How to Reform NHS Clinical Excellence Awards

Alex Mitchell, Consultant in Psycho-oncology, Leicester (UK)

For my 2008 in depth discussion of CEAs see

http://www.slideshare.net/ajmitchell/online-nhs-clinical-excellence-awards-sept08-presentation

ajm80@le.ac.uk

Based on the 2010/2011 status quo

What are CEAs?• In 2003 the Clinical Excellence Award (CEA) scheme replaced the antiquated

distinction award system but still has many problems (disparities, lack of transparency, poor system of evaluation) continue

• In essence this is an NHS scheme designed to financially reward “excellence” largely in order “to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to patient care”

• However, CEAs are now under intense scrutiny and in 2010 National awards were capped by 50% (for new applicants) and in 2011 local (employer) awards were effectively capped by 43%.

• The CEAs is disliked by the public, and many NHS staff (that is those who know about it). However it is generally supported by the BMA and existing award holders.

• Yet true reforms to the system have not been forthcoming.

Whats New?• Since I reviewed the CEAs system in 2008 consultant pay “bonuses” have been

under scrutiny in the media• http://www.bbc.co.uk/news/health-11523370

• …….And from official bodies such as the National Quality Board and the National Leadership Council (see Letter from Sir David Nicholson September 2010)

• http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_119273.pdf

• Some (cost saving) reforms to the CEA have already been suggested => next

Recent Changes to CEAs• 1. National awards have been capped by 50% (for new applicants) but with no

change for existing applicants, thus any new consultant will have to be twice as “excellent” as previous holders to achieve the same level of award

• 2. In the 2011 round local (employer) awards are effectively capped by 43% by a reduced the ratio for new Employer Based Awards from 0.35 to 0.20*“in order to reflect the tighter financial circumstances in the NHS”. Again this only applies to new applicants!

• 3. A five yearly review of level 9 employers awards has now been introduced, the first time a review of local awards has been suggested. However there is now review of lower awards, no matter how long they are held for.

• 4. In 2008 the ACCEA published personal statements on the website. This is a positive step, but full applications are not yet published.

* Employers are told this is the minimum ratio per year but can fall under this minimum providing the funds roll over to the next year.In addition they rarely award more than the bare minimum

What Will be the Effect of the Changes?

How will capping the award rates influence personal progression in future years?

Currently 12% Have a National AwardData from 2009 annual report, sample = 35,000 consultants

Awards Are Rarely “Downgraded”• During the 2009 round 541 applications (731 in 2008) to review existing awards

were received of these 33 cases (16 in 2008), ACCEA found the evidence insufficient to provide assurance that the award was still merited and has

• required the consultants in question to resubmit review papers in 2010 so that it can be satisfied that their excellence continues. Only in 3 cases (2 in 2008), the evidence of awardable clinical contribution was insufficient to justify continuation of the awards and they were withdrawn.

Impression => Less than 1 in 100 consultants fail to continue to be excellent, after achieving excellence. This is barely credible, some consultants must have somewhat lower achievement in some years than others. This shows that the system works as an incremental (ratchet) not a dynamic assessment of ability.

Old CEA Progression Ladder (2003-2009)

L1

L2

L3

L4

L5

L12 / Platinum

L11 / Gold

L10 / Silver

L9 / Bronze

L8

L7

L6

NHS High FlyerTypical NHSConsultant

Typical AcademicConsultant

Comment: Most NHS consultants reach a ceiling a L9 (local) and academics possibly bronze, but even a high flyer will take years to progress in the current system which encourages local awards in 1 point increments

L0 (not successful)

Age 39

Age 34

Age 46

Age 42

Age 36

Age 55

Age 40

Age 35

Age 50

AcademicHigh Flyer

Age 38

Age 34

Age 44

Age 59

Age 57

Illustrated typical year of achieving each level

New Projected Progression Ladder (2010+)

L1

L2

L3

L4

L5

L12 / Platinum

L11 / Gold

L10 / Silver

L9 / Bronze

L8

L7

L6

NHS High FlyerTypical NHSConsultant

Typical AcademicConsultant

Comment: With the new 0.20 local allocation and reduced national awards pot, it is likely to become common for typical NHS consultants to not achieve a L9 and for only academic high flyers to progress beyond a bronze award

L0 (not successful)

Age 42

Age 34

Age 50

Age 46

Age 36

Age 60

Age 44

Age 35

Age 55

AcademicHigh Flyer

Age 40

Age 34

Age 48

Age 65

Illustrated typical year of achieving each level

Problems with the CEA System (as of 2010/2011)

12 Difficult Questions for the ACCEA1. Are the 60% of eligible NHS consultants who are in receipt of a CEA performing

at an excellent level?=> Unlikely but perhaps “good” performance should be rewarded too?

2. Are the national/L9 awards to 13% of eligible NHS consultants fairly distributed?=> Currently academic performance and managerial positions appear to be given

undue emphasis (data submitted to BJP)

3. Should CEA count towards pension?=> Perhaps but because of the final salary scheme it is very obvious that committees

are favouring those about the retire

4. Should CEA disallow submitted evidence?=>How else can they be evidence based?....but submissions must be manageable

and adherence to guidelines about what can be submitted

12 Difficult Questions for the ACCEA5. Should Existing Award Holders be Treated Preferentially? No! The allocation rules 0.35 => 0.2 etc should not be changed for new applicants

alone. 6. Should Those Working Part Time in the NHS be Treated Preferentially? No! Awards should be pro rata, adjusted for number of NHS sessions (sorry, this

included academics, unless CEAs change their remit to include work done outside of the NHS for possible NHS benefit).

7. Should Local Trusts Be Allowed to Operate Local Rules? No. Please keep the rules fair for all, regardless of which trust is the employer.

That is, ban “fallow years” “uprating of section A/B/C etc” “no applications from new consultants within 5 years…” and other ridiculous local rules.

8. Should National Committees and Colleges be Allowed to Operate Local Rules?=>No. Please keep the rules fair for all, regardless of which committee is evaluating.

That is, ban “fallow years” “uprating of section A/B/C etc” “no applications from new consultants within 10 years for national awards” etc.

12 Difficult Questions for the ACCEA9. Should Awards Be Restricted to Medical Consultants? No. Allow any NHS employee to apply on merit. Already non-medical staff are

under-valued and under-paid in the NHS10. Should Awards be Given for Life? No. Create a working review system which evaluated all current and past

applicants at least every 5 years. This must be peer evaluated and carry no less scrutiny than the new application. A completely fair system would be evaluations of forms blinded to personal and demographic information (annonymous).

11. Why is the timetable is unnecessarily complex Why must applicants apply for local and national awards and subsequent years

before results are known?12. Why should non-NHS work be rewarded?=> Currently work conducted outside of the NHS eg with another employer, or not

for NHS benefit it not excluded. An extreme example is of individuals working in private practice during NHS time but not “caught” by the private practice code of conduct who are in receipt of an award.

Reforms to fix the CEA System (as of 2010/2011)

12 Reforms to Fix the CEA System1. Open the CEA to all health care professionals2. Treat all applicants (local and national) the same by banning “local rules”3. Move towards an anonymous scoring system based on reasonable clinical,

academic and managerial markers. 4. Allow submission of specific evidence, predefined by the ACCEA as valid5. Stop trusts capping CEAs (typically at 1 point per year); everyone knows the 0.35

(now 0.20) threshold works as a ceiling not a floor effect6. Award CEAs pro rata according to everyone’s employment contract7. Review exisitng CEAs every 5 years with the same degree of scrutiny8. Disclose the full applications online (as often promised but not delivered)9. Clarify if CEAs include work conducted outside of NHS time (presumably yes) but

only if of benefit to the NHS.10. Work with the National Quality Board to develop patient based feedback on

NHS staff that can be included in CEAs11. Simplify the timetable for CEA to avoid the need for cross-over application12. Allow the public to comment on the CEA and ACCEA rules and guidelines

Appendix – A hypothetical Scoring System

A Simple Hypothetical Scoring SystemInformation Data Type Maximum

points360 Evaluation Score from Colleagues Submitted online* 10 points

Second opinion requests from colleagues Self-report 10 points

NHS innovations, adopted by locally, regionally nationally Submitted online* 10 points

Committee work of NHS relevance locally, regionally nationally Self-report 10 points

Nationally collated patient satisfaction data Nationally supplied 10 points

Teaching & presentations delivered (local, regional, national) Submitted online* 10 points

Audit completed and presented (local, regional, national) Submitted online* 10 points

Research impact on topics of relevance to NHS Web of Science Citation Count since last award

10 points

Research published on topics of relevance to NHS Submitted online* 10 points

Number of Peer Reviews Completed Since last Award Submitted online* 10 points

*Submitted online – means submitted to an independent web site prior to award application eg Royal Colleges, Slideshare, Linkedin etc