New contracts were recently accepted across the devolved nations of the UK as the basis for all future consultant employment in the National Health Service (NHS). All existing consultants have the choice of transferring to the Terms and Conditions of Service 2003 (Department of Health, 2003) or remaining on their existing contract.

The new contract’s basis is that consultants perform ten programmed activities (PAs) a week, typically each of 4 h duration. The European Working Time Directive (EWTD) requires employees working more than 48 h a week to opt-out, in writing, of statutory protection. As PAs performed in premium time (19.00-07.00 h) are of 3 h duration, an EWTD-adherent job plan can comprise more than 12 PAs without requiring the use of the opt-out.

The job plan is an agreement between the employer and employee over what activities will take place, for how long and where, and agreement is made annually. Guidance exists as to how many PAs should be allocated to different types of work and these are defined in the terms and conditions: direct clinical care, supporting professional activities, additional responsibilities, other duties and external duties. The terms and conditions specify that typically consultants should have 2.5 supporting professional activities, and up to 7.5 direct clinical case activities.

Effective job planning

To job plan successfully, consultants will need to keep a diary of all their activities (NHS Modernisation Agency, 2003). Ideally, this should be compiled over a period long enough to be representative. Thus, where bimonthly clinics occur then 2 months is required; if every week were the same, then 1 week would be sufficient. Where there are irregular obligations, such as College work, interview panels or other duties, it is possible to annualise them, and then break them down into weekly fractions of a programmed activity. For example, 3 days as an examiner for one of the Colleges should be recorded as the number of PAs spent examining, including the travel time, premium work and related administration. Thus, ten PAs, or more, might be involved per year.

Of the 52 weeks in the year, 10 weeks are lost to annual/study leave and public holidays. For the job plan, these ten PAs occur over a 42-week period, equal to 0.24 (10/42) of a PA per week, and similar arithmetic can be applied to all responsibilities. Unfortunately, the failure of employers to adequately recognise the time involved in College activities, for example, is commonplace (Chaudhray, 2004; Reference WalkerWalker, 2004).

In some trusts, directorate-wide agreements on aspects of job planning have been reached. Examples include agreements that supporting professional activities may be conducted off-site or flexibly (e.g. continuing professional development performed at weekends or in the evening, or that direct clinical care may be cancelled to lecture at local courses). Producing College guidelines can be persuasive; the Senate of Surgery (personal communication) has written to the Director, Human Resources, Department of Health, that all on-call surgeons must be available to return to work immediately (band A), because of the needs of trainees and patients.

Table 1. Programmed activities and related work

Activity	Example	Band
Direct clinical care	Emergency attendance	C1
	Out-patient or other clinic	C2
	Ward round	C3
	Other patient treatment or relative consultation	C4
	Telephone advice to hospital	C6
	Multidisciplinary meeting about direct patient care	C7
	Investigative, diagnostic or laboratory work	C8
	Travelling time between sites	C10
	Patient administration	C11
Supporting professional activities	Training	S1
	CPD	S2
	Teaching	S3
	Audit/clinical governance	S4
	Job planning/appraisal	S5
	Research	S6
	Clinical management	S7
Additional responsibilities	Caldicott guardian	A1
	Audit/clinical governance	A2
	Clinical tutor	A3
	Medical/clinical directors and lead clinicians	A4
	Additional responsibilities	A5
Other duties or external duties	Trade union duties	D1
	AAC external member	D2
	NCAA, GMC, HC	D3
	Work for Colleges	D4
	Other	D5

When a disagreement is about other duties, consultants could point out that the Director of Human Resources for the NHS Executive stated in his letter (EL (95)93): ‘I would like to encourage employers, as part of their obligations as part of the NHS, to release consultants for a range of duties such as advising the DoH, participating in college duties or examining. These are examples of work necessary for the broader benefit of the NHS but which involve consultants being away from their employment base’. The Modernisation Agency’s Consultant Contract Implementation Team made the same points (NHS Modernisation Agency, 2004a).

Difficulties in reaching mutual understanding

Some trusts are reluctant to implement the job plan supplied. Management may identify inappropriate work patterns or activities; however PAs in excess of ten may legitimately be necessary for a wider service. Where an impasse is reached and both parties cannot agree on which PAs can and should be removed from the job plan, such as a clinic, emergency cover, etc., a request for mediation can be made. This should be made in writing to the medical director, with an explanation of what the areas of disagreement are and why the proposed job plan is unreasonable. If the medical director had been directly involved in the decision not to implement the proposed job plan then it would be inappropriate for them to mediate. Where practitioners have access to an employment advisor or union representative their advice and support is best sought at an early stage.

Mediation can be valuable; examples include clarification of a mismatch between non-clinical managerial expectations and those of clinical directors; clarity over time commitments expected of the consultant or flexibility in clinical work that had not been previously agreed between the parties.

If agreement cannot be reached at mediation there remains formal appeal (NHS Modernisation Agency, 2004b). The appeals process involves a chairperson nominated by the employer, not previously involved in the dispute, a representative nominated by the consultant and a third member from a list agreed between the Strategic Health Authority and the British Medical Association. This panel will consider written and oral evidence and make a written recommendation to the employing organisation. Where there is significant disagreement within a directorate about job planning the prospect of multiple appeals could be daunting to management.

Conclusion

Job planning is a time-consuming and intensive experience, but proper preparation and commitment to delivering quality care can produce a better understanding of the time involved for both trusts and consultants. This becomes the foundation for a mutually acceptable solution. Persistence in explaining the necessary commitments can produce results that profit all parties.