The health of the NHS: As the season of suffering looms, doctors should be brought to account

The British Medical Association says the NHS has moved onto a war-footing for the winter. To frighten the living daylights out of everyone, the doctors are proclaiming that it may soon be necessary to charge pounds 10 for a visit to your GP, or hotel charges for a hospital bed - unless the money is raised from increased income tax.

They don't mean it, of course. But it's a way to focus attention on the underfunding of the NHS. An annual blast from the BMA heralds in the winter - season of flu, pneumonia and cold weather-induced coronaries. Trolleys will soon be piling up in accident and emergency corridors again (except where clever hospitals put thick matresses on their trolleys, rename them beds and wheel them into side rooms called emergency wards).

So how bad is the crisis? The NHS needs and expects 2.5 to 3 per cent a year above inflation, which is roughly what it has had over the Tory years. But that is not what it is getting this year, next year or the year after. Debts are piling up and so are waiting lists.

A lot of what the Tories used to call "noise" will be heard from hospitals soon. Doctors will wave shrouds with pleas for more money and some of those shrouds will be real. More money must be found because people love the NHS and if asked in the right way, would be prepared to pay more, whatever Gordon Brown imagines to the contrary.

But that is only part of the story. Despite reforms and although Britain's system is leaner than most other countries, there is still a great deal of money to be saved and spent better in the NHS. And much of the wasted money is due to doctors' behaviour - the BMA's own members.

It is not that they don't work hard - most do, very hard indeed. But the independent hegemony of doctors means they still effectively (or ineffectively) control the way money in the NHS is spent, and they don't do it well. Tackling the power of the medical profession is something no government has ever managed to do: "If Frank Dobson tries it, they'll saw his legs off," said one health economist gloomily.

There are huge variations in what doctors spend, how they prescribe, and how good they are at what they do. Just one example: colo-rectal cancer survival rates depend entirely on the skill of the surgeon, yet some surgeons have six times the survival rate of others. That kind of variation is repeated time and again right across the NHS. Yet most doctors have little idea what their own success rates are, or how they vary from the best and there is still no clear way of forcing underperformers to change.

The mighty Royal Colleges hold the key. They set the exams to certify consultants' proficiency and then hand out licences to practice for life. While airline pilots retrain every six months, with their competence tested on simulators, consultants never do. It's left up to them. (At least pilots usually die with their mistakes, while doctors bury theirs.)

A new system now asks consultants to fill out forms showing they've done 50 hours a year of Clinical Audit. That means showing they have taken off time to discuss their work with colleagues or attend conferences. (Beanos in the Bahamas to conferences on irrelevant topics also count.) As serious retraining, this system doesn't even begin, although it costs the NHS pounds 200m a year in consultants' time off. While some doctors are deeply serious, following every new development, most haven't a clue how they are doing. Among surgeons, only 70 per cent bother to fill out the voluntary Continuing Medical Education forms, declaring what retraining they have done each year.

Evidence-based medicine is the great buzz-phrase at the moment - but how can doctors follow best practice if they don't know what it is? (A recent survey showed consultants were remarkably ignorant of the findings published in the British Medical Journal, which they claimed they depended on. Even specialists could answer few questions on the findings of their specialist journals.) The mighty Royal Colleges have always done the absolute minimum in obliging their members to keep up to date. The Royal College of Surgeons refused to insist their members were trained to use keyhole surgery when it began: many died and were maimed while surgeons learnt this new craft on patients instead.

The colleges operate like masonic lodges with vast assets, yet draw rich state subsidies because they are charities. They decide what consultants are paid through the merit award system. Behind closed doors, they dole out awards of between pounds 20,000 and pounds 60,000 a year, with no objective tests. There is no way of knowing if they give this NHS money to the most efficient doctors rather than to their cronies because there is no public scrutiny. But that money could and should be used to make doctors strive publicly towards cost-effectiveness and excellence. Will ministers dare take on the Royal Colleges, these bastions of the old world?

If they could get their hands on doctors, they could also change prescribing habits: 13 per cent of the NHS budget goes on drugs. Although it has improved, doctors still prescribe very expensive, heavily advertised brand-name drugs over identical generic drugs. If pharmacists were allowed to substitute the cheaper identical generics, pounds 50m would be saved. Doctors should also have to write on prescriptions what the drugs are for, so it can be checked if drugs are inappropriately dished out.

If ministers want to take on the collosal cost of drugs, now is the time, as the deal between the NHS and the pharmaceutical companies comes up for renewal. The NHS pays more than any other country for drugs. That is because the drug industry is a high export earner, so the NHS subsidises their research and development.

But we should draw a line between a fair price for the NHS to pay, and leave the Department of Trade and Industry to decide how much to subsidise the industry: why is the NHS paying for our trade policies?

Everyone (except the consultants) agrees that money needs to be directed away from the galloping acute services into treatments to stop people becoming acutely ill. But there is a never-ending demand for surgery, with doctors as bad gatekeepers. When day surgery and keyhole techniques came in and more people were treated quicker and better, there should have been money saved to spend elsewhere.

Instead the demand for surgery rocketed, showing that whatever politicians say, waiting lists can be a good thing. (Health auditors increasingly suggest that much surgery may be unnecesary, marginal or ineffective.)

Despite the reforms, doctors still control most of the resources within the NHS. Indeed, they should, but not haphazardly. They should participate in rational management decisions taken on the basis of the best available knowledge. All professional groups guard their independence fiercely, but the NHS is a collective enterprise. Will Labour dare step in to make sure doctors' own priorities no longer warp the way money is spent in the service?

Yes, the NHS does need more money. But it is questionable whether the doctors are the best people to make the case until they use their own professional institutions to insist on the very best value from each of them.