Personal View: What's wrong with having more than one consultant grade?
Authors: Richard Hayward
Journal: BMJ (2004)

At the age of thirty something, budding specialist registrars can expect to become a consultant—a post they may occupy for the next 30 years. But once they have reached this dizzy height what challenges remain to them in terms of career progression? The answer, of course, is none. Consultant-hood is a plateau. There is no higher grade. My own experience, after my appointment as consultant, was one of anticlimax. What was I to do next? Of course my new responsibilities were a challenge: I wanted to establish myself, in my own eyes and among my peers. I ploughed on, but I confess now to having felt not a little depressed. I'd worked so hard to get my new position, and now there was this sudden gap in my life. How was I to fill it?


My experience, after appointment as consultant, was an anticlimax


There were various possibilities. I could lie back and do as little work as possible while I concentrated on non-medical life—on my family, perhaps, a novel idea for a surgeon. After all, in those far off days (before the new consultants' contract), the obligation to do any work at all was little more than hinted at in the contracts I had to sign. Or there was private practice. Servicing rusty necks and lumbar spines would provide steady if unchallenging opportunities for enrichment. Or there was research—an avenue made easier for consultants with appointments to undergraduate and postgraduate teaching institutions.

But what about further advancement? It was after all the lure of promotion that had been my major stimulus so far. It turned out that two financial advancements were then (and are now) available under the NHS. One required no more than that I stayed alive—in which case a small addition would be made to my salary each year for the next so many years, after which the additions would cease. The other did require some activity. I would be eligible for what was then unblushingly referred to as a “merit” award. These awards remain an iniquitous system, despite attempts to define more clearly the qualifications required for them and to make their dispensing more transparent. Back in the early 1980s, the criteria for advancement were (in no particular order) sex (male), race (white), specialty (surgical), age (“Your turn, old chap”), location (London), and hospital (teaching). With a full house, your “C” and “B” awards were pretty well assured—and confidentiality (a euphemism for secrecy in this situation) guaranteed.

Despite improvements, the system (now renamed clinical excellence awards) remains unpopular, because it still depends on secret internal peer review, and now there is the added risk of potential contamination from managerial involvement. I sit on the relevant committee of the hospital where I work. The business is dealt with fairly, but at the same time it is impossible not to sympathise with people whose bids are unsuccessful and who effectively remain in the dark as to why: “Am I on the wrong side of so-and-so?” “Is it because I'm in the 'wrong' specialty?” “Why did she get one this year and not me?”

How can these two problems—clinical excellence awards and the lack of rungs on the competitive promotion ladder—be reconciled? Simple. Instead of having a single level of consultant there should be several, the number to coincide with the levels of clinical excellence award. Newly appointed consultants will start off, as now, on the lowest rung of the ladder. But then, with ambition unchecked by having effectively reached a promotion ceiling, they can, if they so wish, work for advancement to the next level—and the next and the next, and so on up the greasy pole.

And where are these new levels to be found, and what do they represent? Here is an example. A hospital trust needs, say, 10 consultant surgeons. The health department has already suggested that a consultant's life in that grade can be divided into stages that broadly coincide with age and experience: finding your feet and being immersed in service delivery; teaching and training; and finally a broader, more strategic, and perhaps administrative, role. Our trust may decide that it needs (and is prepared to fund) four grade “pre-Cs,” two “Cs,” two “Bs,” two “As,” and no “A+”—with appropriate contracts to match. A consultant at grade C decides that the time is right to move up to grade B. He scans the journals and finds that an adjacent trust is advertising for a consultant surgeon at grade B; or perhaps promotion in his own trust has left a grade B position vacant and he can apply for that. In any event, the advertisement is open, the application is open, and the appointment is open. Competition for the higher grades becomes more intense, just as it does for the higher clinical excellence awards, but all is as transparent as that first consultant appointment with which we are all familiar now.

Two problems solved for the price of one. Now that's what I call cost effective!