Saturday, November 8, 2014

Contract Games part 1: The battle

So it's now a Mexican stand off. The senior and junior doctor negotiations have broken down- both parties have walked away. Both parties have accused each other- and its played out publicly - sometimes a bit undignified, sometimes like a school playground- I suppose depends on who you follow on social media. I have been a clinical manager now for nearly 5 and a half years- and I have always particularly taken interest in job planning- which is why the debate fascinates and intrigues me.

On one hand, you will hear the frustration of managers about the inability to pierce through job plans, the multitude of national body recommendations as regards job plans which doesn't always help with delivery of Trust needs while Consultants will also turn and say that if they were held strictly to their job plans, and they decided to walk away when the clock struck "X". the NHS would collapse. The reality is that both sides actually have a point. Did I hear some say "how dare you- have YOU any idea how hard I work?"...well..calm down and read on.

The present Consultant contract is actually a simple one.The last changes moved to a sessional based contract divided into Direct clinical Care along with Supporting Professional Activities. The national contract was that in a 10 session job, 2.5 were recommended and agreed to be SPA. Fact is most trusts or new appointments breach that and as the College advisor asked to review job plans- thats pretty much a standard answer I give to all- the SPA isn't enough as per national contract requirements. Don't quote me on this but as I understand Foundation Trusts are under no obligation to heed that recommendation. Happy to stand corrected by Human Resources teams! Anyway, so this SPA- most managers don't quite like- reason? Well- it actually if rarely generates much revenue for the Trust or helps to deliver clinical care. The flip of that is incorporates time needed for teaching, education, revalidation, audits, clinical governance..all those things which don't get you revenue (No sir, that's not on PbR) but actually means a lot for patient care.

This is where it all gets a bit complicated. Educational bodies recommend that job plans should have 0.25 PA per trainee- 1 hours / week- sounds amazing for the trainee. So if you hold that to the tee- and then factor in the College recommendation as regards time for revalidation (you need that to be a safe doctor) then all you need is 4 trainees to supervise, revalidation time and boom, your SPA is over. What actually happens? The Consultant tries to squeeze in the other relevant bits such as audit, governance in there- the time for training squeezes, juniors feel left out, training standards drop- and the cycle is complete.

What about the Direct Clinical care? Again, areas of greyness- job plans suggest you start clinic at 9- finish at 1230- have 30 minutes for patient letters etc- there you go, 4 hours done- go home. Reality? Ask around- pretty different...don't get me wrong- there are indeed individuals who take the proverbial BUT that's due to poor management or supervision by the clinical managers. A few bad apples don't make the whole barrel rotten. The debate or cycle continues. Then there is the desire to standardise- why does Dr X see 10 patients while Dr Y sees 18 in the same time? From a managerial point of view- why cant both X and Y see 14? Simple really- thats because they run different clinics with patients of different needs. A patient with pituitary pathology will take anything between 15-20 minutes while a patient on an insulin pump may require 30 minutes- 45 minutes. Standardise that...and you fail both groups of patients.

Finally, the area of debate- "normal working hours" as per standard contract is 7 am to 7 pm- the latest contract round wants to make "normal" till 10 pm. An area of amazing greyness mixed with a whole load of politics. Rather than having a proper discussion, most centres around "If you don't agree to this, then you are not patient centred". Lots of folks who actually dish out that advise don't work 7 days themselves but couch themselves in leadership garbs and showcase themselves as inspiring individuals.Always easy to lecture when you don't do it yourself, isnt it? It's a bit like me suggesting Messi should have curved the ball around the wall, rather than going over the top...
Some Consultants also join the camp..check them out- either their kids have grown up and moved out or they don't have much of a family to go to. A few people's evangelism shouldn't burn the dedication of many.I hear plenty say- it is amazing to have a Monday off instead of Sunday- yes perhaps so- but you know what- at that time, my kids are at school- and I want time with them- not be twiddling my thumb on my own at home. Tricky isn't it? Took this job to help, not be a martyr.

It makes me smile when I see lots of folks quote Gandhi- how he dedicated his life to making India free...can I suggest you check his life story too? There are reams written on his lack of family life, his destroyed relations with his children. History has an odd way of suppressing the faults of those we believe so much in- read a bit more- you will find plenty of interest. Let me be honest- I don't want to be like Gandhi- I would just like to be Partha Kar- with my flaws- trying the best I can do at work- and then going home, enjoying my life with friends and family.

However, there is actually a way around all this as regards contracts- or at least in my opinion. It involves both sides - clinicians and HR/managers working together, being adults and open about solutions, a bit of give and take on both sides... the question is are both sides actually ready for that?

(To be Continued in Part 2)

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