David Roe wrote:

> I need some information on how A&E Consultants are paid for out of hours
> work.  This is entirely theoretical, but if a Consultant works a night
> shift, as opposed to on-call, how should this consume his weekly sessions?
> Is one session at night worth one session? Is it worth 1.5, 2, or something
> else?
> What about weekends?

The short answer is that they are not.

At present an NHS consultant on the standard national terms and conditions of
service is employed to devote "substantially the whole of their professional
time" to the NHS. There is within the contract no limit on the number of hours
worked although the European Working Time Directive does apply to career grade
doctors and this in theory should limit them to 48 hours per week on average
"at the employers disposal AND carrying out duties or tasks".

A consultant should however have an agreed job plan which sets out the
commitments of the post.
These commitments are expressed in terms of "Notional Half Days - NHDs", and a
whole time or maximum part-time post should have 10 NHDs in their job plan.

There are two common misconceptions about job plans -
1) that a whole time consultant is contracted for 11 NHDs. Both whole time and
maximum part time consultants have the same contractual commitment to the NHS
of 10 NHDs, but a maximum part time consultant is "fined" one eleventh of their
salary for the right to do unlimited private practice in their own time.
2) that a Notional Half Day is the same as a session. A Notional Half Day is
said to be equivalent to three and a half hours actually worked. A session
could therefore be equal to a fraction of a NHD e.g. surgical ward round or a
multiple of an NHD e.g. an all day list.
The job plan should be  divided into fixed commitments and flexible
commitments, each expressed in terms of NHDs. A fixed commitment is something
like a ward round, a clinic or an operating list where a consultant has to be
at a specific place at a specific time. A flexible commitment is something like
administration, teaching, CPD, Audit, and being on call from home.

Agreed guidance states that in general, consultants should have between 5 and 7
NHDs of fixed commitments. Where in that range it falls should depend on the
other duties of the post, on call workload etc.

There is no facility in the standard contract to pay extra money for an ongoing
commitment to carry out additional fixed commitments beyond the normal limit of
7 NHDs, or for the fact that some of these may be outside normal hours.

Guidance from BAEM and the BMA suggests that for A&E Consultants any period of
time when the consultant is scheduled to be physically present within the
department and available for clinical work should count as a fixed commitment.
This is generally accepted by most trusts.

There is absolutely nothing in the Consultant contract which requires them to
be present at the hospital at any time other than for their fixed commitments.
As long as the other duties are carried out (including being available for
emergencies when on call) it does not matter when they are done. This is how
consultant surgeons are allowed to do private work during office hours. In
practice because most A&E departments until recently were single handed, many
A&E consultants felt obliged to be in the department 9-5 Monday to Friday.

The NHS contract and guidance makes no allowance for when a fixed commitment is
carried out. Because it was written at a time when it was assumed that fixed
commitments would only be during office hours there was no need for such
guidance.

There are crudely speaking 4 ways of dealing with fixed commitments outside
normal hours -
1) treat them exactly the same as those in office hours, noting that outside
the fixed commitments there is no need for a consultant to be in the
department.
2) reduce the total number of fixed commitments (e.g. 5 rather than 7) to allow
for the fact that such anti-social sessions have a greater impact on free time.

3) Count such commitments as worth some multiple of an NHD for each 3.5 hours
actually worked, but keep the total value of fixed commitments in the upper
range e.g. 7 NHDs.
4) some variation on the above but formally scheduling days off during the week
with an explicit understanding that such time will not be used for work or if
it is another day off will be given instead.

2 and 3 are effectively the same thing and 4 is simply formalising an existing
right. 1 is exploitation (IMHO).

The BMAs Consultants and Specialists A&E sub-committee recommends that fixed
commitments outside the normal working day should count as multiples of NHDs
for each 3.5 hours worked. I think they recommend time and a half for evenings,
double time for nights and treble time for weekends (need to check that one).
One of the problems with this is that one comes very rapidly to 7 NHDs worth of
fixed commitments for a relatively low amount of cover of the department.

There are already a lot of A&E Consultants working fixed commitments outside
the normal working day but I am not aware of any who have a job plan which
explicitly recognises evening or weekend sessions as worth premium rates.
Most that I am aware of however do stick fairly strictly to the concept that if
an A&E consultant is scheduled to be in the department out of hours then 3.5
hours is an NHD i.e. 17:00 - 20:30 = 1 NHD, and also tend to have 5 or 6 NHDs
of fixed commitments rather than 7. The other factor to be taken into account
is the number of fixed commitments which are outside office hours and the on
call commitment. If each individual consultant has on average only one or two
antisocial sessions per week this is obviously a lot better than having 4
antisocial and 3 social. Also departments working in this way tend to have more
consultants and so each will be on call less often. The on call period to be
covered is also shorter as part of it will have been taken up by the fixed
commitment.

As you can tell I have recently been taking an unhealthy interest in this as a
CCST holding, job-hunting SpR!
I have read job descriptions that vary from
- no fixed commitments at all, on call from home 1 in 2, to
- five NHDs of fixed commitments, strictly 3.5 hours each of which one per week
was in the early evening Monday to Friday (1 in 5 on call), to
- a total of 27 NHDs of fixed commitments of which 15 were antisocial to be
shared between 4.5 people (that is over 7 NHDs, mostly antisocial, per week
each allowing for covering leave).

My personal choice would be for a job that did have some fixed commitments
outside office hours, with protected time off to compensate.
I would not be too bothered about having such sessions count double as long as
the other aspects of the job were OK.

The BMA consultants committee is currently trying to negotiate criteria for
intensity payments to consultants and it may be that doing fixed sessions
outside office hours will count towards such payments.
After (if?) they have sorted this out the NHSE has said they want to negotiate
a new consultant contract and who knows what that might involve.

--
Andrew
_______________________________________________________
Andrew Hobart FRCS FFAEM
Birmingham
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