External duties for consultants in England
March 2007
The purpose of this briefing note is to demonstrate how consultants’ external duties deliver benefits to their patients, their employing trust and the wider NHS.
It is also a resource designed to help in the process of consultant job planning, by showing how to accommodate external duties in a job plan.
Contractual basis of external duties
Paragraph 3 of schedule 3 of the terms and conditions of service state that the duties and responsibilities set out in job plans may include external duties.
External duties are defined in the consultant contract as:
“duties not included in any of the three foregoing definitions [direct clinical care, supporting professional activities and additional NHS responsibilities] and not included within the definition of Fee Paying Services or Private Professional Services, but undertaken as part of the Job Plan by agreement between the consultant and employing organisation. These might include trade union duties, undertaking inspections for the Commission for Health Improvement (or its successor body), acting as an external member of an Advisory Appointments Committee, undertaking assessments for the National Clinical Assessment [Service], reasonable quantities of work for the Royal Colleges in the interests of the wider NHS, reasonable quantities of work for a Government Department, or specified work for the General Medical Council. This list of activities is not exhaustive.”
Many consultants will not have external duties. One of the challenges of job planning is determining the strengths of individual consultants. Some will have opportunity and aptitude for external duties; some may instead concentrate on direct clinical care and supporting professional activities.
Consultants should remain aware that all work that is paid for by the NHS should, in some way, benefit the NHS and its patients. This applies to external duties as much as to other job plan activities. Whilst direct clinical care PAs benefit a small number of patients immediately, the work carried out as external duties usually benefits a much greater number of patients, but indirectly and over a longer term. Although this may make it more challenging for local managers to identify the benefits, it is still possible to link benefits from external duties to objectives in the job plan. Some examples of how this may be achieved and how consultants and managers may improve service delivery and patient care are set out below in the medical manager’s diary.
Consultants who need advice on including external duties in their job plans should contact askBMA with their membership number.
Health Departments' support
In April 2004, the Department of Health released the following statement:
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Find out more on the Department of Health web site
The CCSC has already released broad guidance on how to address external duties through the job planning process.
That guidance underlined the need for some consultants to include external duty work in job plans and, where external duty work is irregular, to allocate PAs or substitute the time spent on external duty work for other PAs (not necessarily SPAs). Despite the Department of Health’s endorsement of external duties some consultants continue to come up against unhelpful approaches to this type of work. Consultants facing difficulties should seek support from the BMA and other relevant bodies (i.e. those they carry out their external duty work for). Following the advice in this guidance about identifying benefits to the trust and setting objectives in a job plan can help to resolve disagreements. If necessary, the mediations and appeals processes can be used.
The BMA, as a union, can support members who are having difficulties agreeing their job plans with trusts. However, it is essential to the strength of the consultant body that consultants take a unified approach to this problem. Local BMA staff should be informed of instances of trusts taking unreasonable approaches to job planning and will be able to provide advice and support locally and work with the national office to resolve serious breaches of the 2003 agreement and address ongoing problems.
Objectives and supporting resources
Establishing a series of objectives that can be met through external duties is the ideal way to approach this matter through job planning. If a consultant can demonstrate to a trust that it will benefit from external duties, then agreement on a job plan with allocated programmed activities will be achieved more easily.
Objectives set out in the job plan and supported by the appropriate level of resource can include ‘hard objectives’ such as adherence to the targets or effective use of new working methods, ‘soft objectives’ such as improved communication with patients and a range of other types which may include completion of audit projects, working with the team to develop the service or acquiring specific new skills. Consultants should give some thought to how their external duty work can enable them to provide benefit to their trust and the service in general and how they can distil these benefits into objectives in the job plan. This can be very challenging for external duty work and consultants might want to consider how best to draw out clear benefits that are not simply the attendance of meetings. Examples might include:
- Objective: to have a key role in the production of specialty association guidelines, which will feed into the improvement of patient care across the NHS and service delivery within the trust. The consultant’s role should enable the trust to be a leader for change in this area.
- Objective: to respond to Government consultations as appropriate to specialty, and to brief the clinical effectiveness manager on implications for the trust.
- Objective: to raise the profile and enhance the status of the consultant’s trust, through participation in national work.
- Objective: participating in fellowship examinations to ensure the supply of appropriately qualified doctors for the service; and to use the expertise so gained to establish a regional examinations course in the Clinical Sciences Building.
- Objective: to participate in the medical Royal College council, thereby helping in the process of continual raising of standards; and to brief the relevant medical and non-medical managers on developments, opportunities and threats arising through this work.
Objectives should be supported by resources. In many cases the only specified supporting resources will be an appropriate amount of time, and basic office and ICT support.
Some organisations for which consultants carry out external duties are starting to provide role descriptions. These can assist because they emphasise the work done in support of the NHS while in that role. Such a role description is an appropriate part of the job planning information.
Accommodating external duties in job planning
It is important to remember that the new contract specifically brought in the concepts of SPA and external duties as essentially separate job plan work types. Therefore, job plans must explicitly state the external duty work that is being carried out. This should not impact on all the other necessary aspects of SPA work. Consultants should always have adequate time allocated in their plans to training, CPD, appraisal, audit and other such activities.
Further guidance on SPAs can be found here:
http://www.nhsemployers.org/pay-conditions/pay-conditions-818.cfm
External duties, and their associated objectives, should be specified explicitly in a job plan and should include a written comment such as "Dr A is a member of the Specialty Training Committee and will attend 6 half day meetings each year of this committee. On these occasions, which occur at variable timings in the week, it is agreed that Dr A will not carry out the usual job plan activity."
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Clinical excellence awards
Some trusts make it known to consultants either implicitly or explicitly that they will recognise commitment demonstrated by external duty work through CEAs. This is wrong where the CEA is used instead of proper job planning. It is appropriate where this work is carried out to an appropriate standard of excellence. The CEA scheme recognises work over and above normal contractual expectations in terms of excellence and quality. This does not mean that CEAs should be used to recognise unpaid work. It does mean that the scheme rewards significant achievements, and examples of excellence.
Accordingly, it is not appropriate to exclude external duties from a consultant job plan on the understanding that the recognition will be through CEAs.
A partnership approach
For consultants with an external duty commitment, a detailed discussion between the consultant and their clinical manager on how that commitment may impact on direct clinical care is essential.
Mutual agreement of the inclusion of external duties in job plans will be facilitated by early notification of any work of this nature to trust management. As with all job planning, a partnership approach is desirable and, ultimately, most effective.
A week in the life of a medical director
The following is a sample Medical Director’s diary based on examples provided to the CCSC. It explains how some of the activities during this week in a medical director’s life benefit from consultants (including medical directors) carrying out external duties.
A week in the life: 7 August
(09:00 - 10:00) Complaints manager 1:1 to discuss a 2nd stage NHS complaint
Complaints policies are negotiated locally against a national framework, and consultants on external duties are involved in both of these negotiations. Some consultants will have a particular expertise that can be brought into the trust from their experience of working with or for the Healthcare Commission.
(12:30 - 14:00) Workforce Planning Meeting (Deanery headquarters)
Consultants working for a range of organisations including the BMA contribute evidence toward the health committee on workforce planning and will be able to assist with regional and local planning as a result. Workforce planning is done in close conjunction with consultant representatives from the BMA and the Royal Colleges.
(12:30 - 14:00) Informal Directors (Boardroom)
Many items on a medical director’s agenda will have had consultant involvement through external duties.
(15:00 - 16:00) Phone business school re: Seminars on Public Reform
Consultant participation in medicopolitical work enhances their understanding of the drivers for public service reform and will help trusts in necessary change management.
A week in the life: 8 August
(09:00 - 12:00) Clinical Governance Committee (Boardroom)
Clinical governance procedures are developed using standards published by medical Royal Colleges, which have been developed by consultants on college councils and working parties. These consultants are contributing to the wider NHS through their external duties.
(14:00 - 16:00) Appraisal manager re. documentation
Consultants contributing to the development and monitoring of appraisal will be well placed to lead on trust appraisal procedures to ensure that they adhere to national standards and consequently result in fewer adverse events and other difficulties that appraisal can identify as possible from an early stage. The national appraisal model was proposed by the BMA consultants committee. The appraisal process would not exist had consultants not played a part in its development.
(15:00 - 16:00) SHA lead re: Regional Workforce Planning Priorities
Consultants who participate in College, BMA or Confederation workforce planning groups will be well placed to advise their trust on trends and opportunities.
A week in the life: 9 August
(14:00 - 15:00) Meeting with Clinical Effectiveness manager re: Follow up to Audit Commission reports
Consultants participate, through external bodies, to the research that supports auditing bodies’ reports. Involvement in these processes results in increased knowledge and understanding of the subjects of the audit reports and this in turn will enable a positive contribution to how the consultant’s trust can improve the implementation of, for example, the consultant contract.
Consultants on external duty PAs also form part of the external reference groups that increase the authoritativeness of the reports.
(15:00 - 16:35) Job Planning Workshop
Consultants involved in the negotiation and implementation of the consultant contract will have developed a detailed understanding of the job planning process and how it can work for consultants, patients and the service in general. Forward thinking trusts will want to utilise this knowledge. Job planning itself has been developed in conjunction with CCSC over 16 years and the BMA runs seminars promoting its principles to consultants.
A week in the life: 10 August
(13:00 - 14:00) HR Director re. disciplinary case
The DH document “Maintaining High Professional Standards” was negotiated with national BMA consultants’ representatives, bringing the disciplinary procedures up to date. Central components of the procedures are to refer consultants to the National Clinical Assessment Service and to the General Medical Council. Both these bodies rely on consultants working on external duty PAs to perform much of their work – fundamental to maintaining safety and quality standards in the NHS.
(14:00 - 15:30) Information giving session on CEAs, Discretionary Points and Distinction Awards
(Boardroom)
Consultants who participate in the CEA process in any meaningful way will be able to contribute toward such a session. In particular, those involved in the CCSC’s national or local negotiating functions over recent years will be likely to have a good working knowledge of the system and its failings and have ideas on how the scheme might operate more successfully at a local level.
A week in the life: 11 August
(09:00 - 17:00) BAMM Medical Leaders Professional Council - London
Many consultants who are, or are preparing to be, clinical or medical directors take part in BAMM’s work. This is a central part of educating and training the clinical managers on whom the NHS relies. BAMM policies and guidance are written by consultants combining service expertise and their activities as part of a professional body and these are a valuable resource for the NHS.