1. Abstract
Performance-related pay for senior doctors takes the form of Clinical Excellence Awards (CEAs) in the National Health Service. Despite modest reforms, CEAs have been subjected to limited assessment in terms of their effects on motivation and performance. Through empirical research we examined the current decision-making around Clinical Excellence Awards (CEAs) and what they indicate about the nature and extent of power and pay reform in the medical profession. A rapid review of extant evidence relating to medical power gave rise to four themes that provided the framework for observations (Broadly, they were; format/content, excellence/performance standards, purpose, process/decision-making). An observational study of CEA committees was undertaken in 2014 and 2015. Thirteen committee meetings were observed including national, regional and local awarding bodies. We saw how medical power operated in these meetings and how the uncertain future for these awards affected decision-making. We also discerned new tensions between medical power and challenges to it, centred on control over the decision-making processes and on notions of `medical excellence.’ Medical power may be threatened but we also see how the profession is absorbing such challenges albeit with ramifications for its own members.
2. Introduction and background
· Clinical Excellence Awards (CEAs) were introduced in 1948 as part of the settlement between the government and medical profession to ensure that the latter participated in the NHS.
· Now, 61% of eligible doctors receive an award. The scheme costs over £500M pa.
· The CLEAR team previously undertook an analysis of the submissions to the DDRB consultation on reform to CEAs. Further research is planned.
· This study involved an empirical study of the ways in which clinical performance is defined, interpreted and implemented in the committees allocating CEAs to medical consultants.
The work followed a preliminary documentary analysis (funded by RHUL School of Management) of responses to the consultation on the future of CEAs.
3. Aims
The aim of the study was to explore the medical profession’s power in shaping, interpreting and implementing CEAs as a tool of performance management and as a financial incentive scheme. CEA meetings at national, regional and local levels were observed to explore ways in which ‘official’ definitions of performance were interpreted and applied.
· Empirical aims: To examine the ways in which decision-making processes about CEAs were shaped, interpreted and implemented by national, regional and local committees.
· Theoretical aims: To explore the impact of intrinsic and extrinsic motivation of financial incentives, the salience of power of the medical profession, the role of strategic HRM, and the definition and application of ‘excellence’ in determining performance related pay.
4. Methods
· Between March 2014 and February 2015, we conducted an empirical study into the ways in which clinical performance is defined, interpreted and implemented in the committees allocating CEAs. Ethical approval was secured through Durham University.
· Study design: Observational study of a purposive sample of 13 committees, including national, regional, local and Royal College committees. Meetings lasted between 35 minutes and 3 hours.
· Data collection: We wrote extensive contemporaneous field-notes which were later transcribed in full, then coded according to a priori and emergent themes. Cross-case analysis was then undertaken.
5. Findings
We recognise that a lot of work goes into preparing and scoring these applications before they are presented to the committee for consideration. The findings relate to CEA committee decision-making.
· Board format and content: Committee membership is supposed to be 50% medical, 25% lay and 25% management; this was rarely met. External sources of authority were frequently invoked and members often deferred to the senior doctor. Regional and national meetings had more consistency of membership (and so, perhaps, more expertise).
· Defining excellence: There was some difficulty in comparing across the 5 domains of CEA applications. Some highlighted difficulties in demonstrating excellence in certain medical specialities (eg. psychiatry, anaesthetics), noting certain specialties (eg. academics) were being rewarded for simply delivering their job plans. There was some unease and uncertainty about the effectiveness and fairness of the scoring system (eg. attribution of applicants’ claims).
· Purpose of CEAs: There was considerable difficulty in establishing what activities were ‘over and above’ contractual duties. Discussions sometimes concerned recruitment and retention and the use of CEAs as an extended career ladder.
· Decision-making process: There were common problems with scoring and the appearance of objectivity. Different approaches (often ad hoc) were used to try to compensate for differences between scorers. Questions were raised about equity between applicants, with the perception that it is easier to get awards in some geographic areas. Standards of governance varied greatly.
· Uncertain futures: There was much discussion about the uncertain future of the awards in the face of wider NHS austerity. Differences between national and local awards often put pressure on local committees. The potential for appeals also affected decision making.
6. Implications and recommendations
a) Board format and content: Managers and lay members took little part in decision-making. One recommendation is to encourage the active participation and involvement in decision-making of managers and lay members.
b) Defining excellence: CEAs celebrate excellence quietly. Some committees were cautious about publicising awards. One recommendation is to consider the opportunity costs of rewarding non-medical staff and the effects on morale of NHS workers more broadly of CEAs. Also, excellence is measured across 5 domains but that doesn’t recognise interdisciplinary and collaborative work. Individualists are rewarded. A recommendation is to find a way to value the work of collaborative clinicians.
c) Purpose of CEAs: There was an uncertainty about the justification for CEAs and questions about whether CEAs and its decision-making process are still fit for purpose. The overall cost of CEAs was questioned especially by Trusts. Some Trusts were exploring new ways of rewarding all staff not just doctors.
d) Decision-making: Whilst the decision-making of the committees was transparent rules of governance were not applied consistently. There was some question about the process and utility of scoring. The scoring was often adjusted in an ad-hoc way in meetings often in an effort to ensure fairness. One recommendation is to be less reticent about using the expertise of the panel to ensure the best applicants receive awards not just the highest scorers.
e) Uncertain future: CEAs come under regular review. Although changes are proposed previous attempts to reform have been unsuccessful. One recommendation is to align CEAs to desired performance.
Further information: please contact· Professor Paula Hyde:
· Professor Mark Exworthy:
· Pamela McDonald-Kuhne:
Acknowledgements: We are grateful to the British Academy of Management (www.bam.ac.uk) who funded this project through a Researcher Development Grant. We thank the committees who allowed us to observe their deliberations.