Enthusiastic, or Bullied Pathfinders?

In Cameron's speech earlier this week on the "modernisation" of public services (note that he's no longer "liberating" the NHS he's "modernising" it) he said:

And new powers for GPs, who can join together in consortia, take control of NHS budgets and directly commission services for their patients. People said there would be no appetite for this. But let me tell you today the enthusiasm of ... over 140 GP-led consortia [who] have now come forward, covering over half the country.

I talk to GPs and I do not hear of much enthusiasm for Lansley's top-down re-organisation of the NHS. However, I hear a lot of other emotions: apprehension, hostility and resentment. But often I hear about resignation to the inevitable. But the facts are there, aren't there?: in December 52 GP pathfinder consortia were appointed covering a quarter of the population, and on Monday this was extended to 140 consortia, as Cameron mentions, covering half of the population of England. Doesn't that show enthusiasm?

No, the opposite. It shows the result of bullying.

I have blogged before about the fears of GPs, and significantly their fear of inheriting PCT debts. It is clear that some PCTs have debts, and that the Department of Health have blamed GPs in part for these debts. After all, if GPs over-refer patients to secondary care, the costs of these "unnecessary" referrals have to be paid by someone: the PCT. These debts are potentially very large, and although they are apparent on the balance sheets of some PCTs, they are hidden on others through loans by other trusts.

GPs are often regarded as being "small businesses" (which is nonsense, because they have a UK-wide contract with the government, they have state-provided pensions and their training is paid for by the state, what other private businesses have these benefits?) and this means that they have some justification in being concerned about being handed a debt in 2013 that was generated by state organisations (PCTs). This was a sticking point in the acceptance of GP commissioning and so the Department came up with a compromise. This is outlined in the 2011/2012 Operating Framework, the rulebook for the NHS from April this year:

5.10 GP consortia will have their own budgets from 2013/14. They will not be responsible for resolving PCT legacy debt that arose prior to 2011/12. PCTs and clusters must ensure that through planning in 2011/12 and 2012/13, all existing legacy issues are dealt with. During this period we expect developingGP consortia to work closely with PCTs to ensure that financial control and balance is maintained to prevent PCT deficits in those years. This will reduce the risk for GP consortia that they could have responsibility for any post 2010/11 PCT deficit unresolved at the point of PCT abolition.

This says two things:

1. The department will write off any debt PCTs accrued until April this year.
2. Any debt PCTs generate after April this year will be passed onto the GP consortia.

PCTs are staffed by professionals and, contrary to the right-wing rhetoric of some commentators, they are not profligate. However, read #2 again: any debt that PCTs generate from April this year will be passed on to GP consortia.

Do you understand now the "enthusiasm" of GP practices to become "pathfinder" consortia? If a GP practice joins a year later then it may inherit a debt generated by someone else. Why would any business want to inherit a debt that they didn't create? The GPs simply want to have their hand on the tiller to try and ensure that the debt they inherit in 2013 is as small as possible.

So while there are a minority of GPs who are keen on GP commissioning (for example, the National Association of Primary Care - the cheerleaders for the previous Conservative administration's GP fundholding programme) it is clear that the real reason for the 140 pathfinders is blatantly bullying in the Operating Framework over inheriting potentially crippling debts. Cameron, as usual, is misleading the public over the "popularity" of his policies.

Developing the Health Market

There is a lot of talk about privatising the NHS at the moment. Let me calm you all down. The NHS will not be privatised the day after the Health Bill is passed by toady Tory MPs and their lick-spittle Lib Dem chums. But it will happen a year, or maybe five years after. In a decade's time we will look at our local hospitals and reminisce, wistfully "remember when the community owned all the hospitals and there was proper public accountability?"

The problem is that hospitals are a huge investment (the Department of Health reckons that the hospitals in England are worth, in total, £24bn). Few healthcare corporations are able to invest even a fraction of that amount of money, especially since (as we are told incessantly) NHS funds are tight, so there's not much money to pay for treatments and so profit margins will be small.

However, Lansley has bet his reputation on creating a "healthcare market" of alternative providers. If he doesn't deliver this then he will lose all credibility with his right-wing chums. The likelihood is that few companies will want to invest such large amounts of money right now. So what does a government do when it the private sector refuses to invest through lack of cash? It provides our money, free, for the private sector, of course! This is from the Spending Review document from October last year:

1.89 As well as new opportunities and rights, the Government will assist new providers by improving access to the resources they need. The Spending Review announces that:

• the Government will direct around £470 million over the Spending Review period to support capacity building in the voluntary and community sector, including an endowment fund to assist local voluntary and community organisations. As part of this, the Government will provide funds to pilot the National Citizen Service and establish a Transition Fund of £100 million to provide short term support for voluntary sector organisations providing public services. The Big Society Bank will bring in private sector funding in addition to receiving all funding available to England from dormant accounts;

So, when the government is cutting the NHS budget so that some people are being denied treatment; while the government is cutting local authority funding so that social care budgets are being slashed and vulnerable people are not getting the care they need, while all of this is happening because "there's no more money", we learn that there is more money, but it is being used to maintain Lansley's reputation with his right wing chums by creating a market we do not need. Brilliant!

Health Inequalities

Today Cameron said:

"Health inequalities in 21st century Britain are as wide as they were in Victorian times"

(...and then he talked some bollocks about the rich living longer because they can buy healthcare, which is not the driver in making the rich live longer, it is better diets and living conditions.)

This didn't seem right, so I did some searches and I came up with the Marmot report (2009). I guess if I had spent some time reading this I could have gone further, but there are 147 pages and I could not see a graph that proved the point one way or the other. In any case, scanning through it I could not see any data going back to Victorian times. Instead I resorted to twitter, asking my followers if they knew whether it was true or not. One reply (from @border_rebel) suggested that I looked at the Black report. The problem was that this was 30 years out of date (published in 1980) and I could not easily find inequality figures.

Another Twitter follower suggested that I asked Gary Wallace (@geerai) so I did. He said initially that it sounded like Cameron was talking nonsense, but said he would get back to me with some statistics. In the meantime I saw a tweet from FactCheck covering this topic.

The figures that are used are mortality of the various social groups. Cathy Newman points out:

"The only comparable figures we can rely on begin in 1921"

and then she concludes:

"If the Prime Minister had claimed that health inequalities were worse than at any time since the 1920s, he’d have been on firm ground. But he stretched it too far. There’s no water-tight evidence to show that 2011 holds a mirror to Victorian times."

Clearly Cameron was over-egging the pudding by mentioning "Victorian times". Gary tweeted back a bit later with a link to a lecture online on health inequalities by Prof Danny Dorling. This screen shot is taken from that presentation:

The graph shows the change in mortality rates over the period 1921 to 2005. The ten lines are for various social-economic groups where the darker the line is, the poorer the people are. What is interesting about these figures is that initially the poor improve much more than the rich up until the 60s when the rich started to improve more than the poor. However, it is important to point out it is not that the poor are no longer improving - they do - it is that the rich are improving faster.Since the rich are improving faster than the poor the difference - the inequality - gets larger.

I have heard this mentioned before, and heard someone retort sarcastically when Cameron says he wants to reduce the inequality "how? by making the rich live less long?".

The poor are improving (life expectancy getting longer) but not as fast as the rich. Assuming that policy does not stop the poor improving it will mean that at some point in time they will catch up with the rich. They must! There is a limit to the the life expectancy of the rich, and as the rich approach this limit the change will plateaux. At this time the poor will continue to improve and so the inequality will decrease largely without doing anything. (OK Prof Dorling cautions against this approach, saying that government policy must still target decreasing health inequalities.)

But there is an important issue: the poor are more likely to smoke than the rich and the single-most important health decision you can make is to give up smoking. Labour passed the most important legislation to achieve this: the ban on smoking in public places. This has led to large numbers of people giving up smoking, but the effects on mortality will take some years years to work through.

I wonder if Cameron's speech writers are thinking about these bits of information? Perhaps they know that the combination of, at some point in the future, the rich improvement in mortality will be at a lesser rate than the poor, combined with the benefits of the smoking legislation giving an improvement in mortality of the poor, will mean that in a few years time Cameron will be able to point at the health inequality figures and say "I did that!" when really it would have happened anyway.

House of Lords

The Parliament Act 1911 asserted the supremacy of the House of Commons over the House of Lords. Of course, at the time, since half of the population was excluded from voting in elections for the House of Commons, this is not quite the case of democracy winning over the hereditary principle and patronage, but it was almost there. Since then, there has long been a campaign to abolish or further reform the House of Lords, and these are my thoughts on the subject.

As a result of the Parliament Act (and subsequent acts) the primary aim of the Lords is as a revising chamber: the members scrutinise laws and suggest amendments. The Commons usually accepts the Lords amendments, but they don't have to. In addition, the Salisbury Convention is that the Lords should not block government bills that were mentioned in the government's manifesto. This scrutinising of bills is very important and helps to prevent bad laws being made.

Lords reform has a long history, but the main issues that people cite are privilege and patronage. The privilege issue comes from the fact that some of the Lords are hereditary and their membership of the House is based on an accident of birth: they happen to be their father's child. The House of Lords Act 1999 partially fixed this by removing the right of all but 92 hereditary peers. The problem is that there are still 92 people in that chamber who are there because of who their father was, rather than on their own abilities. When one of these Lords dies there is an election between the members of the Lords to determine which hereditary peer will take up the place. This partially breaks the hereditary principle on the membership of the Lords, but it is hardly democracy since the hereditary principle is used to determine the "candidates" for the vacant post.

The patronage issue comes from the fact that the rest of the Lords are appointed life peers. The majority of new peers are recommended by the political parties and these recommendations are vetted by the Independent Appointments Commission. The Commission also recommends non-party political members. The problem is that this system is wide open to political patronage highlighted by the cash-for-peerages scandal where party donations were sought with an offer of a place in the House of Lords. 

The usual argument is that if the House of Lords is wholly elected then these issues of privilege and patronage will disappear. The problem with this approach is that modern politics is all about privilege and patronage. While there are some MPs who have been elected through their own hard work, there are many who were selected as a candidate in a safe seat through patronage. And there are several MPs who are the children, siblings or even spouses of MPs, so one could argue that there is some hereditary principle in the Commons too!

However, my main concern is what we will miss if we make the Lords wholly elected. Many of the life peers are there because of what they have achieved: scientists, musicians, artists, doctors, people who have run charities. It also has Lords who were judges, and there are bishops of the Church of England (and by convention, the Chief Rabbi is a member). There is a wealth of experience and knowledge in this collection of people and the expert nature of the chamber is ideal for an organisation whose main purpose is to scrutinise and amend legislation. If the upper chamber is elected it is unlikely that these people will wish to stand for election, for the simple reason that they are not politicians. The result of elections to the upper chamber is that we will merely get a mirror image of the House of Commons. Some people have suggested that a different election process should be used, and this could even cause the problem of the upper chamber claiming it has more legitimacy than the Commons because of its election process.

So I propose that the House of Lords should remain wholly appointed. You may think that this is against my democratic instincts, but it is not, as I will explain. First, there must be some tidying up. The House of Lords should be revising only and so after reform legislation only originate in the Commons. There should also be rules about how long bills can be delayed (currently it is one year). The new chamber will also have no hereditary Lords (or rather, none there because of their title).

The new House of Lords will be by appointment, but without political patronage. The important point is that the people nominated for appointment to the House of Lords will be elected by membership organisations. The Independent Appointments Commission will determine which membership organisations will provide nominations, and then appoint their nominations to the House. The appointments should be fixed term and require a renewed approval of their membership organisation (I am not in favour of term limits, but open to be persuaded if there are any good reasons). There could also be a right of recall to take into account situations when a Lord has proven to be unsuitable. If the Commons has fixed term parliaments then the Lords appointments should be of a different cycle (so if the Commons is 5 years, the Lords appointments could be for 3 or 7 years). Rather than appointing the House all in one go, and to keep some continuity, the appointments should be staggered (say, a third at a time).

So what sort of membership organisations would nominate peers? I suggest it should be a wide range, but the important point is that there is a membership. This will mean that trades unions, churches, charities and professional organisations can nominate members. So the Royal Colleges of medicine will have a member each, as will the Chartered Institute of Accountants, the Institute of Physics, RSPCA and the National Trust. The Inns of Court and other lawyers organisations will ensure that there are some legal experts in the chamber. Special care would be taken to make sure that most religions have a member. In addition, organisations like the AA and RAC and sports organisations like the Amateur Athletics Association will have members. The whole point is to ensure that as wide a range of experts as possible are in the chamber.

Each organisation must hold a ballot of their members, in effect, they will do this to nominate their most expert member who will provide their knowledge of their area of expertise to make our laws better.

This will make sure that political patronage is removed almost entirely from the process, while maintaining a chamber of experts elected by their peers. If the range of membership organisations who provide nominations is kept as wide as possible, then it means that everyone in the country will have at least one opportunity to vote for a nomination, and this will give some democratic legitimacy to the appointment.

FT Membership

There are 132 Foundation Trusts in England and these provide acute, mental health and community care. An FT is a "public benefit corporation" which is meant to be loosely based on the mutual concept, that is, the service user "owns" the provider. The way it works is that every FT has a membership, which is some combination of patients, carers, staff and the people living in the geographical locality (interestingly, members can be as young as 16, younger than the age of majority).
Pulse have produced a short guide to FTs and this point seemed interesting to me, referring to FT membership:

But according to David Stout, Director of the PCT Network at the NHS Confederation, this could potentially undermine a consortium’s claim to be the representative of patients locally: “Through their governance strategy Foundation Trusts have a system of membership. Patients are members of Foundation Trusts and that gives the trust some legitimacy in how they operate within the health system – they can say they genuinely represent patient views. That’s potentially a challenge to [GP] commissioners who also claim to represent patient interests and patient views. If you as a commissioner want to redesign services in a way that takes care out of the hospital and puts it closer to home in general practice or community services and the hospital is resistant to that change then their well-developed system of patient representatives might be a challenge to your decision making.”

Lansley says that he will not provide instructions about how GP Commissioning Consortia are managed. He will not require patient involvement (indeed,, he does not even require GP involvement in the consortium board).

The NHS white paper partially acknowledges that FT membership could be seen as more legitimate making the FT boards more accountable than GP consortia where it says:

We will consult on future requirements: we envisage that some foundation trusts will be led only by employees; others will have wider memberships. (4.21)

This seemed to indicate a weakening of the membership model. However, Next Steps, the government's response to the white paper consultation, says:

The Government has considered these concerns and concluded that staff-only
membership would not be compatible with the foundation trust model.(6.17)

Which removes the threat of employee-led ownership (management buy outs) but the document does not provide any more detail on the consultation on membership promised in the white paper. Next Steps does say:

The Health and Social Care Bill will make explicit the duty of governors to hold the board of directors to account, through the chair and non-executive directors (whom they have power to appoint and remove); (6.15)

There is no equivalent public accountability of GP consortia. This means, as David Stout points out, FTs will have memberships, consortia will not.

I wonder if, in the future, we will see a clash between FTs and GP consortia, particularly if the consortia demand service changes (which may involve closing part, or all of a hospital) and the FT refuses stating that they have the support of their membership and hence greater public legitimacy and accountability.

The privatisation starts

Pulse reports that

NHS London has awarded a contract to the KPMG Partnership for Commissioning to support the development of pathfinders across the capital. The partnership, claimed to be the first of its kind, sees KPMG teaming up with UnitedHealth UK, the National Association of Primary Care, Healthskills, NHS Primary Care Commissioning and legal firm Morgan Cole. 

NHS London is the strategic health authority (SHA) for London, as the name suggests it provides the strategic policy for the area. NHS London oversees the commissioning performed by eleven primary care trusts (PCTs), these PCTs commission care from GPs, community health services, acute and mental health trust (hospitals). The "pathfinders" are groups of GP practices (consortia) who, under Andrew Lansley's plans, will take over commissioning from PCTs in the next couple of years. The "pathfinder" status is not a pilot or trial because GP commissioning will happen even if the pathfinders fail. The pathfinder programme is just a way for Lansley to implement his policy without Parliamentary approval; undemocratic, sure, but then again, we have a Conservative government without an electoral mandate.

There are several interesting things about this decision. The first is that there will be one, SHA-wide, organisation providing commissioning, whereas under PCTs there were eleven such commissioning organisations. Can someone tell me how this decision will provide the much lauded "localism" that this government strives for? This seems to me to be taking the commissioning decisions away from the local level and into a large, private organisation.

Admittedly, this decision is just for the interim, the pathfinders are not yet statutory organisations and are in "shadow" form so when they have complete control they will be able to buy services from whoever they choose. However, it is likely that a pathfinder consortium which takes on the services of this company would find it expensive to change provider or to provide the services themselves later on, so this this company will be the provider in the future.

Reading through the comments on the Pulse article raises other questions:

• Anonymous - London | 14 Jan 11 I don't wish to be churlish but, under competition law NHS London are obliged to run a open tender for this contract. I have seen no advertised tender, and suspect there was none - which just isn't right. I doubt if anyone will refer the matter to the competition authorities, however...
  

It would be rather embarrassing for a Secretary of State so obsessed with competition if it proves that NHS London were acting in an anti-competitive way.

Another point is that the commissioning (for the interim at least) is being handed over to one private company. We know that PCTs currently employ commissioners and it has been suggested many times that PCT commissioners would transfer to the new consortia. This has not been the case in London. The commissioning has been handed over entirely to a private company. Of course, that company is likely to recruit existing, experienced commissioners, but this is not the situation that was spread in the Press by Conservatives (in an attempt to allay fears of privatisation). This was picked up by one of the comment writers on the Pulse pice:

• Marie-Louise Irvine - London | 14 Jan 11 This is just the beginning. Now they are the ones providing commissioning support for pathfinder consortia - next they will be providing the commissioning support for actual consortia after 2013. For those who think that consortia will be able to employ ex PCT people directly - I have news for you. At an information event about consortia development I attended the other day we were informed that consortia will very likely have to tender for their commissioning support. Ex PCT people will have to form organisations and competitively bid for the contracts. Organizations like KPMG will be light years ahead of them in knowing how to win these contracts. Some GPs have a kind of fantasy consortium idea in their heads, where they will be able to carry on the kind of co-operative and collaborative relationships they value such as with the local hospital, experienced local ex PCT staff, etc, whereas the harsh truth is that they will be so circumscribed by competition law and and outsmarted by clever and powerful private companies, that they will find they can't do many of the things they'd like to. There will be little room for manoeuvre. But as long as the GPs make the cuts and take the flak they will be serving their purpose. I can predict one thing - it won't feel like "empowerment".
  

If this is an indication of what the future holds, it certainly shows that the publicly owned NHS is on its way out.

BBC News

OK so the last post said I was proud of the BBC, this one is not so complimentary.

Last September Mark Thompson, the director-general of the BBC, visited Number 10. This caused a bit of a stir since the BBC were putting together programmes to explain the cuts. The DG claimed that the impartiality of the BBC was not affected, but it seems to me that since then BBC News have softened on the cuts, and are all too keen to tell us how "necessary" the cuts are (when have you ever heard a commentator suggest that perhaps a higher contribution from tax may be a good idea?). And in particular, even though a year ago the public were clearly satisfied with the NHS, the BBC seem so positive about Lansley's policies for the NHS, and do not mention at all that they are unnecessary and costly.

I've noticed BBC News has a tendency to churn out reports about the NHS that, well, seem to be of tabloid "quality". Let's be frank, 24 hour news is demanding. The BBC journalists have to fill pages on the site as well as radio and TV bulletins. If someone is willing to do some of the work for them, it is tempting for them to accept the help. (For a decade I used to write monthly and fortnightly columns for up to four different magazines and the hardest part was to come up with the initial idea. Once I knew what the article would be about it was then only a matter of finding the facts and writing about them. Rarely would I get a suggestion from an editor about an article subject, but when I did I was always grateful.)

The Department of Health has 40 press officers. That is a lot of people when you consider that the NHS has its own information website specifically for information and statistics about the service. This website should be the first stop for any journalist who wants to write about the NHS, so it makes you wonder what the DH Press Officers do all day. Perhaps they are being helpful to BBC News by thinking up stories for them?

Take for example this one. "Lucrative NHS overtime for consultants questioned". The title is certainly sensational, although I guess if it was in a tabloid the title would be something like "Fat Cat Docs Screw The NHS".

On first sight the article says that some hospital consultants have been "playing the system" over waiting list initiative payments (WLIs) and could make £100,000 in overtime payments. The BMA deny the accusation and point out that if there are any large payments it is due to poor management. For added spice, the radio version of the report has an interview with Prof Maynard, a health economist at York University, who rather helpfully drew a comparison with the banking crisis by saying that the WLI payments are same as bankers' bonuses. So to summarise, you get the impression that all NHS consultants were fiddling their timesheets to get up to £100k a year in overtime and this was either due to greedy docs or incompetent managers. The "bankers' bonus" quote from Prof Maynard was a nice extra bit of tabloid demonisation!

So let's look a bit deeper, and look at the facts. The article says

Basic pay for consultants stands at just under £90,000 a year on average.

The Pay in the NHS parliamentary briefing paper says:

The basic consultant pay scale consists of eight pay points, ranging from £74,504 per year to £100,446pa.

These figures are from the NHS Information Centre which gives figures for average basic salaries, as well as average salaries including performance awards and overtime. The parliamentary briefing paper, says that for total pay:

Consultants’ median annual NHS earnings for the period April to June 2010 were £111,700; mean earnings were £120,400

The BBC article says:

Figures seen by the BBC show that, in some cases, consultants are making more than £100,000 a year. 

Nice touch that "figures seen by the BBC", why can't we see them too? Are these "figures" secret? If so, why? The parliamentary briefing paper I linked to above is freely downloadable, so why didn't the BBC link to it? That phrase is typical of lobby correspondents who are passed unattributable information. If this statement is referring to total pay then it is an underestimate since the median pay for NHS consultants is £112k. I suspect this is implying that consultants can earn this amount of money in overtime. Further down in the BBC report it says:

At Coventry and Warwickshire NHS Trust, one ear, nose and throat specialist made more than £105,000 in 2009-2010 in overtime. Another three consultants from other areas made in excess of £80,000.

That's where the "more than £100,000" comes from. But notice that they give just four cases.

According to the NHS Information Centre there are 33,000 consultants (as of Sept 2010). Yet the BBC could only find four cases, and they could not find any aggregated figures (the average payment of overtime for consultants).

The NHS Information Centre says that the average (mean) basic pay salary for a consultant is £90,200. In other words the "average" consultant earns an extra £30,000 in performance awards and over time. Not quite £100k, but still very nice money. However, the performance awards (in effect rewarding skill and excellence because once awarded the consultant is paid the award each subsequent year) vary between £2,957 and £75,796, so it is likely that this is more likely the source of the extra £30k payment above basic salary.

Now here's the odd thing. The BBC article says:

Overtime rates vary, but are often about £600 for four hours

Again, nice money. So how many hours would you have to work to earn an additional £100k? I work it out to be 668 (rounded up to give whole four hour periods). Assuming a 48 week year that means working 14 hours extra a week. Bear in mind that we are talking about NHS consultants who are typically employed on contracts of 4.5 days a week and they are allowed to work the other 2.5 days in the private sector, why would they spend two of those days doing NHS overtime? It doesn't make sense. There may well be one consultant (or even four) in the NHS who is willing to work these hours, but it is hardly likely to be typical.

Updated using information from the comments:

"the salaries quoted for consultants are for a week of 10 sessions of four hours each. Most consultants agree to work between one and four extra sessions at a pro rata rate, of around £200 per 4 hours. There is also a supplement of between 1 to 8% for on call availability at nights and weekends."

So at £200 for 4 hours it would take a lot more overtime to earn the £100k that the BBC quote. However, the supplement is clearly an important source of income. Take an extreme case (extremely unlikely) of the "average" consultant on £90k on call every weekend and every evening. That means earning about £7200 more. Nowhere near £100k.

I think it is acceptable to say that the BBC have written an article on entirely exceptional cases and that a journalist investigating consultant pay from primary sources would not have produced an article highlighting a situation that is so atypical. Even though the "figures" were given such a prominence on BBC radio bulletins and on their website, the story is essentially made up.

There are lots of interesting nuggets of information in the data on the NHS Information Centre website, as well as in the parliamentary briefing paper I linked to above. For example, the following statement comes from the parliamentary briefing paper:

HM Revenue and Customs conduct periodic analyses of the private practice income of consultants by linking tax return data with information from the NHS workforce census. These are used to inform PCT funding allocations. The most recent detailed analysis of consultants’ private income took place in 2003/04. It found that the ratio of average (mean) private income to NHS income was 0.45; that is, on average, consultants supplement their NHS income by an additional 45% through private practice.

This is far more interesting. Almost half of consultants' income comes from private work. That is, the "average" consultant earning £120,400 from the NHS earns an additional £54,000 from private work giving an "average" total income of £174,000. Note that the £54k will come from at maximum 2.5 days work. Few consultants are likely to work 7 days a week, but let's just assume this extreme case. It would mean that they would get 45% of their pay for 36% of the week, and clearly this means that private work is paid at a higher rate than the NHS rate (a rate 45% higher). Of course if the consultant works fewer days a week for the private sector to get the 45% of their income then the private rate will be much higher.

This is not the sort of news that a government whose whole NHS policy is based upon the mantra that involving the private sector will bring down NHS costs would want to make public.

Updated using information from the comments:

Most surgical consultants have to meet malpractice insurance premiums of around £10-15K, room rental, secretarial and office fees, postage etc, not to mention tax out of this average income of £40K.

The important point that the briefing paper omitted is that the 45% is on gross income rather than a more accurate figure which is income after expenses. (Of course, tax will be on income after expenses, so the tax will be on less than £40k.)

However, I still think the investigation of private income of consultants is interesting, since it shines some light on the government's policy which is to expand this area of the health economy. We are told by the government that their policy will just work, and that ultimately it will be cheaper. I want to see the actual figures.


So why is the BBC making so much fuss about dodgy figures about overtime? If the BBC was impartial and wanted to give a clear, complete picture they would mention the private earnings in their article about "lucrative" pay, but they have not. The reason is that the government does not want the public questioning the rates of the private sector. The government wants to have the private sector fully embedded and providing NHS care before the public realises that it costs more than the NHS but, of course, by that time it would be too late to reverse the changes.

The premise behind the article was clearly written by a Department of Health official with the clear agenda to make the public think that the NHS is wasting money and that a "reform" is necessary. The BBC are simply providing Department of Health propaganda.