Dragging The Health Service from Victorian to Modern Times!
The Scotsman, January 7th 2010
The NHS has always been seen by the public and politicians as something special, off-limits to consideration of future cuts by the Conservatives and Labour, and influenced by the personal experience people have of the health service when they need it.
The reality has always been more complicated than the egalitarian rhetoric which has shrouded the NHS since its formation. At that time Nye Bevan had to weave and navigate to bring the NHS into being with BMA support. Two of these compromises – the UK-wide merit system for NHS consultants and their right to undertake private work – remain to this day.
Not only that, but in an age where Thatcher and then Blair waxed lyrically about ‘feather bedding’ and ‘subsidies’ they have remained off limits to any Conservative or Labour review.
Until now that is. For Nicola Sturgeon, Deputy First Minister and Scottish Health Secretary has blown the lid off these rather cosy arrangements.
Sturgeon has said in these difficult economic times there can be no grounds for increasing the awards to consultants next year. Instead, a less expensive and broader based merit programme for the NHS should be devised.
We are not talking about small amounts of public money. Across the UK the NHS consultancy scheme costs well over £350 million per annum. In Scotland it costs £28 million remunerating a mere 500 consultants who earn an average of approximately £56,000 per year on top of their ‘basic’ salary. This ‘award’ is counted as ‘salary’ and is pensionable, therefore costing even more future monies to the taxpayer.
What is the BMA’s justification of this? Dr. Lewis Morrison of BMA Scotland said the awards ‘recognised the contribution made by doctors in the field of research, education and the provision of exceptional NHS patient care.’ In a superb example of hyperbole he also talked of the ‘economic benefits’ of the scheme: a kind of narrowly focused Keynesianism to the already well-remunerated of society.
The NHS consultant award scheme is one whereby consultants sit and review their peers work, status and reward, and award on top of their very significant salaries, awards of up to a further £74,000 per annum.
NHS consultants in Scotland were recently awarded a three-year pay rise of 38% worth £235 million which caused Audit Scotland to comment that ‘it is difficult to identify whether this entire spending has so far improved patient care.’
Many consultants work long and tireless hours for the public good and have no interest in doing additional private work, but many take advantage of the fairly self-regulated life they can live at our expense: one of the last vestiges of the middle class welfare state along with higher echelons of the legal profession – and Westminster politics.
There is a wider context here in health and public services. The average GP now earns over £100,000 per annum after huge increases in pay these last few years. The BMA and GPs defend this in the most blatant, self-regarding way which will eventually come back to haunt them.
When the GP pay award was made a couple of years ago, Dr. John Rankin, based in Stirling commented, ‘For years we’ve had to accept that lawyers and accountants can charge what they like to their customers.’ The rationale of this argument is a profoundly unattractive, unpleasant, entitlement mentality: others have got their reward, its our turn!
Strong forces have been at work which have maintained these consultant ‘Spanish practices’ and they are what are commonly called ‘producer capture’, which sees vested interests know how to work the system. Then you have the recent rise of the marketisation model, which allows professionals across the public sector (quangos, the BBC) to justify even more sizeable rewards. Finally, there is also the public sentiment that health is best left to ‘health experts’ rather than politicians and bureaucrats. This is a belief that NHS consultants, GPs and the BMA play on.
Thirteen years of Labour Government and ten years of the Scottish Parliament have seen little of this brought to light. Three Scottish Labour health ministers, Susan Deacon, Malcolm Chisholm, Andy Kerr, all decent and trying their best, have come and gone without ever addressing this.
Finally, in chastened economic circumstances Nicola Sturgeon has decided to open this Pandora’s Box into what is for most people a secret society and world. A recent FOI request publicly revealed that NHS Lothian had 412 posts with pay of over £100,000. The two areas of greatest deprivation in the country, Lanarkshire and Glasgow, also had hundreds of senior staff earning these amounts – most of which were consultants.
The recent biennial health report from NHS Greater Glasgow and Clyde by Dr Linda de Caestecker, the Director of Public Health, acknowledges that top salaries have to be part of the equation of change, particularly when tackling inequalities is a key policy priority.
Many consultants acknowledge that change is needed as well and that the merit system is an ineffective, inefficient way of rewarding excellence, innovation and leadership. Why should consultants be the one group picked out and rewarded like this? Why does such a system sit apart from the ‘Agenda for Change’ process which covers the rest of the NHS?
There is a wider environment in which consultant awards need to be acknowledged. Despite having their origins in the age of unquestioned deference and respect for professional authority, they have slowly become part of how the well-heeled come to see themselves and their status and role in society. This is part of the story about how the comfortably off elite view themselves and their lives.
Not only do we have to talk about what is done with our public money, and the issues of reward and supporting real talent and innovation across health. As crucially, there is a deep need to look at the middle class assumptions that have grown up in the last few decades, and judge whether those parallel lives don’t also cause us as a society damage and harm.