Rewarding excellence? Consultants' distinction awards and the need for reform

It is essential that excellence in the performance of doctors in the National Health Service is rewarded explicitly and efficiently. Unfortunately the existing system of Distinction Awards which, for the select few, can double a doctor’s public sector pay is both secretive and of unproven efficiency. Distinction awards have existed since 1948 and at present 34% of consultants receive them. They are payable at four levels: A+ at £46,500 per year, A at £34,260 p.a., B at £19,580 p.a. and C at £9,790 p.a. Since 1989 a few managers have been involved in the allocation of ‘C’ awards but all the other awards are determined by committees of consultants who meet in secret to decide who deserves rewards for “distinction”. The costs of these awards, in excess of about £80 million per year, have to be met by the hospital in which the consultants are employed. Ideally these payments should be related to performance and their award should act as signals to NHS purchasers and customers regarding the excellence of the care that is available. Unfortunately a rationale for these payments is absent. It may be that their allocation reflects excellence in some way but this has not been demonstrated by the advisory committee on Distinction Awards. Indeed the secrecy of the award system and the difficulty of explaining the distribution of awards with available “indicators” works to sustain a conspiracy theory that the awards are made to “the boys” to inflate their income whilst in practice and their pensionable earnings after they retire. Such assertions do little to enhance efficiency and the development of effective clinical management. The distribution of distinction awards between specialties and regions is described, and attempts are made to evaluate its efficiency. This statistical analysis shoes that there is little relationship between the value of awards and available crude indicators of productivity. Tens of millions of pounds are used annually to fund the system of distinction awards for NHS consultants. Those who determine the use of these resources are not accountable for them and few NHS managers understand the system let alone recognise the need to reform it and facilitate the true reward of excellence. There is a need for the medical profession to deal explicitly with payment for excellence and also for them to realise that such a remuneration system will have to be controlled in conjunction with NHS managers. Both professional groups, clinicians and managers must move rapidly to reform the way in which clinical excellence is rewarded in the NHS.