Time is money in the NHS too Taxpayers have a right to know who is working for how much, says Eric Caines

The British Medical Association has an unerring instinct for getting it wrong. First it responded excessively by threatening to work to rule if Virginia Bottomley persists in requiring NHS trusts to introduce systems for determining pay levels for doctors locally. Then the doctors spoke of their determination "to stop covering up the appalling things that are going on to keep the books balanced", just as a draft Audit Commission report on Hospital Medical Staffing was leaked - subtitled A Case fo r Diagnosis and Treatment - suggested that the doctors themselves were not without blame.

Recognising the guarded language in which the Audit Commission's reports are written, there can still be no mistaking the thrust of its statement that the "commission's evidence on the reasons for variations in consultants' workloads and the effects of private practice do seriously suggest that trusts should monitor consultants' fixed commitments"; nor the statement that the commission has found "wide variation in the quantity of consultants' clinical work, which appears to relate cost strongly to theirattendance at sessions rather than [to] differences in their ability to do the work".

It is also worth noting, as makeweight facts which give a better perspsective to the debate, the findings that (i) the mean earnings from private practice of those consultants undertaking private work in addition to their NHS work in 1992 were £27,000 per year, with 16.5 per cent earning more than £50,000 per year and 4.2 per cent earning over £110,000 per year; and (ii) the number of doctors has been growing faster than demand for health care in recent years, with a resultant fall in the number of patients per doctor between 1973 and 1993 in all the main specialities of between 4 and 24 per cent.

No wonder consultants panic at the thought of local pay and particularly performance-related pay. What they have realised is that if trusts do eventually get round to introducing local pay systems they ought, as part of the same exercise, to be asking themselves what it is they want to pay for.

The big gains for the NHS over the next few years in terms of increased efficiency and improved quality will result not from the introduction of local pay per se but from jettisoning outmoded and rigid work arrangements which have been designed to protect the professional and career interests of the different staff groups in the NHS rather than to serve the interests of patients.

By and large, patients are treated like components on a car assembly line, being handed on from one set of workers to another who each do what their grade descriptions (drawn up for pay purposes) define as their duties - and no more.

In a recent poll in a large trust, 60 per cent of staff responding said that "it is not my job" was a statement frequently heard in the areas in which they worked. What doctors fear, therefore, is that the introduction of local pay would mean not only that the requirements of their jobs would be more closely specified but that their performance would start to be managed and measured in ways which would reveal the inefficiencies and low standards which some have been covering up for years.

To quote another Audit Commission finding, "job plans are ... an important instrument in ensuring value for money from consultants" but "in many hospitals job plans ... either do not exist at all, do not contain all the required information and/or are out o f date". Performance-related pay in particular would, they fear, lead to new forms of accountability and openness around "clinical outcomes" (ie, what is actually achieved by what doctors do when they treat patients). A mountain of reports shows that doct ors treat even the most common conditions in bewilderingly different ways, largely ignoring the evidence that some approaches give much better results than others.

Sadder than all these facts, however, is the realisation that most of these issues are unlikely to be subjected to the scrutiny that is so obviously required, not least through the introduction of local pay. Here there has been a colossal failure of management will. It is now coming up to four years since NHS trusts were given the statutory green light to decide for themselves what their staff, from doctors to porters, should be paid. Yet amazingly few have done anything with this important freedom. There has been some tinkering around the edges in a handful of Trusts but no local discussions on doctors pay. The real reason why so little progress has been made is that ministers still do not understand that unless something is made to happen, nothing usually happens.

Out of sheer cowardice or from political judgment (the same thing seen from different ends of the telescope), ministers have been unwilling to dismantle the central pay systems - the review bodies for professionals such as doctors and nurses and the Whitley Councils for non-professionals such as clerical staff, porters and domestics, etc. For the whole period since the last election, the Government has been desperate to avoid stand-up rows with doctors and nurses. But to allow the review bodies and the Whitley Councils to go on from year to year recommending or agreeing overall pay increases has fatally undermined whatever inclinations trusts may have had to introduce local pay. The result has been a Catch-22 situation, with mini s ters unprepared to kill off the central systems before the introduction of local pay in trusts and trusts being unwilling to introduce local pay while the central systems remained intact.

This year probably offers the last chance of making any progress at all on local pay before the next General Election. The Chancellor has announced a public sector pay freeze and a requirement to tie all increases to productivity gains; in pursuit of this policy, health ministers have asked the review bodies and the Whitley Councils to recommend no increases for the coming year, but they have also pressed them to accept that some part of any agreement should be tied to local performance. What a m u ddle.

In reality, therefore, the war the BMA has now apparently declared may be no more than a phony war. What is needed is for one or two trusts to ignore both the politicians and the BMA and start trying to do what they should be doing for themselves in pursuit of improved services. The question is, who will be first out of the trenches?

The author is professor of health management services at Nottingham University and former director of personnel for the NHS.