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40 We referred earlier to what is seen by some as the tribalism of the various groups which make up the NHS workforce. Here we address a particular aspect of this tribal culture which seems peculiar to many consultants. It can be expressed by quoting the words used by Dr Hugo Mascie-Taylor who, in one of his papers submitted for Phase Two, wrote:
`It is interesting to observe the language that consultants use when describing where they work - they say they work at "St X's", or in London, they may say that they are "on at St Y's" but they rarely, if ever, say "I work for St X or St Y NHS Trust".' 
It needs to be said at once that there are consultants who do feel and profess a strong loyalty to their hospital. We do not quote Dr Mascie-Taylor's words, therefore, as constituting a literal truth. Rather, we ask, as does he, about the consultants' sense of belonging and to what or whom they feel greatest identity. The suggestion made is that there are degrees of identity or loyalty, beginning with their patients, peers and the relevant Royal College, then professional bodies, then the hospital and ultimately, at some distance removed, the NHS, as an organisation rather than an idea.
41 The issue is one of self-identity and belonging. The current education and training of the doctor inculcates a strong sense of loyalty and belonging to the professional group. This is by no means a bad thing: indeed, it has its advantages, in terms, for example, of the influence, advice and support of peers. The difficulty begins if the sense of belonging goes no further than merely the professional group. For with a sense of belonging goes a commitment to the wider enterprise, in this case the NHS and a sense of identification in its success, together with a desire to prevent its failure. If, on the other hand, the enterprise is `nothing to do with me: I just work in it', a vital element in building a culture of high performance is lacking.
42 The problem is exacerbated if the other part of the medical workforce, the junior doctors, are only in any particular hospital for a short period of time, as they move from rotation to rotation. Notwithstanding their obvious dedication and hard work, it must be difficult to develop loyalty to any particular institution, or the larger NHS, save as a set of abstract ideas. Moreover, it could be said that the problem is further exacerbated if different professionals are employed on different contractual bases whereby, for example, nurses are treated differently from doctors.
43 For the future, duties and allegiances to professional bodies and groups must be aligned with the duties and responsibilities owed to employers (NHS trusts) and to the public. Now that chief executives have an overall responsibility for the quality of care delivered by the trust, it follows that they must have the necessary authority to carry out that responsibility. It is senior managers' responsibility to see that all healthcare professionals do their job properly. For this to be achieved, local arrangements for accountability need to be strengthened. Not least of these are the relevant contractual arrangements. As we shall say in greater detail later, the contractual relationship of all NHS healthcare professionals to their local employers should be on a similar basis. This will have particular implications for consultants. But, as the NHS Confederation put it in its evidence to Phase Two:
`The employer is accountable for the quality of care ... and a framework which enables the employer to change the practice of employees must underpin that accountability.' 
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