Variation in activity rates of consultant surgeons and the influence of reward structures in the English NHS

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Abstract
Objectives: To explore variation in the National Health Service (NHS) activity rates of consultant surgeons, and examine whether activity is dependent upon the type of contract held and/or bonus payments, after accounting for age and other consultant and hospital characteristics. Methods: NHS Hospital Episode Statistics (HES) for England were used in combination with workforce data in five surgical specialties in 1998/99 and 1999/2000. Descriptive statistics were used to explore variation in activity rates. A multi-level model was used to analyse the relationship between NHS contract and bonus payments, and activity. Results: There is considerable variation in activity rates of English NHS consultant surgeons, with and without adjustment for casemix. Interquartile variation shows that the top 25% of consultants have activity rates 60 to 85% higher than the bottom 25%. A multi-level model indicates that consultant surgeons with a 'maximum part-time' contract have significantly higher activity rates than those with a full time contract (129 more finished consultant episodes (FCEs) per year, 95% CI 97-160). Consultant surgeons who hold discretionary salary points undertake significantly more activity than those without (95 FCEs, 95% CI 62-128). Those with a distinction award (a type of bonus payment) have a tendency towards higher activity rates, but this does not reach statistical significance (48 FCEs, 95% CI -4 to 103). Conclusions: 'Maximum part-time contract' status is associated with higher absolute activity rates among NHS surgeons. Rich data sources like HES merit careful exploration and increased use as an essential first step in measuring and managing variations in specialists' performance.

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