Abstract
Objectives
To explore trends in the clinical activity of hospital specialists in English National Health Service (NHS) hospitals, and test the effect of contract reform.
Design
Retrospective secondary analysis of hospital episode statistics, describing trends and testing for a contract effect using multilevel interrupted time series analysis.
Setting
Ten surgical and medical specialties in English NHS hospitals from 1999 to 2009.
Participants
Hospital consultants on full time or maximum part-time English NHS hospitals.
Intervention
A new contract offered to NHS consultants in October 2003, with higher pay alongside job planning and appraisal.
Main outcome measures
Inpatient finished consultant episodes (FCEs) per consultant per month, with and without accounting for case-mix differences.
Results
In most specialties there was a statistically significant downward trend in FCEs per consultant per month. On average in the surgical specialties, FCEs reduced by 0.14 per month (95% CI -0.16 to -0.11) and in medicine there was a smaller reduction of 0.08 FCEs per month (95% CI -0.1 to -0.06). NHS patients symptoms have increased in severity over time, and the downward trend is reduced after case-mix-adjustment, and reversed in general and geriatric medicine. The effect of the contract on clinical activity was minimal. In five specialties there was no statistically significant effect, but in five specialties there was a statistically significant negative effect.
Conclusions
Consultant clinical activity, as measured by FCEs per month, has shown a general downward trend from 1999 to 2009. The consultant contract was not associated with an increase in consultant clinical activity rates.
Introduction
DECLARATIONS
None declared
KB is funded by a Career Development Fellowship from the National Institute of Health Research. Views expressed are those of the authors and not of NIHR or the Department of Health
Ethical approval was not required for this study, but use of HES and Medical Workforce Census data was approved by the Data Security and Confidentiality Advisory Group of the NHS Information Centre
KB
KB and AM initiated the idea for the study. NF and KB conducted the data analysis and, with AM, interpreted the results. KB wrote the initial draft of the paper, to which all the authors contributed
Richard Lilford
Between 1999/2000 and 2010/11, there were large increases in National Health Service (NHS) expenditure in England, averaging around 7% per year in real terms. 1 These expenditure increases were associated with increases in staff salaries in the NHS, for example, salaries of hospital consultants (fully trained hospital specialists) increased by 27% in three years from 2003/4 to 2005/6. 2 Expenditure inflation and salary increases created a policy focus on returns on spending, and interest in the ‘productivity’ of healthcare organizations and staff. The current drive for austerity in public finance, along with the ‘Nicholson challenge’ requiring year-on-year efficiency gains of up to 6% for six years 3 has heightened the need for productivity improvements in the NHS.
The complex area of public sector ‘productivity’ has been increasingly studied, particularly since the Atkinson report. 4 Using productivity measures developed in York, 5 including not just activity but also measures of quality of care, changing case-mix and outcomes, the Office of National Statistics (ONS) reported that NHS productivity has been falling over time. 6 Their NHS productivity index decreased by 2.7% from 1995 to 2009, an average annual fall of 0.2%. This is attributed to an annual average increase in ‘inputs’ (including staff and other expenditure) of 4.6% and in ‘outputs’ (activity adjusted for quality, case-mix and outcomes) of 4.4%. ONS do report that in the final year included in this study (2009) healthcare productivity increased by 0.7%, following two years of decline, 6 and their methods have been criticized as they do not include various measures of safety and quality of care, and patient outcomes. 7
Staff costs are the largest component of NHS expenditure and hospital consultants are highly paid and key members of NHS staff, influencing all areas of clinical productivity in hospitals. Workforce productivity was described by the House of Commons Health Committee as ‘a vital goal that has been badly neglected’. 8 A number of changes over recent years may have influenced consultant clinical productivity. In particular, in 2003, the contract for NHS consultants was changed after a protracted period of negotiation. The new contract included more focus on job plans, where time slots (programmed activities, PAs) are planned in advance, and, in principle, monitored through appraisal. The standard full-time contract is 10 four-hour PAs per week, but consultants can be paid 11 or 12, in recognition of working over 40 hours a week. There are four types of PAs: direct clinical care (including inpatient duties, outpatient clinics, operating sessions, etc.); supporting professional activities sessions (including training and development, teaching, audit); additional NHS responsibilities (such as management roles) and external duties (such as BMA or Royal College roles).
The contract increased the potential for managing consultants’ activity, and increased the salary level of consultants, but did not introduce fees for service or make any real attempt to link consultants’ pay explicitly to their performance or productivity. Clinical excellence awards remain the only element of ‘performance related pay’ for consultants, and this merit-based system changed relatively little. 9 Nevertheless, in the business case for the contract, the Department of Health reported an expectation that the contract reform would result in year-on-year consultant productivity gains of 1.5% against a decreasing trend, through efficiency gains and quality improvements. 2 Both the Health Committee 8 and the Public Accounts Committee 10 have expressed concern about the impact of the reformed consultant contract on productivity. The National Audit Office 2 reported from a survey of hospital Trusts that consultant management had improved since the implementation of the contract, but that it was too early to tell the full impact of the contract on productivity 2
Other factors influencing productivity include the expansion of the consultant workforce and moves towards a ‘consultant delivered’ NHS, along with expansion of the number of medical trainees, the application of the European Working Time Directive to the medical profession, changes in technology and demands on the NHS, and also changes in targets and incentive structures. These changes may have affected consultants’ working lives and consequently their clinical productivity. In addition, changing organizational features at hospital Trust level (including structures, processes and organizational culture) 11 may influence productivity and performance of all members of staff, and perhaps particularly consultants, given the overlaps and on occasion tensions between organizational and professional cultures.
Earlier research developed a simple measure of clinical ‘productivity’ of individual consultants, using a routinely collected data source, the hospital episode statistics for England (HES). HES includes a consultant identifier assigned to all patient episodes, but until 2001 this code had not been used in research. The feasibility and validity of aggregating inpatient episodes by consultant to explore consultant clinical activity, based on patient episodes per consultant over a time period, adjusting for case-mix differences and linking with other sources of information about consultants using the consultant code in HES, has been established. 12 This research revealed substantial variations in the individual inpatient activity rates of hospital consultants, and also created methods of ‘benchmarking’ activity data, later adopted by the Department of Health as part of the ‘delivering quality and value’ toolkits.13,14 Using multilevel modelling approaches to reflect the hierarchical data, associations between activity rates and consultant characteristics were also explored, revealing important results with regard to higher activity rates of maximum part-time consultants compared with full-time consultants 15 and men compared with women consultants. 16 This cross-sectional research could not be used to explore trends over time, and was limited in its potential to answer questions about why variations exist and what trends may be in the future. We therefore assembled a 10-year panel of this consultant clinical activity data in 10 specialties to describe and explore trends in consultant clinical activity over time and to test whether or not reform of the consultant contract in 2003 affected consultant clinical activity.
Methods
Data source
This analysis uses data from the HES from 1999/ 2000 to 2008/9. 17 Each observation in the extract from HES represents one finished consultant episode (FCE), defined as a period of healthcare under one consultant in a hospital provider. Ten surgical and medical specialties were included (general surgery, urology, trauma and orthopaedics, ENT, ophthalmology, general medicine, gastroenterology, cardiology, paediatric medicine and geriatric medicine). The choice of specialties was made to cover a broad range of surgical and medical activity, and to include most common reasons for admission. HES data record anon-ymized patient characteristics, including age, sex, diagnoses, procedures and length of stay. From these data, healthcare resource groups (HRGs) are assigned to each patient episode, grouping conditions and procedures that use similar levels of resource. Each HRG has an associated tariff cost, which is used as a proxy for case-mix differences. As this was a 10-year extract, several different versions of the HRG grouper were used, and for this reason, to ensure consistency, the data were re-grouped using a single version (HRG3.5). Tariff prices (from the year 2007/8) were assigned to each HRG to provide a weighting for patient severity and case-mix (assuming that a higher tariff represents a more complex patient episode).
HES data also provide information about hospital providers and a code for the consultant in charge of each episode. Episodes were aggregated for each consultant, monthly, over 10 years. The consultant identifier, based on the General Medical Council (GMC) registration code, also permits linking of HES episodes with other routinely collected data-sets, including the Medical Workforce Census. These data provide information on the characteristics of consultants, including age, gender and type of contract held (including full-time, maximum part-time, part-time or honorary before 2003 and old or new contract since 2003). As the workforce census is annual, for those consultants who did not adopt the new contract immediately (in October 2003) we have assumed that they changed contract in January of the year where they switch from ‘old’ to ‘new’ contract in the Census (which is taken in September each year).
Following data linkage we were able to derive data-sets of inpatient episodes per month for consultants in 10 specialties in England. The following information was available: FCEs per month, with and without adjustment for case-mix differences (proxied by tariff costs of each HRG), age of consultant, gender of consultant, contract held, hospital trust (if consultant worked in more than one trust, their main trust was assumed the one where they undertook the most FCEs), specialty of practice (again if the consultant worked in more than one specialty, their main specialty was assumed the one where they undertook the most FCEs). Only consultants who were on full-time or maximum part-time contracts are included in this analysis, so that time trends for full-time consultants are observed, regardless of any trends towards increased part-time working.
Statistical methods
Ten-year time trends of patient episodes were derived per consultant per month (April 1999 to March 2009), with and without accounting for case-mix differences, for consultants in 10 specialties.
To test for a contract effect, identifying any change in the existing trend associated with the contract implementation for each consultant, we used a carefully designed interrupted time series analysis. Separate trends were identified for each consultant, requiring a multilevel approach. An ‘interruption’ occurred when and if they changed their contract. Specifically, we used hierarchical repeated measures analyses with smoothed thin plate splines, programmed in PROC GLIMMIX in SAS (SAS version 9.2, SAS Institute, Cary NC, USA). The procedure identifies radial basis functions as the spline basis and tiansforms them to approximate a thin-plate. For computational expediency, the number of knots is chosen to be less than the number of data points. This approach frees you from having to stipulate a parametric model for the response trajectories over time, and differs from conventional spline-based models in that the fitted splines are based upon generalized random effects.
Results
Table 1 and Figure 1 illustrate trends in patient episodes per consultant per month, with and without conditioning for case mix differences, for consultants in ten specialties over ten years (April 1999 to March 2009, omitting the last two months, to avoid a decrease resulting from incomplete episodes). In general, these trends show a decreasing trend in activity per month, which is lessened through conditioning for case-mix, suggesting that patient severity is increasing over time. Overall, medical specialties are relatively consistent in terms of activity per month, and the activity rate in surgical specialties is decreasing. There are differences between specialties, for example in surgery, general surgery, and trauma and orthopaedics show decreasing consultant clinical activity rates per month, in comparison with urology and ENT, which are relatively flat. In medicine, gastroenterology, cardiology and paediatric medicine show decreasing consultant clinical activity rates per month, in comparison with general and geriatric medicine, which are relatively flat. Paediatric medicine shows a marked seasonal pattern in activity rates, with higher activity in the winter and notably reduced activity rates during the school holidays.
Trends in activity (with and without case-mix adjustment): all 10 specialties, five surgical specialties (general surgery, urology, trauma and orthopaedic surgery, otorhinolaryngology, ophthalmology) and five medical specialties (general medicine, gastroenterology, cardiology, paediatric medicine and geriatric medicine)
Trends in clinical activity per consultant per month (with and without case-mix adjustment)
The measure of ‘case-mix-adjusted’ clinical activity is based on the healthcare resource group (HRG, all years grouped to version 3.5) to which each patient episode is assigned, and the tariff cost attached to each HRG (using a single year, 2007/08 prices). These tariff costs are then aggregated for each month for each consultant, as a proxy for the severity of patients and differences in case-mix - essentially we assume that more expensive patients are more severe
Table 2 shows the effect of the new contact (whenever it was taken up by each individual consultant). In five of the 10 specialties (general surgery, urology, ENT, ophthalmology and geriatric medicine) there was no apparent effect of the new contract on clinical activity per month. In five specialties (trauma and orthopaedics, general medicine, gastroenterology, cardiology and paediatric medicine) the effect of the contract was statistically significant and negative, with and without accounting for case-mix, although the effect was only strongly significant for trauma and orthopaedic surgery.
Effect of the new contract on activity per consultant per month (with and without case-mix adjustment)
This is not the total number of consultants in each specialty group in England, it is restricted to those where it was possible to link Hospital Episode Statistics for England data with contract and other information from the Medical Workforce Census, and within that group to those on full-time or maximum part-time contracts. In addition, if consultants’ work is coded into more than one specialty (e.g. general medicine and gastroenterology, or general surgery and urology), they have been classified into the specialty where they did the highest proportion of FCEs
Discussion
In nine of the specialties under consideration, patient episodes per consultant per month decreased over time, and in geriatric medicine the trend for patient episodes per consultant was flat; although given changes in demographics, an increase might have been expected in this specialty. After accounting for case-mix differences over time, seven of the 10 specialties still showed a downward trend in activity. In ophthalmology there was no change over time, and in general medicine and geriatric medicine there was a small but statistically significant increase over time in consultant clinical activity after accounting for case-mix.
The consultant contract, despite government hopes of reversing the downward trend in productivity and even increasing activity by 1.5% per year, 2 has had very little effect. In five of the specialties studied there has been no statistically significant change in activity associated with a change in contract, and in five specialties the difference was at least modestly statistically significant and negative.
This is the first attempt to explore the clinical productivity of consultants over time, and to analyse the effect of the consultant contract. Our trends are generally consistent with overall trends in NHS productivity, which have been reported as negative until 2008/9 and then slightly increasing. 6 This appears consistent with the trends in consultant productivity illustrated in Figure 1.
The study has a number of limitations, which mainly reflect data availability. We have made no attempt to include any measure of quality of care or patient outcomes in this analysis, so it may be that decreasing activity trends are accompanied by increasing quality. We are also unable to include the number of PAs paid to consultants, as this information is not available for research purposes. It may be that at the introduction of the new contract, more consultants were paid additional PAs (11 or 12 per week), and as new consultants have been appointed, they may be more likely to be paid a standard 10 PAs. We have limited our scrutiny to inpatient episodes in this study, although earlier research has shown strong associations between consultants’ inpatient and outpatient workload. 16 We are unable to observe any effect of the new contract on private practice, as comparable data on private healthcare is still not collected centrally. Finally, we have no information about the number and time commitment of other team members working with consultants, for example, registrars and other doctors in training. Numerous changes to the working hours of junior doctors have occurred over this time, including restricting their work to 56 hours per week in 2003 (as a result of the New Deal) and the European Working Time Directive restricting their working time progressively to 48 hours per week (from 2009). 18 It may be that these changes create pressures on consultant roles, resulting in reduced activity over time.
The lack of an effect on NHS inpatient activity of the new contract is perhaps unsurprising given the nature of the contract, which remains a salaried system with supplementary bonuses (clinical excellence awards) that reward vaguely defined ‘merit’. In principle the reward for extra PAs may have increased the consultant time available to NHS managers, but in practice this may simply have provided extra reward for work that many consultants were already doing. Economists suggest that salary-based systems contain too few incentives for productivity, whereas fee-for-service systems contain too many and risk rewarding inappropriate provision. 19 Reviews of performance-related pay in health 20 have tended to focus on systems like the quality and outcomes framework in UK general practice, where direct explicit financial incentives for performance were introduced and rigorously evaluated. 21 Incentive structures for hospital consultants changed little as a result of the new contract, and evidence on pay and performance of hospital consultants is sparse.
The explanation given by ONS for the overall decreasing trend in NHS activity - an annual average increase in ‘inputs’ (including staff and other expenditure) and a slightly smaller average annual increase in ‘outputs’ 6 appears equally plausible as an explanation for the trends illustrated here (see Figure 2, which demonstrates an increasing trend in patient episodes but a sharper increase in numbers of full-time equivalent consultants). Other possible explanations include expansion of the number of medical trainees, restricting the working hours of doctors in training, changes in technology and demands on the NHS, and also changes in targets and incentive structures in the NHS. Future research could usefully explore these and other possible explanations for the trend, and link measures of activity with measures of outcome (for example, using patient reported outcome measure data) and with measures of quality of care.
Overall trends in patient episodes per year and full-time equivalent consultants.
Conclusions
Regardless of improvements in medical technology, healthcare remains a labour-intensive activity. Since the NHS Plan, 22 there has been an expectation that increasing NHS budgets would create systemic change and improvements in both the quality of care and in NHS productivity 23 Several important indicators have suggested improved quality of NHS care over this time period (including, for example, improvements in life-expectancy infant mortality rates and cancer survival), 7 but in general, increases in the rate of consultant clinical activity appear not to have been delivered. Claims were also made that the consultant contract, which resulted in substantial pay increases for hospital specialists in England, would result in increases in clinical activity of 1.5% per year. These increases have not materialized, and indeed in half the specialties studied, the effect of contract change has been at least modestly statistically significant and negative. The contractual change for senior doctors implemented by the Department of Health in England appears to have been ineffective in increasing consultant clinical activity in the NHS.
Footnotes
Acknowledgments
None