Overpaid or undervalued?: The pay and working practices of consultants in Britain are under fire. Mary Braid and Ian MacKinnon report

IN THE predominantly middle- aged ranks of the medical consultant, Robert Williams is distinguished by precocious talent.

At 32 he became one of Britain's youngest eye surgeons. Six years later, his expertise in one of medicine's more lucrative specialisms earns him more than pounds 90,000 a year.

Like two-thirds of Britain's 18,000 consultants, Mr Williams treats both health service and private patients. His NHS salary at Worthing Hospital, West Sussex, is pounds 44,000 for roughly 40 hours a week. He more than doubles his earnings by working 20 hours in the private sector. On an average 'private' afternoon, he can perform four or five cataract operations, charging about pounds 700 each.

He admits the sums to be made in private practice initially shocked him. But he is a pauper compared with some colleagues. Doctors in full-time private practice can make more than pounds 300,000 a year.

For those who combine NHS and private work, William Laing, a leading health consultant, says the top 2,400 consultants earn pounds 95,000 from private practice, and many double this with NHS pay and bonuses.

Those with the highest earnings are invariably orthopaedic and ENT (ear, nose and throat) doctors, who build up thriving private practices by performing the most common or expensive operations. Specialisms like public health and geriatrics are comparative Cinderellas.

With consultants' earnings so high, there may have been some public glee at last week's announcement by the Monopolies and Mergers Commission of an investigation into the price guidelines for private operations set out by the British Medical Association. The BMA rejects suggestions that its guide prices create a consultants' cartel, preventing competition between doctors. They are, it argues, simply an indication of the 'going rate' for a surgical procedure.

Consultants, however, are beginning to feel persecuted by the questioning of their practices and earnings. Conscious of their poor public image, few will speak on the record, but some suspect an orchestrated assault on the powerful institutions of the Royal Colleges, which critics say perpetuate an 18th-century guild model of training and education in medicine, turning on apprenticeship, patronage and promotion by preferment.

Two weeks ago, a government working party was set up under Kenneth Calman, the Chief Medical Officer, to investigate the Colleges' failure to follow EC directives on the certification of doctors. The directives, set out in 1977, were designed to allow doctors to work in all EC countries. A leak has already revealed that the Department of Health accepts the complaints from the European Commission that Britain's system is 'unlawful and discriminatory'.

Meanwhile, junior doctors are clamouring for admission to the select consultants' 'clubs', arguing that the 10 to 15 years' training needed to gain specialist accreditation is twice as long as it need be, barring them from private practice and NHS 'merit money' or bonuses.

Legal action is being taken to end 'restrictive practices'. Dr Anthony Goldstein, a Harley Street rheumatologist who has failed to gain consultant's accreditation, has won a judicial review of the laws governing specialist medical training.

Private health insurers, increasingly concerned about poor profits and rising costs, are privately delighted by the Monopolies Commission inquiry.

Mr Laing, author of the annual review of private health care, said: 'Health insurers want as good a deal as possible for their clients and they feel the fees are too high. How the level of fees was set in the first place is lost in the mists of time. But Bupa has never negotiated fees with doctors. They just started from the position that doctors' charges had to be fully reimbursed.'

David Cavers, managing director of insurers Norwich Union Healthcare, has commissioned a detailed study by private health care consultants. When it is published next week, it will show that consultant surgeons earn an average of pounds 50,000 a year from their private caseload in just one-sixth of their working week. If they worked full-time in private practice, their annual salary would be pounds 300,000, compared with an NHS salary of pounds 50,000 a year.

'You have to ask yourself, is that rate right?' said Mr Cavers. 'Initially, private insurers needed to pay a premium to attract consultants, because there were so few in private practice. But now two-thirds of consultants do at least some private work and the supply has gone up dramatically. But fees have continued to rise dramatically. In any other market you would have expected economies of scale.'

Insurers are beginning to examine other ways to force down costs. Bupa, with the largest market share of about 44 per cent, may introduce cost-cutting clinical protocols for consultants. The Government's squeeze on consultants began two years ago after complaints that too many were leaving junior doctors to cope while they feathered their nests in private practice. Ministers introduced new 'job plans'

for consultants, formalising for the first time their NHS commitments.

Mr Williams believes that the prevalence of 'shirking' was exaggerated and the government's measures to combat it have proved a waste of time. He estimates that 10-12 per cent of consultants neglected some of their NHS duties and that that remains unchanged. Flexible working patterns mean that much still depends on trust. The vast majority of consultants fulfil their contract or do a little more.

Under his contract, Mr Williams runs three outpatients clinics and three operating sessions a week for the health service. NHS administrative work and private practice occupy the remaining two working days and spill into his evenings. He prefers not to operate or run clinics at the weekend except in emergencies.

He says it is difficult to know what to charge for an operation, and so the annual BMA guide prices introduced in 1989 are useful. He says rival guidelines produced by Bupa are too low and out-of-step with those of other insurers. 'I frequently charge a great deal less than the BMA guideline price and in a couple of cases charge a bit more,' he said.

Professor Miles Irving, chair of external affairs for the Royal College of Surgeons, claims that the BMA guide prices give little cause for concern. He says there is no intentional cartel, and many doctors prefer to follow the Bupa guidelines anyway.

Mr Williams points out that private practice involves costly overheads. He employs two administrators and three nurses part-time and has to fund his own offices. He sees no ethical conflict in combining private and NHS practice. Very committed to the NHS he has no desire to reduce his hours at Worthing Hospital. Private practice is in his own time and never interferes with NHS commitments, he says.

Professor Irving says private practice is a fact of life grasped by Worthing Hospital which is currently considering setting up a private wing in a disused ward. If Mr Williams carried out his private work there, then the hospital would get its cut of the profits which could be pumped back into the NHS.

Mr Williams says estimating one's professional worth is always difficult. 'In one sense I am a total parasite. I am trained by the state and I don't produce anything. But on the other hand I am one of only 400 specialist eye surgeons in England and Wales. This is an extremely competitive profession.'

(Photograph omitted)