Hospital consultants have rejected a deal to give them an increase in pay in return for changes to their working conditions.

Doctors voted by almost two to one against a proposed new contract in a nationwide ballot of 45,000 members of the British Medical Association.

The contract, drawn up after years of negotiations between the BMA and Department of Health, was originally presented as a "win win" deal for consultants.

However, many doctors criticised the contract saying it gave NHS managers too much power and threatened their independence.

Consultant anaesthetist Dr Ian Wilson of the British Medical Association's senior consultants' committee answered your questions in a LIVE interactive forum.

Transcript

Newshost:
It might have given many senior doctors a salary of �85,000 per annum but it wasn't enough and today they voted to reject the latest pay deal.

More than 60% of doctors rejected the proposals which would have meant working more at weekends and evenings. It was hoped the new deal would help cut waiting lists. So what does it mean for the NHS, doctors and, perhaps most importantly, you and me as patients?

To answer your e-mails, we're joined by Dr Ian Wilson from the BMA. Thank you very much for joining us Dr Wilson.

First of all can I ask you your personal opinion on this pay deal - did you vote in favour or against it?

Dr Ian Wilson:
I did vote and I left my vote to the last minute and reluctantly voted no.

Newshost:
Why?

Dr Ian Wilson:
Because in the end although on paper what looked like a good deal for the NHS and the consultants, I believe it held us hostage to fortune and made sure that managers were too much in control of the way that doctors work and hence the way that patients got treated. So we'd become a political football based on target setting and not on quality patient care.

Newshost:
Chris, Birmingham: The tighter working hours restrict the amount of lucrative private work that can be pursued. How much is this influencing the vote compared to clinical freedom?

Dr Ian Wilson:
Well I don't it really influenced it very much at all. It's a bit of a myth to say that we had our private practice curtailed. In fact under the new contract, we'd have very little extra work for the NHS - you'd have unlimited amounts of private practice if you wanted.

But I honestly don't believe people voted on this as a matter for private practice. Very few consultants actually do substantial amounts for private practice. It's a misconception that's actually been, I believe, peddled by the Department of Health in order to try and make consultants look bad in rejecting this contract. It had nothing to do with pay - it was actually about principle.

Newshost:
Paul Sullivan (a consultant physician in the Northwest), Salford: I'd like to see the breakdown of vote by region. Is it really doctors putting clinical freedom before a pay rise or is it that high private practice earners in the south have scuppered the deal?

Dr Ian Wilson:
There's been a breakdown by nationality - by Scotland, Wales, Northern Ireland and England. But I don't have access to a regional breakdown within the UK and as far as I'm aware that breakdown hasn't been done.

I think there's sufficient evidence to say that the private practice issue wasn't influential in there - there isn't a sort of north/south divide just by the way the contract vote had gone in the different nations.

For example, the Scots having voted for it - it's well known that there's much less management interference in Scotland and perhaps that's why colleagues in Scotland felt more inclined to vote narrowly in favour of the contract rather than against it where in England there is a lot more management interference.

Newshost:
You referred again there to the issue of interference - about the setting of targets. Isn't it right that doctors, like everybody else, should actually have some targets about which they should be aiming to achieve?

Dr Ian Wilson:
Sure, I have no problem with targets, per se. I have no problem with quality-based targets. I think most of us would have a problem where those targets distort clinical priorities to the point where patients are being treated for number crunching reasons to basically get the Department of Health off the hook on unrealistic promises it made rather than treating patients who need particular forms of clinical care now. It's been a whole number crunching exercise rather than a quality exercise.

Newshost:
Mike Harris, UK: The contract was not the generous deal it was hailed as. Many of us could actually have been voting for a pay cut, rather than the 20% that was publicised.

Dr Ian Wilson:
I certainly don't think the publicised proportions were anything like that. But then we are victims of government spin on that circumstance.

Superficially there were areas that appeared to be a pay cut and I know that some doctors, particularly part-time doctors, would have looked like they were getting a pay cut. My understanding is that subsequent assurances from the Department of Health reversed that and that nobody would have actually had a pay cut. But either way the matter becomes irrelevant because I don't think doctors voted on a pay issue here - I think they've thrown it out on a matter of principle.

Newshost:
Colin Johnston, Belfast, Northern Ireland: I think it is appalling that doctors are being paid such high wages as it is. How can a massive pay hike be justified, when I as a nurse with 4 years experience and probably more hands on patient care, still earn under �20,000?

Dr Ian Wilson:
It's absolutely a valid point. I don't want to get into a battle between doctors and nurses here at all. I believe doctors are actually underpaid for the work that they do, but that doesn't mean that I was interested in this deal on a pay issue.

What we do know is that nurses and the allied professions - particularly physiotherapists and radiologists are desperately underpaid. I was asking for a proper contract that rewarded the work we do - not for a pay hike - it was to reward the work that we do.

That doesn't detract from the fact that nurses are desperately underpaid. We can't recruit nurses in specialised fields - we desperately need to pay nurses, physiotherapists and radiologists appropriately to get them into the places we need them and to value them. They're leaving the profession in droves.

How on earth are we supposed to run an NHS which relies on those professionals too if they're leaving as well? I'm totally sympathetic to his views on their salary. I disagree with him in making that a doctor versus nurse issue.

Newshost:
Sean Murray, Nebraska, USA: From my understanding of the situation, the new contract may be introduced anyway, and then trusts can decide if they will offer it to their physicians. Is this the case?

Dr Ian Wilson:
We are worried that the Government might well try to enforce it anyway. I think that would be a very unwise move. I think it's much more appropriate that we now work with the Department of Health to find out where the problems were with the contract, as I believe this is an issue about a lack of trust between management and doctors.

And management by default being the representatives of the Government in the hospitals, then we've got a big problem where we need to rebuild that level of trust between the clinicians - doctors, nurses, and everybody else - and the managers and thereby the Government. Unless we get that trust, how on earth are we supposed to take the health service forward and do the reforms that the Government claims it wants.

Newshost:
Presumably the sensible thing is to go back to the negotiating table and say - look, we agree with this bit, we don't agree with that bit, can't we talk about that bit and try it agreeable to both of us?

Dr Ian Wilson:
I think that would be an extremely sensible thing to do. We now need to see whether the Department of Health will act with that degree of commonsense.

Newshost:
Do you think they will?

Dr Ian Wilson:
The opening gambits have been less than positive and they did say right from the start that this was their final offer and they weren't going to offer anything else. But the bottom line is they want reform, we want reform - we both actually want the same things.

I believe it's the Department of Health that has scuppered this deal by failing to give reassurances on the areas we were concerned about on management control. Indeed the Department of Health representatives are ruining the whole process by saying quite the opposite - that they would impose management control, that they would force doctors to work late nights, evenings, weekends in addition to their normal work and in addition to the emergency work they already provide evenings and weekends.

So what choice did doctors have when the Department of Health was saying - well actually all the things you're worried in the contract are right?

Newshost:
Johan McKinnon, Aberdeen: No mention has been made of "Merit Awards" and how they affect consultants' salaries at present. Could you please explain why no mention has as yet been made of these and the effect they have - in many cases - doubling a consultants' salary?

Dr Ian Wilson:
The merit award system is incredibly complex - I'll try and keep it as simple as possible.

There is an award system for the jobbing consultant and the jobbing doctor in most hospitals which recognises where people have put extra effort in where they don't particularly need to, to take forward the health service or work within their hospital. The merit award system is really to recognise work of national and international importance and wasn't on the table during this discussion. But I think most people would recognise that it's something that does need looking at and does need reform.

Dr Ian Wilson:
Karl Downes, Worcestershire: Patients before profits. Long waiting lists create misery for NHS patients and lots of business profits for private clinics. Is there is a conflict of interest with consultants having a foot in both camps?

Dr Ian Wilson:
I think private practice is pretty difficult area. My belief is that the majority of consultants have a great deal of integrity about any private work that they do and there's certainly sufficient controls there to make sure that that happens.

As I said right at the beginning, there are very, very few consultants earning any significant amount of money in the private sector. It is actually a myth about these consultants who just waltz off to the, what they might call, "the golden nugget" - it just doesn't exist. In those areas where it does exist, it's relatively small numbers of people. Certainly in the places that I work, it's a little bit extra that you do in your own free time.

I have a waiting list that 28 weeks long. I have moved heaven and earth to get my waiting list down and I would be extremely offended if anybody thought that I was trying to maintain a waiting list artificially high in order to maintain private practice which in my case is extraordinarily insignificant.

The fact is, I have a high waiting list because our service is a very, very high quality service, supported by my nursing and physiotherapy colleagues. And in order to provide a high quality service, we need to give patients time and quality to go through the issues that they have - to go through the problems that they have - and treat them properly.

What I am desperately trying to resist is to be forced into piling an awful lot of patients through, half treated with poor quality treatment, just to meet a number-crunching exercise.

Newshost:
George, Bristol: Why do consultants consider themselves different from the other staff who work for the NHS? Why is it that they feel that NHS managers should not have the power to manage? Why do they need to be "independent"?

Dr Ian Wilson:
I don't think anybody is saying that we don't need the service managing - we absolutely do. Doctors often don't make the best managers - some doctors are very good managers, some doctors are very poor. We need managers in order to provide the facilities that we need to treat the patients and ensure that those facilities are met and also to ensure that quality standards are met and make sure that patients are getting a fair deal.

What we're against is managers manipulating the system. I am actually on the managers' side at a hospital level here. I think they get treated appallingly badly by their employer, the NHS Executive and thereby the Government.

I think the Government puts untold pressures on management where if they don't achieve certain targets, they're out - no question - they're out that afternoon. So the pressures that then come on to doctors are to distort waiting list figures, to push through GP referrals.

Let me give you an example. The only things that show up on waiting lists are general practitioners' referrals. Why should a cancer patient who has come from a GP take priority over a cancer patients from another consultant? Yet waiting lists and managers are forced to apply waiting lists only account for the patients who come from GPs. So what we're saying is we should have the clinical freedoms to work with the patients for the patients' benefit to work out who takes priority in a cash limited system and make sure the patient gets the quality service that they need for their complaint - not the one that's politically expedient.

Newshost:
Peter Roberts, Aberystwyth, Wales: I Is the primary reason for this debate is that we are not training enough doctors in the first place?

Dr Ian Wilson:
I wouldn't say it's the primary reason, but you're absolutely right, we don't train enough doctors. We have substantially fewer doctors in this country than they have in most countries throughout Europe. If we don't have enough doctors, we can't treat enough patients.

The Government set its own targets for increasing the number of consultants by 7,000. It's not going to achieve that. We in the BMA have been telling them that for years that they're not going to do it. Until they treat doctors and their other healthcare workers properly and get the right numbers in of all the specialities, they will have a health service that's starts to fail.

Newshost:
Dr Ian Wilson, thank you very much for joining us.

This forum has now finished. Thank you for your questions.