Clinical excellence awards

Having once more been through the annual awards process of reviewing citations and CVs, within both trust and College systems, we are writing to express our sense of disillusionment and distaste at the whole rigmarole. Not only is it extremely time-consuming for all involved, especially the applicants, but it is intrinsically unreliable and demeaning as a method of enhancing doctors’ pay. The changes in the system from A, B, C to clinical excellence awards and various precious metals have been accompanied by a series of ‘domains’ that overlap remarkably and for which we have yet to see an agreed model criterion. How does one assess whether an individual doctor is ‘delivering a high quality service’ or ‘ managing a high quality service’? What is the definition of a high quality service?

A doctor working overtime because of the poor quality of the service that he or she is involved in perhaps should be preferentially rewarded for staying there rather than going to an easier place. Is ‘high quality’ defined as patient outcome, for example how many patients with depression are cured or surgical operations carried out without complaint or side-effects, or is it because the service is carried out in accordance with the wishes of the trust, strategic health authority or government? Carrying out an audit or introducing a ‘modernised’ style of service are automatically noted as positive, but continuing to see difficult patients who complain, don’t get better and generate ‘untoward incidents’ may even downgrade you in your chief executive’s eyes.

As with the previous system, the busier and more active the doctors are in seeing patients and providing a comprehensive service - usually beyond contracted hours in the case of many general adult psychiatrists - the less likely they are to be able to sit down and fill out the form with sufficient details of committees or working groups attended, papers published or lectures given. What are termed ‘clinical excellence awards’ are really awards for clerical excellence. Most of the information is entirely impossible to check, particularly since we do not have a routine patient feedback system (as they do in the USA) or any generally valid outcome measures.

However, even after having created time to fill in the forms, the clinician seeking a national award is then faced with a cruel timetable of waiting until November to find out if an award has been offered and, if not, then having to re-scramble the whole application over Christmas. This is a very difficult time for committees to meet in order to comply with the narrow timetable for submission before the end of January. Once the forms are despatched, the processes and decision-making of the higher Advisory Committee on Clinical Excellence Awards committee levels (i.e. beyond trusts and colleges) is so obscure as to be post-Kafkaesque. Again, it is likely that these committees and assessors have even less knowledge of the realities behind the forms and will be faced by hundreds of CVs. How can they deal with variations in specialty, age, gender and ignorance of the true resources or quality of care in any given trust?

At the local level matters are even more delicate, small amounts of money per point gained contrasting with the substantial demoralisation following rejection. Many trusts have operated an every second year policy, but is this consistent nationwide? Why not only try and pull your weight every other year? The process becomes essentially an alluring form of salary redistribution that conveniently hides a ceiling on salaries, since the chance of progressing nationally, beyond level 8, remains less than 10%.

Our view is that these embarrassing and essentially uncertain processes should be abandoned and that the consultant pay scale should be extended into areas of incremental seniority via standardised reviews based on the appraisal process. Committee and managerial work should be allocated additional sessions, openly assessed and competed for and again acknowledged via seniority. Loyalty of service - it takes years to generate an effective knowledge of locality and networks - should also be acknowledged to counter the disheartening spectacle of locums being paid more than committed ‘ regulars’. We admire the dedication and care of all those involved in trying to help develop scoring and assessment systems for these awards, but our own view remains that the aftermath is always one of a sense of embarrassment, depression and pervasive ennui.