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The consultant contract

The British media covered the consultants' rejection of a new national contract with surprising intensity last week. Both the Times and the Daily Telegraph splashed the result on their front page.

The Daily Telegraph called it a principled stand against the "lash of Whitehall," whereas the Daily Mirror warned, "Don't let top docs stitch up the NHS." Other newspapers ran equally dramatic copy, using military metaphors to show the growing rift between doctors and the health secretary, Alan Milburn. Doctors face "guerrilla war" over contracts, thundered the Times. The fighting talk continued elsewhere, with doctors "on a collision course" or simply "at war" with the government.

Beyond the headlines, however, there was considerable sympathy for why consultants had rejected the contract, which offered an average pay rise of 15% in return for more managerial control over their work. The Sun warned its readers not to assume this was the action of "idle fat cat consultants." "For the bulk of these experts, priority number one is not their bank balances. It is to ensure that patients get the best treatment as quickly as possible," wrote its health editor. The Independent was not alone in drawing comparisons with firefighters' pay dispute: "As with firefighters, teachers and many other groups of public service workers, the real issue was not primarily about money but working practices and the values of public service."

But the Daily Express put the boot in hard. "Many consultants have an outmoded attitude to NHS work, seeing it as doing their bit for charity while earning their real money, often three times their salary, elsewhere," it commented. Yet its main story acknowledged that 75% of consultants made little or no cash from private practice.

The Daily Mail used the "no" vote as an opportunity to vent its well worn fury against "New Labour control-freakery"; of which, it believes the consultant contracts are just another example. It claimed the doctors' refusal to accept the deal was not about greed, arrogance, or "bloody-minded intransigence," but their concern for an NHS already "bombarded with politically-motivated targets."

But such warm support for the refuseniks was swiftly cooled by a think piece on the same page by Alan Maynard, professor of health economics, quoting Aneurin Bevan that "the only message understood by a doctor is written on a cheque."

Below a picture of fictional autocratic consultant Sir Lancelot Spratt from the film Doctor at Large, Maynard raged that consultants get the "best of both worlds . . . Featherbedded by the state, but with access to lucrative private work. The BMA with its affluent, articulate, middle and upper-class membership and with its role in preserving life, enjoys a unique influence over the establishment and the public, which is ruthlessly exploited to ensure that its members remain well-paid but unaccountable."

Like the Mail, the Daily Telegraph also put the "no" vote down to doctors' distaste for the government's "centralising drive." It argued that the "flood of directives and targets" from Whitehall was now becoming seriously counterproductive: "Just this week heart surgeons said that it is no longer worth their while to treat high-risk patients, because if that patient subsequently dies, it could adversely affect the surgeons' rating in the health department's forthcoming league tables."

(Credit: THE KOBAL COLLECTION/RANK) Sir Lancelot Spratt: was it better in his day?

But the pro-government Guardian thought the consultants were trying to have it all: "We would all prefer to go to work, be paid a lot of money and have no one to tell us what to do." Although some doctors were considering setting themselves up into independent groups, this would ironically make them more subject to control by managers, the paper argued.

The Guardian backed Milburn's plan to seek local deals with consultants. But Jeremy Laurance, health editor of the Independent, wasn't so sure. He pointed out that local deals were not likely to be accepted by those the government most needed to hit waiting list targets, namely the surgeons and anaesthetists.

Some papers believed that the consultants were ultimately powerless against the forces of NHS management. The Financial Times called the consultants' intransigence "the last roar of a dinosaur." It warned that senior doctors who opposed the deal because it compromised professional autonomy and clinical freedom may have to accept that "the days of the autonomous consultant à la Sir Lancelot Spratt are long gone." The paper quotes an anonymous manager saying that consultants should accept being managed "as happens in any other walk of life."

Rebecca Coombes, freelance journalist.