NHS Clinical Excellence AwardsHints, tips, myths, pitfalls, secrets and suggestions

Alex Mitchell, Consultant in Liaison Psychiatry, Leicester (UK)

Compiled from information in the public domain; September 2008

ajm80@le.ac.uk

Introduction and Background

What Is It All About?

• Since 2003 the Clinical Excellence Award (CEA) scheme replaced the antiquated discretionary point/distinction award system *

• This is an NHS scheme designed to financially reward “excellence” largely in relation to demonstrable clinical high quality; or in the words of the ACCEA specifically “to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to patient care”

* February 2001, DOH consultation document “Rewarding commitment and excellence in the NHS – proposals for a new consultant reward scheme”

Purpose• ACCEA stands for

– Advisory Committee on Clinical Excellence Awards (ACCEA) not the Armenian Center for Contemporary Experimental Art (try google!)

– Main weblink http://www.advisorybodies.doh.gov.uk/accea/– For Scotland http://www.shsc.scot.nhs.uk/shsc– For Northern Ireland - Northern Ireland Clinical Excellence Awards Committee

(NICEAC).

• Scheme claims to be– fair and uniform criteria – (partly correct but criteria are not strict)– transparent and equitable processes (not really, submissions still not published)– clear operational frameworks (probably and improving)

Principles according to Prof Ghodse• “A system for rewarding clinical excellence has been in place since the

inception of the NHS in 1948. Since then it has gone through many changes with greater emphasis over the years on widening the associated consultative and nomination procedures. However, the fundamentalprinciples of the system remain the same today as 60 years ago: to encourage, identify, acknowledge and reward high standards in consultants’ clinical and related work.

•• While individual contributions may be very varied, sheer clinical quality

remains the major criterion for assessing excellence. Of necessity, the Clinical Excellence system is competitive in nature. It is therefore essential that it is fair, and trusted by the profession, with its work underpinned by principles of transparency and impartiality. To achieve this, ACCEA will work to increase knowledge and understanding of the principles of the scheme at all levels among consultants. Then, recognising that the Employer-Based Awards (EBA) are fundamental to the operation of the scheme

Cited from ACCEA 2007 Newsletter #2

Some Background Data – Eligible #• There were 39,801 NHS consultants in post Sept06• There were 10,572 Staff Grade, Assoc Spec. in post Sept06• There were 43,850 GPs in post Sept06• NHS Employers reported that 44% of staff said morale had deteriorated

(only 7% said improved) *• Academics with honorary NHS contracts are down (up a little in 2008)

*NHS Consultants in Post.Data from Review Body on Doctors’and Dentists’RemunerationThirty-Seventh Report 2008

Are Consultants Reasonably Paid?

*Data from Review Body on Doctors’and Dentists’ RemunerationThirty-Seventh Report 2008

CEA Headlines 1 of 2

• 59% of eligible NHS consultants are in receipt of a CEA!• 13% of eligible NHS consultants have a level 9 or above• CEA are quickly awarded and v. rarely taken away• CEA count towards your pension• CEA reward any “good” work, not specifically NHS work or

“excellent” work, as claimed• The rating is essentially by peer opinion not by submitted

evidence• No matter how outstanding you are, you will not get a high

award without repeated applications ie you will not receive a realistic rating in year 1.

• No actual submission of hard evidence is required or indeed allowed!

• No applications are allowed by non-medical staff!See later slides for justification

Headlines 2 of 2

• It usually takes 10+ years to achieve “Bronze”• Consultants can apply for an award after their first year • Employer based awards cannot be removed and are not reviewed• Grounds for removal of a national award are effectively dishonesty on the

form (rare) and national discrace, GMC issues etc• The amount of award could be as little as £2,500PA or as much as £75k• Questions bias by ethnicity, specialty, gender and age have been raised

and partially addressed• ACCEA has to justify that the scheme is “value for money”• Scheme subject to a glass floor and glass ceiling

See later slides for justification

Making a Local Application

ACCEA Timeline for National Awards• Forms Available July of previous year• Applications received Nov of previous year• Trust-based committee Dec of previous year• Trust Board ratification Jan• Ranked lists to ACCEA Jan• Consultants notified Jan• Appeals heard March• Payments April• Annual Reports to ACCEA May

Timeline for Local Awards• Application are subject to a bizarre timeline. Take 2008

– 2008 application forms available from July 2007– Local 2008 awards announced August 2008!– Payments are backdated to April 2008– 2009 application begins before 2008 results out!– Applications seem to state what has been achieved in the first half of

the year and what will be achieved in the second half!

– This is probably to fit in with the financial year although the period of interest is not clear on the application. For 2008 is it Jan01 to Dec31 2008 or April01 2008 to March 31st 2009 or it April01 2007 to March 31st 2008!

Crudely, How Much Are CEAs Worth?£ if on 10 sessions£ if on 11 sessionsCEA level

2,6482,913L 1

5,2965,826L 2

7,9458,739L 3

10,59311,652L 4

13,24114,565L 5

15,88917,478L 6

21,18523,304L 7

26,48229,130L 8

31,77834,956Bronze - L9

41,77745,955Silver - L10

52,22157,443Gold - L11

67,88774,676Platinum - L12

Comment: the award goes from negligible to generous, proportionate the number of hours worked.Strangely, no one complains that the ££ are too high; BMA has said cap may be too low with influx of academics

Thinking of Applying?• Eligible: NHS Consultants

– if they have at least one year’s experience at consultant level at 1 April in the award year

• Eligible: Honorary NHS consultants (academics)– Luckily “the awards taking into account contributions to the NHS which are

defined in wider terms of benefit to the NHS than direct patient care alone.”One loop-hole is that work done in non-NHS time is also allowed.

• Eligible: Deans, post-graduate deans

• Not Eligible: Locum Consultants

• Not Eligible: Consultants employed in full-time General Management– Such as chief executive or general managers and who do not undertake clinical

work as a consultant under a separate clinical contract.

Nuts & Bolts• There are 12 levels of award (see next page).

– Levels 1-8 are awarded locally and Levels 10-12 (Silver, Gold and Platinum hereafter) are awarded nationally.

– Level 9 can be awarded locally or nationally.

• ACCEA and its regional sub-committees recommend individuals for Bronze, Silver, Gold and Platinum awards. Applicants for Levels 1-9 are recommended by Employer-Based committees.

• ACCEA monitors the employer-based scheme and publishes an annual report on the awards that includes information on their distribution.

• Quantity of work => linked closely with Pas

• Quality of work => MAY be linked with CEAs

Will I Receive A Fair 1-12 Appraisal?• Sadly no! The scheme is controlled by local panels whose aim is not to rate each

applicant on a 0-12 scale but to give a “minimum” number of points. They don’t like to downgrade awards so this pushes them to give the lowest reasonable award. Take the example of an outstanding consultant of 8 years who applies locally for the first time. He/she will not be rated as say 7/12 (as should happen); he/she will be likely to receive 1 or 2 points from the “pool available”

• Why does strange system exist? In short there is a glass ceiling (which is written in guidance as a glass floor) as follows: “The minimum number of awards to be funded is calculated according to the formula 0.35 awards per eligible consultant.”

• So if there are 70 consultants who are eligible for local CEAs this requires the award of 25 points at a total cost to the Trust of approximately £72,500 p.a. Therefore approximately 1/3 of applicants will be “successful” each year.

• Nearly all trusts interpret this as the number “available” ie the minimum and maximum. In reality they could award as much as they wished (see over for data)

Glass Ceiling or Floor – Data from ACCEA• 32% of NHS employers awarded less than the “minimum”

recommendations in 2007

• About 60% “towed the line” or gave a little bit more than minimum. Only 2 (out of 100 surveyed) could be described as generously awarding as they saw fit

What is Rewarded by Category

• 1 Delivering a high quality service.• 2 Developing a high quality service.• 3 Managing a high quality service.• 4 Contributing to the NHS through research and innovation

(note stand alone form for local applications too)• 5 Contributing to the NHS through teaching and training.• (note stand alone form for local applications too)

Local (Employer Based) Committees

• 10 – 15 members• 50% Consultants (Medical Director = manager)• Chaired by CE or non-exec Director• Up to 3 managers• 1 or 2 lay representatives• 1 university representative if appropriate• All to have diversity training

Regional ACCEA Committees

• Up to 24 members• 6 lay members (including Chairman)• 12 medical members (including medical Vice

Chair)• 6 employers (CEOs)

Scoring

• Each domain is scored• 24 members of committee score• 12 medical members• 6 employer representatives• 6 lay members• Scores are 0, 2, 6, 10

Scoring –Local Form Example

Tips 1• Award for supposedly for excellence not working hard but in reality local

awards are.

• National awards are for national activity (not at expense of local work) but no-one lists a detriment or failing!

• National awards currently need chief exec support, but this may change.

• List dates and as far as is possible “evidence” but space is very short

• Follow ACCEA guidance document (on website)

• Ask colleagues about their form and the trust may have an open policy for some very honest and open people making their forms public (this is rare)

• Be factual on the form, as if you may justify it (although in reality the form is based on “claims of excellence” your colleagues will be judging it.

Tips 2• ACCEA committees review lots of applications across a range of specialities.

Clarity and ease of reading are important

• You will not get marks through the overall ACCEA competitive process for working hard and being nice; it is essential to provide evidence of audits, surveys and peer reviews etc.

• Put your contributions in the correct domains – otherwise you will risk not having it counted

• Focus on what you have done since your last award (in the last five years for national)

• Document all of your achievements, don’t be modest!

• Indicate specific contributions and achievements stressing their significance & impact.

Some tips adapted from Royal College of Radiology online CEA advice

Tips 3• Avoid repetition.

• Use bullet points, present information in short, easy to read sentences, use Capitals for headings

• Check your spelling. There is no spell checking facility – you might want to prepare text for the different boxes using Word and copy the text into the module.

• Try to avoid abbreviations or acronyms. They do not facilitate easy, rapid reading.

• Keep your CVQ up-to-date so that if you are not successful you can resubmit the following year.

• Before you submit your forms - critically re-read them with these pointers in mind. Consider asking someone to read the form and give you feedback.

• For the ACCEA online module: Make sure that you are completely happy with your form before you submit it to your employer for completion of Part 2. At this point, the form becomes "read-only", and no further changes can be made without you making a specific request to the ACCEA to unlock it and then re-submitting to your employer. You can save the form as a Word document, before or after submitting it to your employer, and can email it to the College or to any specialist societies.

Some tips adapted from Royal College of Radiology online CEA advice

Making a National Application

National Award: CEA Olympics!

National Awards by Region

Can I go National at any stage?• 20% of successful Bronze applications came from consultants with

less than level 4 and that some had no previous CEA at all.

Previous level of award held by consultants receiving Bronze in 2007 (% at each level)

Increasing the Chances of Success

Levels Awarded - Cumulative

Comment: there are a lot of level 9 holders because many NHS consultants progress almost“automatically” via local levels. There are only 99 top division medics in England & Wales

Total Award Holders in ACCEA database

What Level do consultant Apply to?• 32% apply at local level and

are unsuccessful

• Of all holders, about 90% of awards are held at local level

• About 10% who apply, apply at National level

What is Rewarded?Comment:From the ACCEA guidance:

notePlease note: consultants and academic GPs applying for awards are not expected to meet every objective.

“outstanding”?make an outstanding contribution to professional leadership.

fairare recognised as excellent teachers and/or trainers and/or managers;

At least this is measurable> contribute to knowledge base through research and participate actively in research governance;

How?> embrace the principles of evidence-based practice;

Regardless of resources?> through active participation in clinical governance contribute to continuous improvement in service organisation and delivery;

Basically routine practice> in their day-to-day practice demonstrate a sustained commitment to the values and goals of the NHS, by participating actively in annual job planning, observing the private practice Code of Conduct and showing a commitment to achieving agreed service objectives;

Note “sustained” not defined, generally interpreted as long period of service, eg 5+ years

> sustain high standards of both technical and clinical aspects of service whilst providing patient-focused care;

Note not “excellence”> sustained commitment to patient care and wellbeing, or improving public health;

What Are My Chances of National Success?

Comment: across the board chance of an award is 30.5% if you submit a bronze level application, but 44% if academic GP and 20% from anaesthetics & dental

Who is Successful?• Those who apply repeatedly• Those who have something in all domains• Those Academics and NHS consultants with research• Those with a high profile• Those in a high profile post• Those held in high regard by peers• Those who are older

Who is Unsuccessful?• Those who do not submit (the #1 factor)• Those who complete only part of the form• Those who under-sell themselves• Those with no research or teaching listed• Those without chief executive support (….why!?)

Appeals, Renewals

No Fair – Shall I appeal?• In 2007 there was 1x national appeal and there were three local appeals –

one each in the South East, Cheshire and Mersey and London North West.

• In all cases, the Chair and Medical Vice-Chairs of the appropriate Regional Sub- Committees were asked to investigate the local processes.

• Only in one case, was there concluded to be a process failure

• In no case did the amount of award change

• Comment: bottom line, save your energy, apply again next year

Appeal Rules• Appeals can only be made against the process not the

decision itself• Local resolution

– if not resolved locally, appeal goes to the Chairman/Medical Vice Chairman of the appropriate ACCEA Sub Committee

• In cases of appeal against a Sub Committee, goes to ACCEA Secretariat Head who in consultation with Chairman & Medical Director will investigate and if necessary set up a special sub-group of ACCEA.

• Decision of the Sub Group will be final

Basis for Appeals• (1) that the material duly submitted to support an application (i.e.

application and citations) was not considered by the relevant committee;

• (2) that extraneous factors or material were taken into• account; there has been discrimination on the unlawful bases• of gender or ethnicity or age;

• (3) that the established evaluation processes were not followed;

• (4) That there was bias or conflict of interest on the part of the committee.

Reviews of Awards• Awards are not meant to be given “forever” and since 1989 awards were subject to

five-yearly reviews.

• You should focus on activity within the five-year period leading up to the review.

• If ACCEA deems the paperwork you have submitted for the review is insufficient for award renewal, it will invite you to resubmit an application the following year.

• In cases where the evidence you supply is unclear the award be renewed for less than five years

• If you still do not submit sufficient evidence, a recommendation will be made to ACCEA that your award be withdrawn or downgraded. However even in that case, “you then have the opportunity to make a written submission to ACCEA before the final decision.”

• Comment: Bottom line; only 1 award was down-graded in 2007 and only because the evidence submitted originally was shown to be untrue. Once a consultant becomes “excellent”, apparently they never stop doing excellent work or indeed relinquishes any work listed without taking on more. That’s either incredibly good news or rather unlikely depending who is looking.

Review of Awards - Data

Review Applications 2006 2007

Total 459 590

Signed off:5 year renewal or higher award 440 538

Caution:2 year renewal 10 8

1 year resubmission 8 43

Downgraded:Withdrawal of award 1 1

Bias & Under/Over Represented Groups

According to the BMA• ACCEA will be expected to monitor awards at all levels,

against the criteria for award, to ensure that:

– There is a fair distribution of awards between specialties – There is a fair distribution of awards geographically – There is a fair distribution of awards between types of hospital– Groups, such as female consultants and consultants from minority

ethnic groups, who have in the past received disproportionately small numbers of awards, are being fully and fairly considered.

http://www.bma.org.uk/ap.nsf/Content/CCSCContractCEA

Evidence of Bias - Women• Women are more likely to hold lower levels of CEAs than men

• Proportionately fewer applications were received from women than from men.

• Women are under-represented on ACCEA sub-committees

• The chances of success for women if application submitted is pretty much the same: 30.8% for men and 29.5% for women but there were only 59 applications by women and 279 by men

• Comment: In short, no evidence for discrimination but low applications

Evidence of Bias – Age+Gender

Comment – This shows official data on Percentage of consultants holding National Bronze Award by year of Appointment and gender

The mean age at each level are: Level 9 - 49.9 years old Level 10 – 54.0 years old; Level 11 – 51.5 years old; Level 12 – 56.9 years old

Typical Age for Success

Typical Age CEA Awards Comments

35 Level 1 More consultants are getting their first point within 2 years ofappointment

41 Level 4 Average rate of 1 point every 2 years

50 Considered for a national Level 9 Mean age of a bronze award/ Level 9

57 Considered for a national Level 12

Mean age of a Level 12

CEA Progression Ladder

L1

L2

L3

L4

L5

L12 / Platinum

L11 / Gold

L10 / Silver

L9 / Bronze

L8

L7

L6

NHS High FlyerTypical NHSConsultant

Typical AcademicConsultant

Comment: Most NHS consultants reach a ceiling a L9 (local) and academic Bronze, even a high flyer will take years to progress in the current system

L0 (not successful)

Age 39

Age 34

Age 46

Age 42

Age 36

Age 55

Age 40

Age 35

Age 50

AcademicHigh Flyer

Age 38

Age 34

Age 44

Age 55

Evidence of Bias? Age Effects

Data for 2007 shows that you “need” to be at least 7 years in post to have a decent chance of a national award, and after 10 years there is a big leap.

Evidence of Bias - Ethnicity• About 75% of bronze applications at

white British; chances of success 29.4%

• 25% ethnic minorities; chances of success = 24.8%

• Chi squared P=0.13; non-significant trend towards worse success by minorities

Observed values and totals:72 218 290240 577 817312 795 1107

Expected values:81.734417 208.265583230.265583 586.734417

Uncorrected Chi² = 2.187364 P = 0.1391Yates-corrected Chi² = 1.96843 P = 0.1606

Evidence of Bias? Academics• Those with honorary NHS contracts comprise a small % of

overall applicants (about 10%) but receive more than half of National awards…in short they are over-representated.

• BMA cites “The current requirement for six NHS sessions per week to be undertaken to establish full eligibility for an awardwill be amended in the light of the Follett Report. Eligibility for awards will be based on the contribution made to the NHS defined in wider terms than direct care to patients. The entitlement to full eligibility for an award will be based on five programmed activities in the jointly agreed job plan being devoted to activities beneficial to the NHS including teaching and clinical research.

NHS vs Academics at local level

05

10152025303540

Number of Applicants

NHS Consultants Academic Consultants

Consultant Group

Successful Applicants - Comparison between NHS and Academic Consultants

2004200520062007

Data from South London and Maudsley Trust in Public Domain

NHS vs Academics at National Level

0

12

3

45

6

78

9

Number of Nominations

NHS Consultants Academic Consultants

Consultant Group

National Clinical Excellence Awards Nominations - Comparison between NHS and Academic Consultnats

2004200520062007

Data from South London and Maudsley Trust in Public Domain

Detail About Domains

Delivering a service - Scoring• 0 Not eligible

– For a number of reasons ranging from doing the minimum required or questionable conduct as a clinician or a colleague just doing the job

• 2 Meets contractual expectations – Performance in some aspects of the role could be assessed as ‘over and above’ expected standards. But

generally, on the evidence provided, contractual obligations are fulfilled to competent standards and no more.• 6 Over and above contractual expectations

– Some duties are performed in line with the criteria for ‘Excellent’, as below. However, on the evidence provided, most are delivered above contractual expectations, without being in the highest category.

• 10 Excellent– Contracted post is carried to the highest standards. Evidence for this should come from benchmarking

exercises or objective reviews by outside agencies. Where this is not available, there should be other evidence that the work undertaken is outstanding – in relation to service delivery and outcomes – when compared to that of peers.

– Leadership role in service delivery by a team, with evidence of outstanding contribution, such as awards, audits or publications.

– Innovative contribution to clinical governance and/or service delivery. Evidence presented may include audits and publications and the take-up of the innovations elsewhere.

– Exemplary standards in dealing with patients, relatives and all grades of medical and other staff. Applicants should ideally include reference to a validated patient or carers’ survey, or feedback on the service (external or peer review reports).

Developing a service - Scoring• 0 Not eligible

– For a number of reasons ranging from doing the minimum required or questionable conduct as a clinician or a colleague to no local input

• 2 Meets contractual expectations– The applicant has fully-achieved their service-based goals and provided comprehensive services to a

consistently high level. But there is no evidence of them making any major enhancements or improvements. 6 Over and above contractual expectations

– The applicant has made high quality service developments, improvements or innovations that have contributed to a better and more effective service delivery. This should be demonstrated by:

– better uptake of evidence based practice;– improved outcomes (clinical effectiveness);– greater cost effectiveness;– services becoming more patient-centred and accessible; or– benefits in prevention, diagnosis, treatment or models of care.

For this score, the activity would be expected at local and possibly regional level – especially if in the face of difficult circumstances or constraints

• 10 Excellent– Service innovation – introduction of new procedures, treatments, or service delivery, based on original research

or development or effectively overcoming barriers to clinical effectiveness. This should be backed up by relevant, completed audit cycles or research that have been adopted at regional, national or international level, with demonstrable change in evidence-based practice.

– Clinical governance – introduction or development of clinical governance approaches which have resulted in audited/published advances taken up elsewhere.

– Leadership in the development of the applicant’s specialty at regional, national or international level. This should include evidence of wide participation in promoting the development of evidence based practice in the specialty, including patient and public involvement.

Leadership and managing a high quality service - Scoring

• 0 Not eligible– Does not contribute

• 2 Meets contractual expectations– Applicants should receive this score if they are delivering a high level of service. They will need to give

evidence of successfully contributing to the running of a trust or unit, especially in difficult circumstances, and maintaining excellent staff relations – by encouraging nursing and PAM colleagues.

• 6 Over and above contractual expectations

– To score 6 points, applicants must show successful management skills, especially in innovative development and hard-pressed services. They may also have been involved in recognised advisory committee work, at area and particularly national level (especially if as secretary or chair). Other criteria that would merit this score include effective chairing of a trust or university committee as, for example, clinical director. Look also for examples of how applicants have carried out appraisals for peers/non-career grade doctors or been involved in major reviews, enquiries or investigations or as part of a College/Specialty Advisory Committee. ACCEA does not expect to reward membership of such committees in itself. You should look for evidence that the contribution made by the applicant has been over and above expectations.

• 10 Excellent• Applicants scoring 10 in this domain will have shown evidence of outstanding administrative achievement in a

leadership role – as confirmed by their employer and/or other citations. Medical directors and other clinical managers should not be given this score purely because they hold the post – there must be clear evidence that they have distinguished themselves by leadership in advancement of health policy and delivery.

•• Other evidence that could merit this score includes:

– involvement in shaping national policy, aimed at modernising health services (might include effective chairing of an area or national importance advisory committee);

– successful directorship of a large nationally-recognised unit, institute or supra-regional services; – planning and delivery of area or nationwide services; – other evidence from citations of exceptional activity and achievement.

Research and Innovation - Scoring0

– No assessable contribution to this domain

2 Meets contractual expectations– If the applicant is an academic consultant, they should be considered by their employer to be “research active” – at a level

commensurate with their contract. This rating would be based on the applicant’s research output and associated publications within the past five years.

– If he or she is an NHS consultant, they will have undertaken clinical research, alone or in collaboration, which has resulted inpeer-reviewed publications. Or they may have collaborated actively in basic research projects established by others. They may also have actively encouraged research by junior staff and supervised their work.

6 Over and above contractual expectations • All applicants should present evidence in the following areas:

– Formal training in teaching and/or training through courses such as ‘Training the Trainers’ and Institute of Learning and Teaching (ILT) membership.

– The quality of teaching and/or training through regular audit and mechanisms such as 360-degree appraisal. This should include evidence of adaptation and modification, where appropriate, of these skills as a result of this feedback.

– Involvement in quality assurance of teaching and evidence of success with regulatory bodies involved with teaching and training.– High performance in formal roles such as working with under and

postgraduate deans, and involvement with postgraduate educationalprogrammes in roles such as head of training/programme director, regional adviser, clinical tutor etc.

• 10 excellent• The applicant’s research work will be of considerable importance to the NHS by its influence on the understanding, management or

prevention of disease. This will be demonstrated by evidence of the following:– Major peer-reviewed grants held currently and/or within the last five years, for which the applicant is the principal investigator or

main research lead. They should have included the title, duration and value.– Research publications in high citation journals.*– National or international presentations/lectures/demonstrations given on research.– Supervision of successful doctorate students, some of whom might have come on national or international fellowships.– Patent of an innovation.– Other peer-determined markers of research eminence.– Evidence, for all these elements, is only relevant if it refers to work the applicant has carried out since gaining any previous

national awards.

Research and Innovation - Scoring• Comment - output is “peer normed” in theory so

academic consultant should will be measured against the output expected from the applicant’s peers.– Eg. Typical “good” full time academic produces 5-10 papers

per year, but 5 in high impact journals would be excellent. Outstanding can produce 20-40 papers, 10 in high impact journals

– Eg. Typical “good” NHS consultant Full time NHS produces 0-1 papers per year. Outstanding can produce 5-10 papers, 1-2 in high impact journals

– Grants are also listed in the research and innovation form

“For applicants for a Bronze award, the evidence should be predominantly ofachievement within the last five years.” This has been clarified from 2007 as 5 year

listing for National Awards

Teaching and training • 0

– No assessable contribution to this domain• 2 Meets contractual expectations

– Evidence of having fulfilled the teaching/training expectations identified in the job plan, in terms of quality and quantity.• 6 Over and above contractual expectations

• All applicants should present evidence in the following areas:– Formal training in teaching and/or training through courses such as ‘Training

the Trainers’ and Institute of Learning and Teaching (ILT) membership.– The quality of teaching and/or training through regular audit and mechanisms

such as 360-degree appraisal. This should include evidence of adaptation andmodification, where appropriate, of these skills as a result of this feedback.

– Involvement in quality assurance of teaching and evidence of success withregulatory bodies involved with teaching and training.

– High performance in formal roles such as working with under andpostgraduate deans, and involvement with postgraduate educationalprogrammes in roles such as head of training/programme director, regionaladviser, clinical tutor etc.

• 10 Excellent• In addition to achievements listed in 6, applicants should show evidence of performance over and above the standard

expected in the following:Leadership and innovation in teaching, including:

– new course development;– innovative assessment methods;– introduction of new learning techniques;– authorship of successful textbooks or other media on teaching/training.– National and international educational leadership, such as presentations, invitations to lecture, peer-reviewed and other publications on

educational matters.– Innovation and trend-setting in teaching and training, including examination processes, for a college, faculty, specialist society or other national

professional bodies.

Quality Publications Listed by ACCEA• General Journals• Nature (top of list)• New England Journal of Medicine• British Medical Journal• Lancet• Journal of Clinical Investigation• Journal American Medical Association• Clinical Science• Science• Nature Medicine• Movement Disorders• Neuro-pediatrics•• Genetics• Nature Genetics• American Journal of Human Genetics• Human Molecular Genetics• Familial Cancer• Clinical Genetics• Journal of Medical Genetics• Cytogenetics & Gene Therapy

• Anaesthesia• Anaesthetic Journals• British Journal of Anaesthesia• European Journal of Anaesthesia• Pain Journals• Pain• Anaesthesia & Analgesia• Regional Anaesthesia & Pain Medicine•• Intensive Care Journals• Critical Care Medicine• Intensive Care Medicine•• Respiratory Journals• American Journal of Respiratory and Critical• Care Medicine• European Respiratory Journal• Chest• Thorax• Occupational Environmental Medicine

•

• Public Health Medicine• American Journal of Epidemiology• Journal of Epidemiology & Community Health• Journal of Public Health Medicine• European Journal of Public Health• International Journal of Epidemiology Social• Science and Medicine•• Geriatrics• Age and Ageing• Journal of the American Geriatrics Society• Gerontology•• Paediatrics• Paediatrics• Journal of Paediatrics• Archives Diseases in Childhood•• Accident and Emergency• Academic Emergency Medicine• Journal of Trauma• Resuscitation• Annals of Emergency Medicine• Emergency Medicine Journal•• Psychiatry• General• Archives of General Psychiatry• British Journal of Psychiatry• American Journal of Psychiatry• Trends in Neurosciences• Psychological Medicine• Acta Psychiatrica Scandinavia• Addiction• Learning Disability• Journal of Intellectual Disability Research

Cited in ACCEA 2007, Assessor’s Guide

Quality Publications Listed by ACCEA• Pathology• General• American Journal of Pathology• Journal of Pathology• American Journal of Surgical Pathology• Human Pathology• Journal of Clinical Pathology• Histopathology• Journal of Molecular Diagnosis• International Journal of Immunopathology• Journal Allergical Clinical Immunolgy• Laboratory Investigation• Modern Pathology• Seminars in Diagnostic Pathology• Molecular Endocrinology••• Neuropathology (see neurology)• Neuropathology and Applied Neurobiology• Brain Pathology• Journal of Neuropathology and Experimental• Neurology•• Cancer• Journal of the National Cancer Institute• Journal of Clinical Oncology• Annals of Oncology• International Journal of Radiation Oncology

• British Journal of Cancer• Cancer• European Journal of Surgical Oncology• Cancer Research• Oncogenesis• Cell•• Medicine• General• Annals of Internal Medicine• Quarterly Journal of Medicine• American Journal of Medicine• Journal of Experimental Medicine

• Archives of Internal Medicine•

• Cardiology/Cardiovascular• Circulation• Arteriosclerosis• Thrombosis and Vascular Biology

• Heart• Atherosclerosis• European Heart Journal• American Journal of Cardiology• American Heart Journal•• Cardiothoracic• Journal of Thoracic and Cardiovascular Surgery

• Annals of Thoracic Surgery• European Journal of Cardiothoracic Surgery

• Heart• Thorax•• Dermatology• Journal of Investigative Dermatology• Journal of the American Academy of Dermatology• British Journal of Dermatology• Archives of Dermatology• Contact Dermatitis• Acta Dermato-Venereology• Archives of Dermatological Research• Experimental Dermatology• Melanoma Research• Seminars in Cutaneous Medicine & Surgery• Dermatological Surgery•• Neurology• Brain• Annals of Neurology Neurology• Stroke• Archives of Neurology• Nature Neuroscience• Behavioural Neurology• Epilepsia•

Quality Publications Listed by ACCEA• Diabetes/Endocrinology• Diabetologia• Diabetic Medicine• Diabetes Care• Endocrinology• Journal of Clinical Endocrinology&Metabolism• Clinical Endocrinology•• Gastroenterology/Hepatology• Gastroenterology• Gut• Scandinavian Journal of Gastroenterology

• Hepatology• Journal of Hepatology• European Journal of Gastroenterology and

• Hepatology•• Haematology• Blood• British Journal of Haematology• Leukaemia• Thrombosis and Haemostasis• Blood Coagulation and Fibrinolysis• Transfusion• Haematologica•• Obstetrics & Gynaecology• British Journal of Obstetrics & Gynaecology

• American Journal of Obstetrics & Gynaecology

• Fertility & Sterility• Human Reproduction•• Surgery• General• Annals of Surgery• British Journal of Surgery• Archives of Surgery• American Journal of Surgery• World Journal of Surgery• The Surgeon• Diseases of colon & rectum•• Paediatrics• JournalofPaediatricSurgery•• ENT Surgery• Laryngoscope• Archives of Otolaryngology• Journal of Laryngology and Otology• Clinical Otolaryngology •

• Head and Neck Surgery• Annals of Otolaryngology• Ear and Hearing• Otology & Neurootology• Rhinology• European Archives of ORL-HNS• Current Opinions ORL-HNS• Otolaryngology Clinics of North America

• Otolaryngology, Head and Neck•• Orthopaedics• Journal of Bone and Joint Surgery• ACTA Orthopaedica Scandinavica• Injury• Journal of Arthoplasty• Clinical Orthopaedics and Related Research

• Osteoporosis International• Journal of Hand, Foot and Ankle• Proceedings of Society of Bone & Tooth

•• Ophthalmology• Investigative Ophthalmology and Vision Science

• Eye• British Journal of Ophthalmology• Ophthalmology• American Journal of Ophthalmology• Archives of Ophthalmology•• Neurosurgery• Journal of Neurology, Neurosurgery&Psychiatry

• Journal of Neurosurgery• Journal of Neurotrauma• Neurosurgery•• Plastic Surgery• Plastic & Reconstructive Surgery• British J of Plastic Surgery•• Urology• Journal of Urology• British Journal of Urology• European Journal of Urology•• Radiology• Radiology• American Journal of Roentgenology• Clinical Radiology• British Journal of Radiology

Future: Could the System Be Improved?

Main Issues• Weak definitions of “sustained” “excellent” “outstanding”• Ceiling and floor effects due to 0.35 rule interpretation• Local bending of the rules (eg 1 application per 2 yrs allowed)• No dynamic rating• Poor rating for young consultant or those who apply infrq• Low applications by women, and some specialties• Low national success for true NHS work

Issues of Transparency 1/2

• According to Abel & Esmail upto the 1990s the Award scheme operated in an almost totally closed and secretive manner.

• Analysis of the bias in the allocation of distinction awards ledthem to call for the system to be abolished because ‘it remains immutably unfair, divisive, and in its secrecy, contemptible. Noother profession would copy this system and consultants would gain respect by scrapping it—especially self-respect.’*

* Bruggen P, Bourne S. The distinction awards system in England and Wales 1980. BMJ 1982;284:1577–80

Further Information• Review Body on Doctors’and Dentists’ Remuneration Thirty-Seventh

Report 2008 Chairman: Ron Amy, OBE

• Pete Abel and Aneez Esmail Performance pay remuneration for consultants in the NHS: is the current system fair and fit for purpose? J R Soc Med 2006;99:487-493

• Andrew Cash and Andre Somers Performance-Related Pay for Hospital Consultants Thoracic Surgery ClinicsVolume 17, Issue 3, August 2007, Pages 425-429

• Annual reports http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082329

Why incentive plans cannot work.

• Kohn argued that reward schemes can undermine quality management. ‘Excellence pulls in one direction; rewards pull in another. Tell people that their income will depend on their productivity or performance rating, and they will focus on the numbers. Sometimes they will manipulate the schedule for completing tasks or even engage in patently unethical and illegal behaviour.

Kohn A. Harvard Business Review 1993;September/October: 54–63

How Should CEAs Really Work?• All levels of achievement should be recognized, not just arbitrary “excellence”

– If all consultants applied each year the field would be more representative• Local Bending the Rules should not be allowed

– Eg. Apply every other year

• Awards should not be only upgraded and never downgraded, they should be dynamic

– Review of all awards every 2 to 3 years

• Excellence should reflect current status and not cumulative status

• Subjective claims should be down-weighted in favour of evidence

• Submitted evidence should be allowed

• All submission should be publicly available for scrutiny (this would discourage exaggeration and error). A new section of the form could be created for confidential information if absolutely necessary.