Not sure this entirely belongs on this list being more political than
academic. Nonetheless I have fairly strong views myself and now the thread's
been started...
Personally I think there are a lot of problems with the new framework, but I
disagree with you on a few points:

> - They will be counting how many patients you see and paying you 
> accordingly. There is no currently implementable system to audit ANY
> OTHER aspect of A&E work except its mere quantity. So the only goals
> you could prove you have met are numbers... Who will be deciding on
> these targets?

Waiting times to be seen is another possibility. Number of admissions is one
I think some managers would like to see. Thrombolysis times.
'employer's responsibility to draw up and agree job plans with the
consultant, setting out main duties, responsibilities and objectives in
qualititative and quantitative terms'. Your employer draws up (and decides)
the objectives. Difficult to view it differently.

> - Sounds like consultant on-call duties will be eliminated in A&E
> departments with SpRs on call - the section on on-call duties 
> states that 
> this would happen if consultants are "rarely" called upon to come in.

I may be wrong, but I don't think you can have trainees working without at
least some form of consultant cover. More likely that you will have
consultants working in the department without SpRs (or possibly without
SHOs) once the working time directive hits trainee rotas.
However, available on call is available regardless of how often you get
called (call ins should be paid separate)- although personally I rather like
the idea that 10 minute availability/resident on call gets paid at one rate,
40 minute availibility at another and 90 minute availability at another.

> - That section also limits the budget to be spent on on-call pay as a
> proportion (3.48%) of total consultant pay bill. This means 
> that if this is 
> insufficient, the next step would be to to use preferentially those 
> consultants who are on a lower pay level to do on-call work, thus
> reducing the bill by creating a lower rank of consultant. 

Another odditity is that if you are on a 1:6 on call it is cheaper to drop
one person off the rota and make it a 1:5. Despite a stated desire to get
rid of on call heavier than 1:4, the person who holds the budget determines
the rota and the cheapest cover is achieved on a 1:2 followed by a 1:3 (then
1:5, 1:9, 1:10, 1:4 in order). I believe the term to be 'perverse incentive'
(but could be wrong).

> - What happens to SpRs who, when it comes time for them to 
> switch to a 
> consultant post next year, are above the £63,000 initial level?

The only way for them to be above this is by working longer that 40 hours a
week (and having this recognised), I think. If they continue to work longer
hours, they will get paid more. Dropping your pay a bit in return for a
reduction in hours seems fair enough. There are problems on how it would be
recognised, but I think that overall the idea that a consultant's basic
salary for working office hours with no on call can be lower than a top
point SpR salary including out of hours is not unreasonable.

> P Hawker said there was a choice between higher overtime 
> payments and lower
> salaries: 
> The argument that to properly recompense for out of hours 
> work would result
> in lower salaries overall is invalid

Even assuming it is a valid argument, it still seems fair to pay those
working the longest and most unsocial hours and with the heaviest on call
commitment the most. Clearly a reduction in basic salary in order to better
remunerate those with heavy committments would more likely to lead to a
rejection of the framework, but this is simply a political expediency and
should not pretend to anything else.

> PH said GP's were set to lose money by dropping out of hours care:

GPs around my area (and indeed Dr Hawker's area) have done their sums and
reckon they will keep broadly the same income after dropping out of hours
(OK they tend to do a lot of non core stuff which will be well paid)- most
intend to withdraw. That said in an adjacent PCT, the great majority intend
to keep out of hours. The ability at any stage in your career to drop out of
hours commitment (including all scheduled evening and weekend work)
altogether is useful even if it does mean a drop in salary.

> The only small fly 
> in the ointment
> is that it is you and me who will be providing this and 
> missing out on going
> to our childrens school plays, socialising etc, and not be financially
> rewarded at enhanced rates for unsocial working.
> The Govt (according to PH) will not agree to enhanced rates.

This worries me. Either:
1. Regualar out of hours cannot be imposed (the BMA's view). In which case
it seems likely that most people won't want to do them, so no extended
consultant hours.
2. They can be imposed (Mr Milburn's view) which I consider a problem in
itself.
3. There are enough people out there who want to work evenings and weekends
at standard rates, which is a possibility (personally I wouldn't- family,
social etc., but if I had no family, friends etc. I might see it
differently)

> 4. PAY RISE
> 
> Tempting on the face of it, not so goog after reading the 
> small print. 

Mr Milburn has stated to the House of Commons that the pay rise will be
7.5%.

> 6. BIG SALARIES FOR WORKING MANY SESSIONS
> 
> a) We will ultimately not get paid for more than 48 hrs (10 + 
> 2 sessions:
> see 5), the work load is not going to get less, clinical work 
> gets priority
> (good), so we will end up doing appraisal, admin, clin governance ,
> answering complaints etc, etc for nothing (as per now).

Agreed. Our notional hours will go up from 35 (actually a bit less- on call
availability is currently taken out of NHDS) to 40 even if we don't take on
any extra sessions. Mr Milburn has stated that he expects an increase in
work done from this. I can hardly see a finance director agreeing to pay
someone more than 40 hours for doing the work they have previously done in
35. There seems nothing in the framework to make it easier to impose than
the existing contract. (The statement: 'The BMA and Health Departments agree
that the contract should not involve any element of clocking on and off and
overtime payments will not be available' speaks for itself)

> The 7 year ban on PP was always a nonsense, the only people 
> to take this
> seriously was the BMA. 
> The 'victory' in fighting this is illusory.

However, if an individual trust wishes to ban it, it can ban it on the basis
of a 'real of perceived' conflict with NHS work. If your private work takes
you above 48 hours a week; if it leaves you feeling tired; if it is
increased by increased waiting lists, then there is a perceived conflict of
interets and it can be banned.


> 9. THE START OF SOMETHING BETTER?
> 
> The Govt have got what they want, they will not be in any 
> hurry to move
> forward.

I agree with this. We are currenly in a fairly good negotiating position.
The new framework would put the government in an extremely strong position
in the future.

Matt Dunn
Warwick


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