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National Health Service History
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Introduction The sixth decade of the NHS, 1998-2007, saw major changes in medical education, staffing and the roles of doctors.
Since the early days of the NHS there have been attempts to
Medical Schools and medical education The planning of doctor numbers, some 100,000 out of more than a million workers in the NHS, has been a concern of the centre since the earliest days of the NHS. The results of centralism, understandable because government is responsible for the costs of medical education and is also the main employer of doctors, have often been unfortunate. The 1968 Royal Commission on Medical Education (Todd) recommended a doubling of medical school intake to 4,230 to be achieved by 1980, numbers not achieved until 1992. Reviews were often based upon pessimistic assumptions about growth in health expenditure, rather than changes in the size of the population or the services that were needed. Treasury insistence on limiting expenditure and professional concerns about medical unemployment went virtually unchallenged. Small increases were suggested by the Medical Manpower Standing Advisory Committee from 1991 onwards but during the sixth decade of the NHS policy altered. From 2000 onwards, plans to improve the capacity and quality of the NHS were crucially dependent upon professional staff, doctors and nurses and it was clear that there were too few. A major expansion of training facilities (see below) was set in hand. (see Smee C, Speaking Truth to Power, Nuffield Trust 2005) In view of the increasing workload, and the working life of doctors (30 years for a man and 22 for a woman) the third report of Medical Workforce Standing Advisory Committee proposed in 1997 that the UK should aim for self-sufficiency. It concluded that the annual student intake should be increased by 1,129 above the 1996 figure of 4,820, in the most cost-effective way as soon as possible. When in July 1998 Labour announced substantial additional money for the NHS, some was earmarked for the proposed expansion of medical (and nursing) education. However the enlarged intake coincided with a resource reduction from university sources for many medical schools, particularly as the money from research grants fell. The Schools felt that they were being expected to train more students at the same time as they were having to make medical school staff redundant. The problems of Academic Medicine were highlighted in the CMO's annual report on the State of the Public Health for 2004. Medical student expansion was partly by increasing the size of existing schools and partly by establishing new ones, the University of East Anglia and the Peninsula Medical School (Plymouth and Exeter). The NHS Plan (2000) promised a further increase of 1,000 in medical school places to nearly 7,500. The Joint Implementation Group, joint between the HEFCE and the Department of Health, decided that the additional places should be allocated through a competitive bidding process and invited bids by 1 December 2000. The allocation took into account regional priorities, innovation, quality, graduate entry, widening participation, and value for money Universities scrambled to secure some of the new students, and the money that went with them. The pattern of medical education had changed radically, as indicated by a map prepared by the HEFCE. There had been no new schools for 30 years. In June 2000 and March 2001 Alan Milburn announced further medical school schemes. Three years running the Higher Education Funding Council for England invited bids for the additional places, in 1999, 2000 and 2001. In London major organisational changes were taking place as medical schools expanded and merged within multi-faculty colleges (see Hospital Services and London). A welcome but abrupt rise in numbers took place. Between 1997-98 and 2006-07 there was a 71 per cent increase in medical school places. Intake to English medical schools increased from 3,749 in 1997-98 to 6,194 in 2006-07, partly as a result of four new medical schools, and four new medical centres of education three of which were established in collaboration with existing medical schools bringing the number of medical schools in England to 24. The Joint Implementation Group continued to attempt to fine-tune the numbers, planning an intake of 6078 for 2005/6 in England (including overseas students) plus of course students at the universities in Scotland, Northern Ireland and Wales. Additional bids for 100 places were sought, particularly in areas of the country with a shortage of doctors. Schools that in 1948 had an annual entry of perhaps 100 might now have 300-400. 59% of successful applicants were women. Alan Maynard was scathing about the policy of self-sufficiency, seeing ‘nothing wrong with employing people trained in excess by misguided foreign states’.
Several medical schools aimed to 'widen participation' in medical education. The Universities of Bradford and Leeds established a collaborative scheme to recruit students from a broader range of social and ethnic backgrounds. Birmingham sought to attract an increasing number of students from local, socially deprived areas. The enlarged intake would increase the number of new doctors in training, contributing to the delivery the Government's NHS Plan commitments. The four new medical schools took full advantage on the reforms the GMC wished to see, integration of basic and clinical sciences, use of community settings for teaching, early contact with patients, and a wider basis for student selection. previously without a medical school lacked the experience of older established institutions. Each claimed that it was a joint venture with the NHS, but schools might not understand the close linkages of service and education, and the need to ensure that student placements matched the clinical linkages and networks that existed, or would need to be established. They appointed staff from a dwindling pool of academics, stressed the role of the community in teaching, encouraged joint training of medical, nursing and other health professions and developed their facilities. None had a problem in attracting applicants, widening the entry to graduates of other disciplines and those from access courses; for example Guy's Kings and St Thomas' (GKT) formed links with local schools to recruit bright students on the basis of their suitability for medical training, rather than performance at A level. Such extra medical places had a focus on opening up a career in medicine to students from middle and lower income families. The move from student grants to student loans was thought to have led to the entry of more students from a middle class background, and in allocating the new places the Government tried to ensure that they went to campuses where it would be easier to recruit students from a wide social and ethnic range (e.g. Leeds at Bradford), and which served poorer parts of the country. (In 1998 more students from social class one were accepted into medicine than the combined totals of classes 3,4 and 5.) Progress was summarized in a document from the Chief Medical Officer, Medical Schools - Delivering the Doctors of the future.
A number of proposals met the objective of widening participation:
District general hospitals, general practitioners and heath centres were used even more widely for student education and the presence of a new medical school was an aid to consultant recruitment. The enlarged intake coincided with a resource reduction from university sources for many medical schools, particularly as the money from research grants fell. The Schools felt that they were being expected to train more students at the same time as they were having to make medical school staff redundant. The problems of Academic Medicine were highlighted in the CMO's annual report on the State of the Public Health for 2004. In 2007 the University of Birmingham was commissioned to carry out an independent review into the expansion of medical school student numbers and reported on the many changes, including the increased number of mature entrants and reduced number from social classes 1 and 2. The University of Buckingham - a private university - planned the UK's first private medical school, to open in 2008 and provide a postgraduate qualification. Changes to the curriculum Medical student education was changing and, in line with guidance from the General Medical Council in 1993 (Tomorrow's Doctors) emphasis on factual knowledge decreased, and more stress was placed upon self-learning, communication skills and sociological understanding. The GMC guidance was revised in 2003 and continued to stress touchy-feely qualities as well as the need for a knowledge base, and keeping up to date. The medical student's curriculum tried to integrate scientific knowledge and clinical practice from the earliest weeks and to encourage students to be problem solvers. Education became "topic" based and students were increasingly learning outside the walls of the teaching hospital. Problem based learning, and teaching across professional disciplines was introduced particularly in the new schools. The foundation in biomedical sciences now included cell biology, molecular biology and genetics; and in the US the events of 9/11 led to the addition of problems of bioterrorism. Older professionals - and some patients - were worried lest excellent interpersonal communications masked ignorance of basics, such as the ability to name the main bones or know the anatomical positions of nerves. The decision in 2002 by the new Peninsula medical school to remove anatomical dissection of the body completely from its medical course was not reassuring. Earlier there had been a downward trend in the number of applicants for medical schools, perhaps due in part to the reduction in the number of students taking chemistry at A level, a requirement of most schools. The selection ratio, the number applying for each place, began to rise in 2002 and the demography of the student population was changing. Compared with the general population, white males were under represented, while conversely there was a substantial proportion of men and women from an Asian background. A report by the British Medical Association showed that
source The Demography of Medical Schools, BMA 2004 The NHS and the medical profession was having to adapt to the increasing number of women in the profession, just over a third of hospital doctors and GPs. The high proportion might, in the view of Professor Carol Black PRCP have substantial long term effects. Medicine was being feminized whilst previously it had been dominated by white males. Would the profession maintain in the future the same status and influence, in view of the difficulty women had in doing all the things formerly seen as part of professional life - research, teaching, medical politics, societies, committees, regulatory bodies and government advice? (Independent 2 August 2004) New forms of medical course reduced in length from five to four years were introduced on the recommendation of the Medical Workforce Standing Advisory Committee (MWSAC). Such courses, long the norm in the USA, were developed for mature students and graduates in other fields, not necessarily scientific. Ten courses were introduced at well established schools. Perhaps up to a thousand students a year would eventually qualify in this way and clinical facilities were expanded by the use of hospitals not previously used to students. Graduate entry courses
In 1997 the Higher Education Funding Council for England (HEFCE), and the Department of Health, established task groups to see how to handle the interdependency of teaching, research and patient care in the funding of medical and dental schools. It was clear that effective liaison arrangements were required to assist exchange of information, and joint management of the higher education/NHS interface was necessary. Universities and the NHS needed to plan jointly and share information locally, and where changes in funding flows were likely to manage them to minimise turbulence. Physicians assistants In 2005 a new type of professional was proposed, Medical Care Practitioners (MCPs), modeled on the US Physicians Assistants, to help doctors and nurses to treat patients in both primary care and hospital settings. After training and under the continuous supervision of a physician, healthcare professionals would be able to:
Attempts to organise, plan and rationalise the training of young doctors for career posts in the NHS have a long and chequered history. For over 50 years responsible and strenuous efforts have created as many problems as have been solved. As a centrally planned system one might have thought that it would be possible to get it right. However the NHS is not static but highly dynamic. The number, type and skills of the doctors required by the NHS do not emerge from planning decisions 10-15 years previously. Developments in subspecialties generate new requirements (e.g. interventional radiology). If there are proposals to reconfigure hospital services, and deliver care nearer to the community or to centralise it in regional units, this must affect the career openings. Alterations in the money available to the NHS, changes in society such as the acceptable length of a working week, and the increased number of women doctors, have upset the best efforts of government and the profession. Apparently unchallengeable assumptions have, in the event, created disasters in the career and hospital staffing structure. Surely all doctors should take part in life-long postgraduate education, but has the NHS an obligation to employ all doctors trained in this country? However now the medical market place is increasingly international, how does one take account of doctors training in Europe, British citizens who go to overseas medical schools because they do not find a place in the UK and who then want to return, let alone well qualified doctors from elsewhere in the world? The Calman scheme, which mainly affected the later years of training, was followed in 2004 by a new initiative, Modernising Medical Careers. This like Calman, had its origin within the Department of Health and its desire to shape medical training in a way more concerned with the needs of the hospitals and the NHS, and less with the educational and training role of the Royal Colleges. It aimed to reform the SHO grade that contained half of all doctors in training, criticised for combining a high work load with poorly structured training opportunities. In 2005 a Foundation Programme Curriculum was introduced that would provide a structured two-year training to give trainees exposure to a broad spectrum of specialties including accident & emergency, obstetrics & gynaecology and anaesthetics. Each trainee would experience primary care and the chance of experience in smaller specialties and academic medicine, not normally available at this stage of training. The second year would effectively replace the SHO grade, require high quality training with progress dependent on competence rather than time in post. As in the case of Calman education was appeared to be placed ahead of service needs, but. the changes to a tried and trusted system, produced problems for both. Placements would be in acute trusts, mental health trusts, primary care trusts, general practices and other settings. Young doctors, rotating through multiple posts, would probably make a smaller contribution to running the service. Trusts would be relying increasingly on staff grades and consultants or perhaps, as in the US, physicians assistants.
Subsequently doctors would opt for either a general practice registrar or a specialist registrar post (SpR - at least four years) with formal training programmes. There are two types of specialist registrar training. In type I there is the assumption that training should lead to consultancy, and there are annual in-training assessments. Satisfactory performance leads to the award of a Certificate of Completion of Specialist Training (CCST) and entry to the Specialist Register held by the GMC. The Specialist Training Authority (STA), supported by a recommendation from the relevant royal college or faculty, decides whether or not an individual doctor has met the standard required for a specified training programme, to merit the award of a CCST. Type II specialist registrars have fixed term training appointments, and the programmes are designed to meet the needs of the individual doctors, but they do not lead to a CCST. Doctors are able to transfer from a type II to a type I post if they are successful in open competition. London teaching hospital trusts are best supplied with training posts. By 2006 the new scheme was in operation and it ran into difficulties. In 2007 it was worse. Young doctors from several years were competing for a single year's posts, and computer system of the Medical Training Applications Service which was expected to provide a level playing field was flawed, as it failed to select appropriate junior doctors for training posts. Inappropriately qualified candidates might take precedence over better trained ones. Doctors in SHO posts had to compete with those from the growing UK medical school output and with doctors who had come from overseas under the Government’s Highly Skilled Migrants Programme (HSMP) so there were far too many applicants, 28,000 applicants for 15,500 training places. The system could not cope with the volume of applications, limited the number of applications doctors could make, made judgments on doubtful criteria ignoring past experience, and failed to produce adequate short lists for interviews. Many faced the blighting of their careers, and possible emigration. The medical profession that had been party to the development of the system, but whose warnings had sometimes not been heeded, was united in protest along with hundreds of candidates. Professor Alan Crockford, the National Director of Modernising Medical Careers resigned. Sir Liam Donaldson, the chief medical officer, rejected the suggestion that he to should go. The Department of Health announced an urgent independent review chaired by Sir John Tooke, Dean of the Peninsula Medical School, Chair of the Council of Heads of Medical Schools and Chair of the UK Health Education Advisory Committee. This examined the genesis of the problem and issued an interim report in October 2007. Modernising Medical Careers (MMC had been, Sir John said, a sorry episode from which nobody had emerged with credit. According to his hard-hitting interim report the changes to medical training introduced since 2002 had been rushed, poorly led and badly implemented. They did not provide doctors with enough broad experience because it encouraged them to specialise early in their careers, nor did they allow for enough flexibility to meet NHS needs. The report called for fundamental reforms for the system had been introduced without any clear definition of what it was meant to achieve, while weak departmental policy development, implementation and governance made it even worse. The way the programme was designed “was unlikely to encourage or reward striving for excellence”, the interim report concluded. The Department announced an agreement with the profession for a modified and more local process for the coming year and consulted on the handling of applications from outside the country. The Health Minister Ben Bradshaw said that with increased English medical school entry from 3,749 in 1997 to 6,451 in 2007, the NHS was less dependent on international medical graduates (IMHs). If UK medical graduates, trained at great cost, could not obtain specialist training because of a large number of applicants from outside Europe, then it was right to consider change; shortly after restrictions on IMG job applications were put in place. The NHS Confederation and its branch, NHS Employers, saw manpower planning as a major issue. Medical graduates had unrealistic expectations and there was a need to persuade people to enter fields where the demands were greater, even if they are less glamorous
Sir John Tooke's final Report was published in January 2008 after extensive consultation on which there had been substantial agreement. The report argued for the separation of the first two years, allowing universities to guarantee a first medical post to their graduates. To the previous proposals was added the need to ring fence the money needed to train the next generation of doctors to prevent the NHS spending it on other priorities as it had in 2007 when the service was in financial deficit. It also recommended that postgraduate education should be managed by a new body, NHS Medical Education England (NHS-MEE), and taken out of the hands of the Department of Health after its mismanagement of funding and job applications. The Department of Health's response in February 2008 glossed over the gravity of the problems there had been, said there had already been much progress, accepted many recommendations (some "in principle") and categorised many of the more difficult ones as requiring further work. Substantial ones such as a ring-fenced budget and NHS-MEE were in this category of "not now but we might think about it." Among the recommendations accepted was to bring the Postgraduate Medical Education and Training Board into the General Medical council by 2010, bringing all stages of medical education and training under one roof. In May 2008 the Commons Select Committee on Health was also highly critical of the chaotic planning and poor coordination with the Home Office over immigration controls. Non-consultant grades Trusts first priority is to keep the service running and they increasingly appointed doctors to hospital posts that were created for this purpose despite the resultant Department of Health ceilings on training grade numbers, as Trusts tried to comply with restrictions on working hours for doctors in training, and the European Working Time Directive.BMJ 2003;327:961-964 The new posts were generally in acute specialties and did not conform to the standard NHS grades and were on terms and conditions set by individual trusts. Those roughly at SHO level were usually referred to as 'trust doctors', and those with 3 or more years relevant experience as staff grade, hospital specialist or 'associate specialist', non-consultant career grade posts. The doctors appointed were often from outside the European Economic Area, had widely varying experience and might not have specialist qualifications. They were employed to work, not study, and there was often no strategy for their education or supervision. The number of such posts increased rapidly and in 2003 there were around 5000 doctors on local contracts for whom the national grade was unclear. It was hard to move from such posts to consultant ones. Some remained in such jobs until retirement. Their growing numbers, and the limited extent of career development open to non-consultant grade doctors, created increasing problems, an underclass of doctors, something strenuously avoided in the early years of the NHS. In 2005 negotiations began on new contracts and pay scales for these doctors. European Working Time Directive The Directives substantially changed the way medical care was provided in hospital and had more effect than the "new deal" on junior doctors' hours. To cover the work hospitals needed more doctors than existed in the current training-post quota. Covering nights and weekends would be difficult as the Directives specified
Guidance to the NHS suggested several options including developing new healthcare practitioner posts, sometimes utilizing experienced nurses to take on work currently carried out by doctors,
The problems of providing a safe service were complex and hospitals struggled to conform. In the middle of the night a patient needed somebody to take complex decisions, and the competence to carry out specialised procedures, impossible without appropriate training and experience. If hours of work were to be limited, at least five specialist registrars were needed in each subject, and if educational commitments were taken into consideration, double that number. Ten were needed in order to have one specialist registrar for 24 hours every day with a reasonable amount of work in ‘normal hours’ for training, skill development and in-patient management, and cover for leave. The effect of the Calman pattern of training and the European Working Time Directives was to reduce substantially the time between becoming a senior house officer and appointment as a consultant from some 30,000 hours to 8,000 or less. It seemed inevitable that the experience and skills of newly appointed consultants would be less than in the past, probably as generalists and almost certainly in advanced subspecialties. The NHS - and many European health care systems - would need to undergo dramatic changes even to comply with rules specifying an average working week of 58 hours, reducing five years later to 48 hours. A survey of emergency cover at 211 hospitals by the Royal College of Physicians showed that in June 2003, 14 months before the Working Time Directive was due to be implemented, 166 acute hospitals in England (78.7%) did not have sufficient specialist registrars to provide continuous cover of acute medical admissions; if middle grade "Trust" doctors were used on a rota in addition 134 acute hospitals (63.5%) would still not have sufficient to establish workable full-shifts. Recruitment World wide, job dissatisfaction within the medical profession was growing and the reasons ranged, according to The Lancet, far wider than money. Apart from overwork, stress, and underfunding of the health service, surveys suggested poor opportunities for training, the rising trend in medical litigation, bullying, and racism. One factor increasingly generating intense frustration among doctors was the steady erosion of their autonomy over management of patients as the NHS, and elsewhere health-maintenance or health-insurance organisations, tightened their rules on the pattern of clinical work and how and which patients could be treated. The loss of doctors from the NHS remained stable. Surveys of those qualifying from 1977 onwards showed that some 80% of both men and women were working in medicine in the NHS. The proportion working in general practice however had fallen. There was an accelerating trend for consultants to retire early, and greater demand for them in a "consultant delivered" rather than a "consultant led" service. There were higher numbers of women doctors in the hospital service (33% in 1998), some of whom chose to take a career break. About half the women were working part-time. Studies suggested that young doctors viewed commitment to the NHS differently. While prepared to be committed to fulfill a reasonable contract, they demanded time for self-fulfillment and family responsibilities in a way that previous generations of doctors had not. It was generally agreed that there was a shortage of indigenous, UK trained, doctors both in general practice and in hospital medicine that could only be remedied in the long term by increasing student numbers as a result of which medical schools were expanded. The NHS continued to rely extensively on doctors from overseas. 10% of Senior House Officers came from the European Economic Area, and 28% from outside it. Year on year, half or less of the doctors registering with the GMC had received their medical education outside the UK. To try to meet the pledges on the number of NHS doctors made in the NHS Plan, Government began a world-wide advertising campaign for consultants and GPs in September 2001. Sir Magdi Yacoub, recently retired from transplant surgery, was recruited as a global talent scout for the NHS, an initiative similar to one employed during the 1960s 'brain drain' and no more successful. Pay awards in 2001 aimed to increase recruitment, particularly into training posts for general practice. A national "returners" scheme was launched and in December 2002 advertisements appeared in the quality press encouraging doctors who had retired or given up medicine to come back to the NHS. New contracts for GPs and consultants in 2004/5 raised pay to unprecedented levels but a further factor now appeared, the 'feminisation' of medicine. The high proportion of women medical students was now feeding into the training grades and it seemed that women doctors remained very selective about the specialties they chose. Specialties with a major on-call commitment, for example cardiology and gastroenterology, were substantially less popular with women than oncology or radiology. New registration by country and area of qualification
EEA is a new name for the EC. The term EEA means countries who are either members or who have bilateral agreements with the EEA (for example, a bilateral agreement between the EEA and Switzerland came into force recently) Source GMC 2001/2002 The consultant contract and private practice For many years the UK pay system for consultants was a fixed salary (with incremental points) and selective bonus payments (distinction awards) that were introduced early in the history of the NHS. Consultants with a "full-time" contract could undertake limited private practice, with remuneration no higher than 10% of their NHS salary. Those with a part time contract (including maximum part time at 10/11 of a full time salary) could undertake unlimited private practice. By the end of the 1990s both the doctors and the government thought that the contract, though modified over the years, was now inappropriate and substantial revision was necessary. Private practice remained a bone of contention. After some years of manoeuvering the consultants' negotiating body, the CCSC, published proposals in October 2000 and the Government published its own the following February. The latter were reminiscent of those of the 1974 Labour administration and reflected the NHS Plan. The government, supported by NHS managers, wished to tighten the grip over consultants and reduce their freedom especially as far as private practice was concerned. There would be a substantial increase in the number of specialists, not a new idea, but welcome. Proposals to merge distinction awards and discretionary points onto the pay scale, and to make the system more open and "fair", were also welcome. Clinicians were concerned about proposals to review consultants' job plans and to introduce appraisal systems. Most controversial was a suggestion introduced into the NHS Plan at the last minute that newly appointed consultants would work exclusively for the NHS for the first seven years of their career, providing eight fixed sessions and more of the service delivery out of hours. Existing ‘full-time’ consultants, although having the right to undertake limited private practice, would have to prove that they were fulfilling NHS requirements. Full time commitment would bring significant financial rewards. However the BMA opposed in principle the view that consultants should be able to do nothing outside their NHS contract and saw the proposal as a vindictive attack of uncertain legality. A contract along the government lines might have unintended consequences, for example the encouragement of younger doctors to emigrate, or older ones to devote themselves entirely to private practice. The doctors' leaders spent two years negotiating a contract that would give consultants considerable increases in pay in return for agreeing to be better "corporate citizens," fitting in with what managers and politicians thought best for the NHS, and working flexibly - possibly "unsocial hours". In June 2002 the contract was put to the profession. The basic working week would be of ten four-hour sessions instead of 11 sessions of three hours; this made possible a longer normal working day and might enable the service to 'work around the clock' rather than merely 9 a.m. - 5 .p.m. Government abandoned attempts to place private practice off limits for younger consultants, but the consultants' obligations to the NHS were set out more precisely. Young consultants would have to offer the NHS two additional sessions before they did any private practice, and consultants 7 years into their appointment an extra one. To deter consultants from early retirement there would be annual increments over 20 years. There would be greater managerial control over the consultants’ working week and an agreed job plan and work timetable. The new contract offered more money in return for accepting greater managerial control and the potential to be obliged to work unsocial hours. The negotiators misinterpreted the mood of consultants and both the junior doctors and the consultants rejected it. In October 2002 consultants in England and Wales rejected it by a margin of two to one. Specialist registrars, the consultants of the future, rejected it by five to one. The BMA CCSC chair Dr Peter Hawker resigned. Three major areas of concern had swung opinion against the contract in England and Wales; deeply unhappy relationships between NHS managers and doctors, fear that consultants would be subjected to unreasonable or unachievable demands because of pressures on NHS managers to meet government performance targets that consultants often see as not in the interests of patients and that on top of emergency work, doctors would be forced into working unsocial hours on a routine and long term basis. New negotiators asked the government to renegotiate the contract, suggesting comparatively minor changes. The government refused but when John Reid was appointed Secretary of State, the Chairman of the Central Consultants and Specialists Committee (CCSC), Dr Paul Miller, asked him to resolve the impasse. In July 2003 he accepted that consultants could opt out of evening and weekend work, and eased restraints on newly appointed consultants in respect of private practice .In October 2003 consultants and specialist registrars voted by 3 to 2 to accept the deal. The contract was based upon job planning and it rapidly became obvious that consultants had frequently and genuinely been working more than their contracted hours. Now the Department and NHS management wished everything to be spelt out, consultants did just that. The bills escalated, for apart from their clinical commitments the deal entitled them to 2 1/2 sessions for study, research and similar relevant and important activities. The costs of the new contract proved far higher than had been predicted by the Department of Health, sometimes throwing hospitals into financial deficit. Back pay alone might amount to tens of thousands of pounds, and it was joked that the consultants' car park resembled the most up to date car showroom. In April 2007 the National Audit Office confirmed formally what had become apparent. The pre-existing workload of consultants had been underestimated, and that they now received some 25% more money without apparently working any longer hours.;
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