education and skills
creating opportunity, releasing potential, achieving excellence
A Review of Appraisal, Disciplinary and Reporting
Arrangements for Senior NHS and University Staff
with Academic and Clinical Duties
A report to the Secretary of State for Education and Skills,
by Professor Sir Brian Follett and Michael Paulson-Ellis
The inquiry into Alder Hey Children’s Hospital, Liverpool, exposed some terrible events there. David Blunkett, then Secretary of State for Education and Employment asked Sir Brian Follett and Michael Paulson-Ellis to review the appraisal, disciplinary and reporting arrangements for joint appointments between the NHS and universities. Deficiencies in these arrangements were seen as a major problem at Alder Hey. Both the universities and the NHS were determined to ensure that there would never be another Alder Hey. This report is the outcome of the review.
John Hutton, Minister of State at the Department of Health and I are grateful to Sir Brian and Mr Paulson-Ellis for their work and welcome the report as a valuable contribution to solving difficult and long standing management issues.
Looking forward, we expect the implementation of the recommendations of this report to support more effective relationships between the universities and the NHS. Relationships that will benefit not only the managers and staff, but most importantly, patients.
But this report is just the beginning. It is now for the Department for Education and Skills along with the Department of Health and the National Health Service to work with the universities and trusts, and all other representative and professional bodies with responsibility for the medical and dental services in this country, to ensure that the recommendations of the report are implemented. John Hutton and I will be looking for real and positive progress towards full implementation of the recommendations by the end of this year. Any other outcome is not an option.
Minister of State for Lifelong Learning and Higher Education
CONTENTS Page No.
Summary of Recommendations 4
Scope of review 6
A corporate framework for relationships between the 9
NHS and the University
Accountability of staff 10
New and replacement posts 12
Contracts of appointment 14
Appraisal and performance review 15
Disciplinary procedures 19
Flexibility in the clinical academic contract 21
The clinical academic contract – special situations 22
Dental Schools 23
Appendix A 26
Appendix B 29
Appendix C 30
Review of appraisal, disciplinary and reporting arrangements for senior
National Health Service (NHS) and university staff with academic and clinical
Summary of recommendations
; The key principle for NHS and university organisations involved in medical
education and research should be ‘joint working to integrate separate
responsibilities’ (Paragraph 13).
; University and NHS partnerships responsible for medical education and
research should establish joint strategic planning bodies, with joint subsidiary
bodies responsible for staff management policies and procedures for staff
with academic and clinical duties (Paragraphs 14-17).
; Universities and NHS bodies should formally make all senior NHS and
university staff with academic and clinical duties fully aware to whom they are
accountable for the separate facets of their job (Paragraphs 18-23).
; The key principle of joint working to integrate separate responsibilities should
be applied to the management of senior NHS and university staff with
academic and clinical duties (Paragraph 24).
; The job descriptions for new and replacement senior NHS and university staff
posts with academic and clinical duties should be jointly prepared and
formally agreed by both partners prior to advertisement (Paragraphs 26-30).
; Appointments to senior NHS and university staff posts with academic and
clinical duties should be jointly made under procedures agreed by the
partners (Paragraphs 31-38).
; NHS regulations for consultant appointments, as well as those of the relevant
university, should be applied to selection committees for clinical academic
posts involving honorary consultant appointments (Paragraph 33).
; Substantive and honorary contracts for senior NHS and university staff posts
with academic and clinical duties should be explicit about separate lines of
responsibility, reporting arrangements and staff management procedures, and
should be consistent, cross-referred and issued as a single package
; The substantive university contract and the honorary NHS contract for clinical
academics should be interdependent (Paragraph 41).
; Universities and NHS bodies should work together to develop a jointly
agreed annual appraisal and performance review process based on that for
NHS consultants, to meet the needs of both partners (Paragraphs 46-60).
; The process should:
a. involve a decision on whether single or joint appraisal is appropriate for
every senior NHS and university staff member with academic and clinical
b. ensure joint appraisal for clinical academics holding honorary consultant
contracts and for NHS staff undertaking substantial roles in universities;
c. define joint appraisal as two appraisers, one from the university and one
from the NHS, working with one appraisee on a single occasion;
d. require a structured input from the other partner where a single appraiser
e. be based on a single set of documents; and
f. start with a joint induction for those who will be jointly appraised
; Associated universities and NHS bodies should jointly prepare a formal
agreement on the procedures for the management of poor performance and
for discipline to be followed for senior NHS and university staff members with
academic and clinical duties (Paragraphs 61-66).
; As a minimum, these procedures should:
a. ensure joint working in the process from the time implementation of it
is first contemplated;
b. specify which body is to take the lead in different types of cases;
c. ensure suitable cross membership of disciplinary bodies; and
d. be expeditious (Paragraphs 62-63).
; The current review of the NHS award scheme for consultants should remove
barriers to the full participation of clinical academic staff with honorary
contracts (Paragraphs 67-68).
; The recommendations in this report should apply equally to Dental Schools,
with appropriate modifications to take account of their special features
; Implementation of our recommendations should be facilitated by structured
joint national action initiated by the Department for Education and Skills and
the Department of Health (Paragraphs 78-84).
; Universities should consider new formal and informal means of collective
action to assist them in implementing our recommendations (Paragraph 80).
1. When presenting the Report of The Royal Liverpool Children’s Inquiry to the thHouse of Commons on 30 January 2001, the Secretary of State for Health said that one of the resulting actions would be the establishment by the Secretary of State for Education and Employment of a review of the accountability and management arrangements between NHS Trusts and Universities where senior staff are employed on joint contracts.
2. We were appointed in March 2001 to undertake this review and following discussions with the Departments of Education and Employment and of Health our Terms of Reference were agreed as follows:
; To review the arrangements for managing consultant medical and dental
staff holding contracts (whether honorary or substantive) with both the
universities and the NHS to undertake academic and clinical duties; and in
particular to examine the procedures for appraisal, discipline and reporting.
In doing so, the review will want to take account of appointment procedures
and contracts of employment; and
; To make recommendations.
3. It will be noted that these Terms of Reference are limited to particular aspects of the accountability and management arrangements for defined groups of university and NHS staff.
4. On 30th March 2001 we circulated information about the review and an open invitation to contribute to it. This circulation resulted in a wide range of submissions from representative bodies, individual NHS and university institutions, and individuals. We are grateful to all those who took the trouble to write to us. We also arranged meetings with a number of representative bodies and NHS and university institutions, which proved most helpful and informative. A full list of the contributions and meetings is included in Appendix A.
5. There have been many reports in recent years which touch on the issues we have been asked to review, and we have benefited from our reading of them. We have been particularly impressed by and commend for further attention the recent report of the Nuffield Trust Working Group on NHS/University Relations entitled University Clinical Partnership: Harnessing Clinical and Academic Resources, as well
as Clinical Academic Careers, the report of an independent task force chaired by Sir Rex Richards, published in 1997. Both emphasise the necessity for robust relationships between the NHS and universities if medical education and research are to be delivered, and highlight the peculiar problems faced by clinical academics who appear to have two posts with separate employers and yet actually have a single professional job. A full list of the reports we have consulted is at Appendix B.
Scope of review
6. The principal group of staff covered by our terms of reference are senior clinical academics who are employed by a university but hold an honorary consultant contract in one (or more) NHS body for clinical service. We estimate (CHMS Survey
of Clinical Academic Staffing Levels in UK Medical and Dental Schools, March 2001)
that some 3,250 professors, readers and senior lecturers are employed on this type of contract in the UK. The salaries of about 50% of these are supported by Funding Council funds, 33% by NHS funds and 17% by funds from other sources, principally
the research councils and medical charities. Any distinction awards payable to these staff are centrally funded by the NHS. At a more junior level – clinical lecturer and
clinical researcher – there are a further 2,500 staff, 17% supported by Funding
Council funds, 20% by NHS funds and 63% by other, usually research, funds. We have not considered those staff who do not hold an honorary consultant contract in our report although many of the principles apply equally to them. Towards the end of the report we offer specific observations upon academic staff in Dental Schools where the situation is slightly different. The second group of staff covered by our terms of reference is the many thousands of NHS consultants who hold honorary teaching (and occasionally research) contracts with their local university. In these cases the teaching commitments are rarely more than one session per week. We note that under the terms of NHS SIFT agreements, NHS bodies must contribute to teaching and training of medical undergraduates.
7. We are aware that there are other groups of staff who hold contracts both with the NHS and with universities. In particular the development of education for the health professions means that there are clinical academic posts in nursing and midwifery, the therapies, and other professions. Many non-clinical researchers who interact with individuals in a way that has a potential bearing on patient care also have honorary NHS contracts. Our terms of reference do not cover these staff, but since our report sets out principles to be applied to staff management, it should be readily possible for universities and NHS bodies to consider how far our conclusions are appropriate to these groups.
8. In dealing with the issues raised by our terms of reference, it is important to be clear about the broad context in which NHS bodies and universities work. While individual NHS bodies have a measure of independence, they are all part of a large organisation where central management can determine objectives and procedures, and can give instructions which are mandatory on the bodies. Many such instructions exist in respect of staff management. Universities on the other hand are legally independent and autonomous bodies. Many aspects of their work are subject to central assessment and sometimes regulation, principally by the Funding Councils, but this does not apply to staff management matters, in which universities remain independent except insofar as they voluntarily enter into collective agreements. Exceptionally, standard provisions for staff redundancy, discipline and grievances were imposed on chartered universities in the early 1990s as a result of primary legislation. A further important point is that relationships between universities and the NHS bodies who are their partners in medical education and research vary considerably, and with the current development of new medical schools further new models are being created. Thus so far as universities are concerned our recommendations will fall to be implemented individually by institutions which will need to fit them to their legal structures and existing staff management procedures. Our report is concerned only with the situation in England, although our conclusions may well be applicable in the rest of the UK.
9. Medical education is no longer restricted to partnerships between a university and one or more teaching hospitals. In recent years there has been considerable development of partnerships and networks with other NHS organisations, including health authorities and community and primary care organisations. Academic general practice in particular is playing an increasingly important part in medical education. It is for this reason we refer in our report to NHS bodies rather than hospitals or trusts.
10. Given all these facts, we have confined our report to the principles which we believe should be applied to the various issues we raise. Assuming our recommendations are accepted, the NHS and universities and their collective bodies
will have to decide what measures and processes are necessary to ensure that they are implemented. We say more about implementation at the end of our report.
11. Our review focuses upon the present and future and specifically does not address the situation, and any failings, in the past. It is proper, however, that given the origins of our inquiry – events which occurred at The Royal Liverpool Children’s
Hospital (Alder Hey) – we should note at the outset the key findings and
recommendations from the subsequent Redfern Report. The essential problems lay around:
; The initial resourcing of the post held by Professor van Velzen, the method
of appointment, the implementation and supervision of a job plan;
; Failings in clinical service;
; Failures over many years to follow up on formal complaints and implement
proper disciplinary procedures;
; A failure to catalogue stored organs; and
; Failings in delivery of research which was part of the justification to collect
The Redfern Report offered a number of specific recommendations on staff management issues (set out in full in Appendix C) and these centre upon:
; Relationships between universities and NHS bodies;
; Appointment, job description, formal annual appraisal, joint procedures for
; Resourcing of academic appointments; and
; Management standards and audit.
12. Our report and recommendations begin with two key issues, the relationship between universities and NHS bodies, and accountability. We then move progressively through the various stages involved in creating clinical academic and other posts, making the appointment, ensuring delivery on all facets of the contract and dealing with those rare but regrettable instances when disciplinary procedures have to be invoked. Working together on these tasks will heighten the sense of responsibility for the common enterprise. It will ensure the creation of robust arrangements for this enterprise that will stand alongside and integrate the separate responsibilities of the partners. We emphasise throughout that a clinical academic post is a single job held by a whole person, not two jobs held by two different half persons in one body. The objective is to have (both for the individual and for universities and NHS bodies) clear, unambiguous, jointly agreed arrangements which are in harmony.
A corporate framework for relationships between the NHS and the University
13. The key principle of our report is to recognise that NHS bodies and universities have separate responsibilities for medical education and research and for their associated clinical service, but that neither can fulfil these responsibilities without close joint working with the other. As the Funding Councils’ Joint Medical Advisory Committee said to us 'first, we remain convinced that medical and dental education and research will only flourish when both universities and the NHS express and realise their joint ownership of this activity. The second general principle underpinning best practice that we would highlight is transparency and openness.' This interdependence is expressed in our first recommendation that:
; The key principle for NHS and university organisations involved in
medical education and research should be ‘joint working to integrate
14. We are clear that putting 'joint working, separate responsibilities' into practice requires a strong corporate framework. Good personal and professional relationships between senior NHS and university staff are essential, but not sufficient. Similarly cross representation on the key governing bodies of the partners is unlikely by itself to provide an adequate structure. Nor is liaison and consultation sufficient: if anything it tends to reinforce separateness. We do not propose a single model to be applied in all circumstances, since those circumstances vary widely. The recent reports to which we have referred have addressed these issues and include many examples of good practice. Generally speaking relationships between NHS bodies and universities are good, but they are still characterised by a lack of clear accountability. This is in marked contrast with the quite unequivocal responsibility that has been formally placed over the last decade or so upon the NHS Chief Executive (for health service delivery and financial probity) and upon the University Vice-Chancellor (for the delivery of teaching and research and financial probity). As a result they, let alone the clinical academics, require a much stronger corporate framework in which to operate.
15. We therefore believe that there should be a joint body responsible for managing local NHS/university partnerships. We have already mentioned the partnerships and networks that some medical schools have with a range of local NHS bodies and with general practitioners. It would be for each institution to decide whether to incorporate all of these into a single body or whether to have a number of bilateral ones. The joint body would develop the strategic vision of the partnership, ensuring that it is aligned with the strategic direction of the individual partners, and then establish objectives to deliver that vision and procedures to ensure that delivery takes place. These would need to be recorded in formal agreements and other appropriate documents.
16. This joint body should be supported by a number of subsidiary bodies responsible for joint working in individual areas. These will doubtless vary from place to place, but might cover topics such as research, education, and estate and services management where university and NHS facilities are integrated. One such body is however essential: to cover human resources matters for those staff of both partners who have responsibilities both in the NHS and in the university. It would be responsible as a minimum for the development and documentation of agreed procedures in the topics covered by our report and for overseeing their implementation. Its objective must be to improve the management of individual staff, not to be yet another administrative structure.
17. The aim of these joint bodies, in the words of one of our correspondents, is to be 'a corporate framework for handling the issues of relationships between the University and Trust hospitals in respect of matters which have traditionally been contained locally'. There is a very real risk that the pressures of service delivery on the NHS, and of the delivery of education and research on universities will result in them growing further apart. Active joint working is necessary to combat this, and to contribute to a better understanding of each other's institutional cultures and preoccupations. Indeed we understand that NHS bodies have a 'duty of partnership' in many of their dealings with other organisations. Partnership in the enterprise of medical education and research is what we wish to see as the basis for working methods in the future. We therefore recommend that:
; University and NHS partnerships responsible for medical education and
research should establish joint strategic planning bodies, with joint
subsidiary bodies responsible for human resource policies and
procedures for staff with academic and clinical duties.
Accountability of staff
18. The real difficulties with clinical academic positions are that the individual, while formally employed by a university, has responsibilities that involve more than one organisation. It is normal for all academics in research-intensive universities to have ‘more than one job’ in the sense that each individual undertakes (i) teaching (to undergraduates and to postgraduates), (ii) research and (iii) administrative and management duties. The situation in a medical school is even more severe since a fourth component – clinical service – is also undertaken by virtually all clinical
academics. They normally spend six weekly sessions on clinical service and five sessions on the academic duties of research and teaching (we return to this distribution of time later in our report). Management and administration is spread across all three major roles. Clinical academics must remain in medical practice, as it is essential for their teaching and research. However, it is also true that by undertaking medical practice individuals assure themselves of being remunerated on clinical academic rather than on academic scales – a noticeable upward
differentiation - whilst if they undertake a minimum of six sessions of clinical work they are additionally eligible for full NHS distinction awards and discretionary points. To add to the complexity the individual is effectively working for two employers – the
NHS whilst undertaking service, the university whilst undertaking teaching and research. The lines are traditionally blurred and the priorities interwoven.
19. A special challenge is the potential conflict that can arise between service on the one hand and research and teaching on the other. This is exacerbated in the many cases where the individual may be a university employee but his or her post is fully funded by the NHS. The NHS will also be funding support services for the individual’s post which can be as expensive as his or her annual salary.
20. Many efforts have been made over the years to resolve this complexity, as will be clear from the reports to which we referred earlier. Most point out that a number of factors are required for the individual to deliver well on all fronts. One is that the overall workload should not be excessive; yet evidence suggests that individuals choose to do too much on too many fronts. Another is that with the recent changes in the NHS – acutely demonstrated by the new requirement from April 2001 that consultants be appraised annually – the importance of quality and quantity of clinical
service has become even more paramount.