The NHS clinical excellence award system, administered by the ACCEA is in short a broken system criticized by the media for unfair consultant bonuses worth up to £75k per year. Partial (cost saving) reforms were suggested in 2010. Here I make my own suggestions how the CEA scheme should be reformed. My previous slideset on this topic was here http://www.slideshare.net/ajmitchell/online-nhs-clinical-excellence-awards-sept08-presentation

1. How to Reform NHS Clinical Excellence Awards
Alex Mitchell, Consultant in Psycho-oncology, Leicester (UK)
For my 2008 in depth discussion of CEAs see
http://www.slideshare.net/ajmitchell/online-nhs-clinical-excellence-awards-sept08-presentation
ajm80@le.ac.uk
Based on the 2010/2011 status quo

2. What are CEAs?
• In 2003 the Clinical Excellence Award (CEA) scheme replaced the antiquated
distinction award system but still has many problems (disparities, lack of
transparency, poor system of evaluation) continue
• In essence this is an NHS scheme designed to financially reward “excellence”
largely in order “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”
• However, CEAs are now under intense scrutiny and in 2010 National awards were
capped by 50% (for new applicants) and in 2011 local (employer) awards were
effectively capped by 43%.
• The CEAs is disliked by the public, and many NHS staff (that is those who know
about it). However it is generally supported by the BMA and existing award
holders.
• Yet true reforms to the system have not been forthcoming.

3. Whats New?
• Since I reviewed the CEAs system in 2008 consultant pay “bonuses” have been
under scrutiny in the media
• http://www.bbc.co.uk/news/health-11523370
• …….And from official bodies such as the National Quality Board and the National
Leadership Council (see Letter from Sir David Nicholson September 2010)
• http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/do
cuments/digitalasset/dh_119273.pdf
• Some (cost saving) reforms to the CEA have already been suggested => next

4. Recent Changes to CEAs
• 1. National awards have been capped by 50% (for new applicants) but with no
change for existing applicants, thus any new consultant will have to be twice as
“excellent” as previous holders to achieve the same level of award
• 2. In the 2011 round local (employer) awards are effectively capped by 43% by a
reduced the ratio for new Employer Based Awards from 0.35 to 0.20*“in order to
reflect the tighter financial circumstances in the NHS”. Again this only applies to
new applicants!
• 3. A five yearly review of level 9 employers awards has now been introduced, the
first time a review of local awards has been suggested. However there is now
review of lower awards, no matter how long they are held for.
• 4. In 2008 the ACCEA published personal statements on the website. This is a
positive step, but full applications are not yet published.
* Employers are told this is the minimum ratio per year but can fall under this minimum providing the funds roll over to the next year.
In addition they rarely award more than the bare minimum

5. What Will be the Effect of the Changes?
How will capping the award rates influence personal progression in future years?

6. Currently 12% Have a National Award
Data from 2009 annual report, sample = 35,000 consultants

7. Awards Are Rarely “Downgraded”
• During the 2009 round 541 applications (731 in 2008) to review existing awards
were received of these 33 cases (16 in 2008), ACCEA found the evidence
insufficient to provide assurance that the award was still merited and has
• required the consultants in question to resubmit review papers in 2010 so that it
can be satisfied that their excellence continues. Only in 3 cases (2 in 2008), the
evidence of awardable clinical contribution was insufficient to justify
continuation of the awards and they were withdrawn.
Impression => Less than 1 in 100 consultants fail
to continue to be excellent, after achieving
excellence. This is barely credible, some
consultants must have somewhat lower
achievement in some years than others. This
shows that the system works as an incremental
(ratchet) not a dynamic assessment of ability.

8. Old CEA Progression Ladder (2003-2009)
L1
L2
L3
L4
L5
L12 / Platinum
L11 / Gold
L10 / Silver
L9 / Bronze
L8
L7
L6
NHS High FlyerTypical NHS
Consultant
Typical Academic
Consultant
Comment: Most NHS consultants reach a ceiling a L9 (local) and academics possibly bronze, but even a high flyer will take years to progress in the current
system which encourages local awards in 1 point increments
L0 (not successful)
Age 39
Age 34
Age 46
Age 42
Age 36
Age 55
Age 40
Age 35
Age 50
Academic
High Flyer
Age 38
Age 34
Age 44
Age 59
Age 57
Illustrated typical year of achieving each level

9. New Projected Progression Ladder (2010+)
L1
L2
L3
L4
L5
L12 / Platinum
L11 / Gold
L10 / Silver
L9 / Bronze
L8
L7
L6
NHS High FlyerTypical NHS
Consultant
Typical Academic
Consultant
Comment: With the new 0.20 local allocation and reduced national awards pot, it is likely to become common for typical NHS consultants to not achieve a L9
and for only academic high flyers to progress beyond a bronze award
L0 (not successful)
Age 42
Age 34
Age 50
Age 46
Age 36
Age 60
Age 44
Age 35
Age 55
Academic
High Flyer
Age 40
Age 34
Age 48
Age 65
Illustrated typical year of achieving each level

10. Problems with the CEA System (as of 2010/2011)

11. 12 Difficult Questions for the ACCEA
1. Are the 60% of eligible NHS consultants who are in receipt of a CEA performing
at an excellent level?
=> Unlikely but perhaps “good” performance should be rewarded too?
2. Are the national/L9 awards to 13% of eligible NHS consultants fairly distributed?
=> Currently academic performance and managerial positions appear to be given
undue emphasis (data submitted to BJP)
3. Should CEA count towards pension?
=> Perhaps but because of the final salary scheme it is very obvious that committees
are favouring those about the retire
4. Should CEA disallow submitted evidence?
=>How else can they be evidence based?....but submissions must be manageable
and adherence to guidelines about what can be submitted

12. 12 Difficult Questions for the ACCEA
5. Should Existing Award Holders be Treated Preferentially?
⇒ No! The allocation rules 0.35 => 0.2 etc should not be changed for new applicants
alone.
6. Should Those Working Part Time in the NHS be Treated Preferentially?
⇒ No! Awards should be pro rata, adjusted for number of NHS sessions (sorry, this
included academics, unless CEAs change their remit to include work done outside
of the NHS for possible NHS benefit).
7. Should Local Trusts Be Allowed to Operate Local Rules?
⇒ No. Please keep the rules fair for all, regardless of which trust is the employer.
That is, ban “fallow years” “uprating of section A/B/C etc” “no applications from
new consultants within 5 years…” and other ridiculous local rules.
8. Should National Committees and Colleges be Allowed to Operate Local Rules?
=>No. Please keep the rules fair for all, regardless of which committee is evaluating.
That is, ban “fallow years” “uprating of section A/B/C etc” “no applications from
new consultants within 10 years for national awards” etc.

13. 12 Difficult Questions for the ACCEA
9. Should Awards Be Restricted to Medical Consultants?
⇒ No. Allow any NHS employee to apply on merit. Already non-medical staff are
under-valued and under-paid in the NHS
10. Should Awards be Given for Life?
⇒ No. Create a working review system which evaluated all current and past
applicants at least every 5 years. This must be peer evaluated and carry no less
scrutiny than the new application. A completely fair system would be evaluations
of forms blinded to personal and demographic information (annonymous).
11. Why is the timetable is unnecessarily complex
⇒ Why must applicants apply for local and national awards and subsequent years
before results are known?
12. Why should non-NHS work be rewarded?
=> Currently work conducted outside of the NHS eg with another employer, or not
for NHS benefit it not excluded. An extreme example is of individuals working in
private practice during NHS time but not “caught” by the private practice code of
conduct who are in receipt of an award.

14. Reforms to fix the CEA System (as of 2010/2011)

15. 12 Reforms to Fix the CEA System
1. Open the CEA to all health care professionals
2. Treat all applicants (local and national) the same by banning “local rules”
3. Move towards an anonymous scoring system based on reasonable clinical,
academic and managerial markers.
4. Allow submission of specific evidence, predefined by the ACCEA as valid
5. Stop trusts capping CEAs (typically at 1 point per year); everyone knows the 0.35
(now 0.20) threshold works as a ceiling not a floor effect
6. Award CEAs pro rata according to everyone’s employment contract
7. Review exisitng CEAs every 5 years with the same degree of scrutiny
8. Disclose the full applications online (as often promised but not delivered)
9. Clarify if CEAs include work conducted outside of NHS time (presumably yes) but
only if of benefit to the NHS.
10. Work with the National Quality Board to develop patient based feedback on
NHS staff that can be included in CEAs
11. Simplify the timetable for CEA to avoid the need for cross-over application
12. Allow the public to comment on the CEA and ACCEA rules and guidelines

16. Appendix – A hypothetical Scoring System

17. A Simple Hypothetical Scoring System
Information Data Type Maximum
points
360 Evaluation Score from Colleagues Submitted online* 10 points
Second opinion requests from colleagues Self-report 10 points
NHS innovations, adopted by locally, regionally nationally Submitted online* 10 points
Committee work of NHS relevance locally, regionally nationally Self-report 10 points
Nationally collated patient satisfaction data Nationally supplied 10 points
Teaching & presentations delivered (local, regional, national) Submitted online* 10 points
Audit completed and presented (local, regional, national) Submitted online* 10 points
Research impact on topics of relevance to NHS Web of Science Citation
Count since last award
10 points
Research published on topics of relevance to NHS Submitted online* 10 points
Number of Peer Reviews Completed Since last Award Submitted online* 10 points
*Submitted online – means submitted to an independent web site prior to award application eg Royal Colleges, Slideshare, Linkedin etc