The Maynard Doctrine : Time to reform Clinical Excellence Awards!

Professor Alan Maynard OBE proposes changes to the vexed and vexing system of Clinical Excellence Awards.

The NHS is facing severe financial problems and the Department of Health requires the service to save and re-cycle £15-20 billion over the next three years.

At the same time as this edict from the Department of Stealth is being implemented, hospitals and PCTs across the country have been given their annual earmarked funding to finance clinical excellence awards (CEA).

These payments are supposed to recognise “excellence” i.e. they are a form of payment for performance. They were initially introduced in 1948 as part of the government package to stuff the medical professions’ mouth with gold, and acquire consultant’s agreement to join the NHS.

There are local and national awards. The local system entails the award of up to nine CEA points, initially each worth nearly £3,000 and pensionable - and after six points worth double this amount. The national system has silver, gold and platinum award levels, graduated with the latter being worth nearly double the annual salary of a consultant.

Stark contrast to the poor bloody infantry
This generosity compares starkly with the near national minimum wage (NMW) levels of payment made to thousands of poorly-paid portering and other staff who keep the NHS functioning. The current NMW is £5.80 per hour or with a 40 hour week, just over £12,000 per year.

Thus 4 lower national CEA points or two high CEA points at the local level can raise consultant salary levels by an amount equal to the basic pay of a NHS ancillary worker. This gross inequality can be compared with the even more contentious remuneration levels of bankers working in such near-nationalised banks as Northern Rock and Royal Bank of Scotland.

The local awards are allocated by a committee consisting of consultants elected by consultants with some ‘lay’ membership. A national organisation regulates the system with “guidance”, which is used to manage the allocation of CEA funds.

Basically the committees grade applicants in relation to criteria such as contributions to local and national NHS service provision, research and teaching.

Style over content?
The style of the applications varies enormously. Some applicants detail achievements with evidence. Others assert achievement with little evidence. Given applicants can apply each year; some are unclear about what they add from year to year.

Generally the quality of the applications varies from abysmal and insulting to reasonable, and occasionally good.  Some hospitals require the use of data in CEA applications e.g. hospital episode statistics which can show comparative activity rates, and mortality data. Others seem to prefer words to data!

Each hospital gets earmarked funding e.g. a middle-sized trust may get funding for 60 points for an eligible consultant body of 160. Funding can be carried over from one year to another, but it cannot be unlocked from the CEA allocation to use in patient care. The local CEA committee usually awards one point to a successful consultant, but can give out more.

The ‘A’ word
The nice issue is whether the NHS can afford these awards when the quid pro quo is unclear and there is national concern about high paid public servants. The Prime Minister has requested a review of those paid more highly (e.g. paid more than the Prime Minister).

The NHS has yet to realise that this includes consultants and GPs, although with the latter “self-employed”, it will be difficult to cut their incomes in the short term.

Obviously the profession and its trade union, the British Medical Association, will object strongly if pay cuts are implemented. Furthermore, if pensionable incomes are capped at £100,000, this will be even more unpopular.

But we are in tough times. The Iraq inquiry is revealing further the characters of the quixotic deacons making up government. The pay awards in 2004-5 to doctors were excessive, and produced no quid pro quo that improved population health significantly.

With regard to clinical excellence awards, the choice is either to abolish them, or to reform them and tie them much more closely to quantifiable measures of performance - using, for instance, comparative activity, cost and outcome data.

The Prospect of loss
If reform, rather than abolition, is implemented it should include not only CEA bonuses but also penalties for poor performers i.e. what Bulstrode and Maynard entitled “demerit awards” in the British Medical Journal some fifteen years ago!

Prospect Theory suggests that small penalties may motivate more than these generous bonuses!

A sensible Labour Secretary of State, advised by a good Sir Humphrey-style Permanent Secretary, would no doubt set up an inquiry in these awards that reports after the election! But even that may sadly be too radical – albeit wholly consistent with the current Whitehall cacophony of rhetoric about increased productivity and value for money.