Negotiations on new contracts for National Health Service doctors

In June 2003, after prolonged negotiations, UK doctors working in local general practice voted in favour of a new contract, involving significant reforms in in their pay and conditions and in the organisation of primary healthcare services. In July 2003, agreement was reached on a new contract for hospital consultants, subject to approval in a ballot.

An agreement on the reform of pay and conditions of employment covering a million National Health Service (NHS) staff was concluded at the end of 2002 (UK0303104F), and ratified later in membership ballots held by trade unions (UK0306103N). Separate negotiations between the government health departments, NHS employers and the British Medical Association (BMA) - a powerful professional association and the main trade union for more than 100,000 doctors - proved to be more difficult. The negotiation and ratification of new contracts for 43,000 local doctors (general practitioners or GPs), and for 27,000 hospital consultants and specialist registrars, exposed serious tensions within the BMA and in its relationship with government ministers. This feature first explores the completed contract negotiations for GPs. It then outlines the main elements of a tentative agreement on a new contract for hospital consultants reached on 17 July. If this is accepted in a ballot of BMA members in August, it will end the threat of industrial action by hospital doctors.

The new contract for GPs

After lengthy negotiations with government, the general practitioners’ committee (GPC) of the BMA secured a three-to-one vote in support of the principles of the framework document on a [new contract](http://www.bma.org.uk/ap.nsf/Content/__Hub gmscontract) in a membership ballot held in June 2002. One of the main objectives of all of the parties was to encourage more newly-qualified doctors to choose a career in general practice, rather than in hospitals, and to reduce the number of GPs leaving the profession. A survey of the views of GPs conducted by the BMA found that intense workload pressures, relatively poor pay, pensions and working conditions, and limited career development opportunities had led to widespread recruitment and retention problems, and chronic shortages of GPs in some areas of the country.

Considerable progress was made in negotiations between the GPC and the representative body of health service employers, the NHS Confederation, in the second half of 2002 and in early 2003. In February 2003, leaders of the GPC announced that the government had agreed to increase the income of the average medical practice by 33% over three years, linked to the acceptance of changes in employment conditions. The initial response of GPs was very positive. On 12 March, however, when they received detailed advice from the BMA on the way that they could calculate the impact of the contract and the new funding formula on their practice, the majority of GPs discovered that their income would decrease. Predictably, support for the new contract collapsed from around 70% to less than 10% in a few days. Crisis talks between the GPC and the government led to the offer of a 'minimum practice income guarantee' to prevent the loss of income in any practice. Delegates at the special conference of leaders of the local medical committees of the BMA on 14 May, however, criticised the failure of their negotiators to communicate adequately with GPs, and called for amendments to the flawed funding formula. Further negotiations between the GPC and the NHS Confederation led to some amendments and the clarification of other contentious issues, and the GPC decided on 29 May that a membership ballot on the new contract should be conducted immediately. On 20 June, it was announced that 70% of members had voted, and that almost 80% of those voting supported the new contract.

In welcoming the positive outcome of the ballot, the chair of the GPC, John Chisholm, argued that it delivered a number of benefits for GPs:

• there would be an average rise in net incomes of 26% and a large rise in pensions, funded by a 33% increase in investment in primary care over the next three years;

• there would be more flexibility and autonomy for GPs and practice teams to decide how services will be delivered within a practice-based contract. The current 24-hour responsibility of GPs for patient care will end, and out-of-hours cover will be provided mainly by specialist deputising services;

• all practices must provide 'essential' services, but they can choose whether or not to provide 'additional' or 'enhanced' services, previously available only in hospitals, for extra income; and

• the income of GPs will depend on the range of services provided in their practice, and on the quality of patient care, measured by evidence-based targets set out in a 'quality and outcomes framework'.

Government ministers and health service managers expressed their delight that the new contract had been accepted, agreeing with BMA leaders that it should lead to higher quality healthcare. Practice-based contracts should provide doctors with more time to deal with the diagnosis and treatment of chronic conditions currently treated in hospitals by encouraging patients to see nurses and therapists for check-ups and the treatment of minor health problems. The new contract for GPs requires urgent legislation so that it can be implemented fully by the target date of April 2004, as well as effective planning by GP practices and primary care organisations responsible for local healthcare provision.

The hospital consultants’ contract

In October 2002, hospital consultants and specialist registrars voted decisively against a new contract that had been recommended by their negotiators. The proposed contract offered a 15% increase in average earnings in return for more consultant time for direct patient care. The majority of hospital consultants, however, believed that the contract provided senior managers with too much potential control over their working hours, and threatened their professional autonomy. It also restricted their freedom to enhance their earnings by engaging in private practice outside the NHS.

Following the resignation and replacement of the consultants’ negotiators, the then health secretary, Alan Milburn, refused to renegotiate the contract. Throughout the first half of 2003, the Department of Health restated its primary objective - namely, 'to give greater reward to those consultants who do the most for the NHS'. It noted that non-emergency work would not be scheduled at weekends, or in the evening, without the agreement of individual consultants. More controversially, the Department of Health also encouraged the local implementation of the contract by hospital trusts, although this tactic was entirely unsuccessful. The BMA strongly resisted this threat to its role in national negotiations, and delegates at a consultants’ conference on 19 June voted overwhelmingly to call on the BMA to ballot members on industrial action if the government did not announce a timetable for renegotiating the contract.

This acrimonious impasse between the government and the BMA was overcome soon after Alan Milburn, responsible for the overall reform of NHS pay and working practices, resigned from his post of health secretary and was replaced by John Reid. A meeting with the chair of the BMA consultants’ committee on 4 July was followed by a period of intensive negotiations leading to the 17 July agreement on revisions to consultants’ contract. The health secretary reported that both sides had been willing to compromise without renegotiating the previously agreed deal. He argued that if the agreement is approved in a membership ballot in August, it will mean that 'representatives of all 1.2 million workers in the NHS are now signed up to new pay deals which enshrine the principle that those who do more for the NHS should get more'.

The chair of the BMA consultants’ committee, Dr Paul Miller, reported that progress had been made on a number of important issues for consultants:

• a new clause specifies that non-emergency work scheduled for evenings, nights or weekends would be voluntary and rewarded at an enhanced rate;

• job planning will give priority to the clinical judgment of consultants, and difficulties will be resolved by an appeals panel with an independent member; and

• newly appointed consultants will not be treated differently from established ones in the rules covering private practice. All consultants must offer the NHS one session of four hours per week before engaging in private practice.

Commentary

It is not surprising that the negotiations on new contracts for the two most important groups of NHS doctors proved to be so difficult. In both cases, the government sought significant reforms in pay and conditions of employment that challenged working practices and contractual and professional expectations. The reform of GPs’ contracts raised relatively few conflicts of principle, but was delayed, and almost undermined, by technical problems arising from the complex formula for calculating practice income based on the range and quality of services provided. The negotiation of a new contract for consultants directly challenged the autonomy of the most powerful professional group in the NHS, and led to a serious deterioration in the relationship between the BMA and the government. The willingness of both sides to make concessions in the 17 July agreement arose from the recognition that they could suffer serious damage if the conflict was unresolved. In the first week of June, the BMA initiated a 'wide-ranging review' of the way in which the negotiations on GPs’ and consultants’ contracts were handled 'to learn the lessons from the errors made'. For its part, the government eventually had to accept that its ambitious plans for health service reform depend crucially upon the active support of doctors, and a less antagonistic relationship with the BMA. (David Winchester, IRRU)