Is there room for compromise? We would certainly want to see any agreement between our profession and the government at least including an ‘NHS only’ contract as a voluntary option, in fairness to those working in specialties where private practice is irrelevant.

It seems perverse that those charged with negotiating for us should reject the idea out of hand, without even exploring the financial basis. They must remember that they represent all doctors: those in specialties with private opportunities and those with little or none, those who wish to take up such opportunities and those who, for whatever reasons, prefer to commit themselves solely to the NHS.