George Osborne’s stated purpose in opening up the issue of local pay rates is to ensure “public sector pay does not distort local labour markets”.

This translates, one imagines, as “or take advantage of depressed conditions in local labour markets”. If the cost of living is much lower in depressed Durham than in affluent Ascot, why should pay rates not reflect this differential? If young nurses can’t afford more than bedsits in London, why should their peers in Llanelli be able to buy entire houses?

“There goes Agenda for Change” has been one immediate NHS interpretation. But Agenda for Change wasn’t the only fundamental pay reform. The new consultant and general medical services contracts were ushered in at the same time, and for broadly the same reasons.

As a result we now have some of the best paid doctors in the western world. And, as with other NHS staff groups, we’ve also spent years quietly flooding the market with trainees, gaining enough leverage to claw back the largesse of 2003-04. Osborne’s purpose, whisper it soft, applies equally to the medical profession. Why should a consultant at Craigavon, or a GP in Jedburgh, be paid as if their living costs matched those of their Home Counties peers?

Actually, why stop with pay? Why not trim other benefits accordingly? You were relying on a generous pension, doctor, to retire somewhere nicer? Somewhere warmer? I see. Did you ever consider a private pension?

If such a dialogue seems unlikely, it’s possibly because the medical establishment doesn’t see itself as part of a local labour market, but as part of a nationwide profession. Working for half a lifetime in East Armpit Hospital, toiling in obscurity like Emma Bovary’s husband, isn’t an economic choice but part of a commitment to selfless service.

Yet it’s hardly surprising if, as is happening in Scotland, a devolved assembly questions the priorities implicit in a nationally negotiated quality and outcomes framework settlement.

The technical difficulties of introducing local pay are overstated. In England the tariff system already offers, in its “market forces factor”, a handy set of indices. The cultural difficulties, however, are rather greater.

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