Published: 17/03/2005, Volume II5, No. 5947 Page 29

The slow-down in implementing payment by results is likely to cause problems at a number of levels.

For trust finance departments it means re-opening hours of detailed negotiations on local delivery plans.

For doctors, who have just switched on to the potential benefits of payment by results - guaranteed income for growth for those who provide a high-quality, efficient service for less than the tariff - it risks switching them off again.

Payment by results is a clever way of encouraging modernisation and continual service improvement, based on a business model rather than the historical quest for bigger and better irrespective of cost.

The beauty is that it takes a holistic approach - with investment aiming to reduce length of stay and morbidity while improving quality of care and patient experience. But the financial gap created by the goslow risks undermining the huge initial enthusiasm of clinical teams.

This issue of clinician engagement was again highlighted for me when a member of our trust modernisation team sought my advice on how to engage consultants in developing the trust directory for choose and book.

We need to involve nearly 80 consultants, responsible for around 300 clinics per month, and ask them to complete over 30 fields for each clinic.

I had visions of my beleaguered colleague spending weeks trying to get an hour with each consultant to explain the system and get their cooperation for the implementation.

The feeling in my stomach was reminiscent of a line in Bob Dylan's Just Like Tom Thumb's Blues: 'Your gravity fails and negativity do not pull you through'.

Faced with a similar problem, the government used cash to engage GPs in adopting choose and book - three dollops of it between June and Christmas.

It remains to be seen whether this will work: most GPs I have talked to still feel too overwhelmed by the new contract to move on to the next initiative. Only the IT savvy with robust existing infrastructures in their surgeries seem to appreciate the flexibility, immediacy and possibility of a better interaction with the consultant that choose and book promises. But in the acute sector, cash incentives are a luxury we do not have.

Fortunately, that afternoon I went to a meeting of our clinical executive committee, where the guest speaker was NHS Confederation policy director Nigel Edwards. Speaking on the psychology of dealing with the burden of policy fatigue, he likened his approach to the television series The A-Team, in which every episode concludes with a vehicle equipped for the job, assembled from whatever is at hand.

The message: to think ahead to where you want to be. And when asked to jump, instead of asking how high, ask for flexibility on how and where you jump.

Fired up by the possibilities of this new perspective, I now see choose and book as an opportunity. The directory is a window on the hospital and, done well, offers us the chance to market ourselves more effectively to a wider audience beyond the remit of patient choice.

With payment by results, we need to work more closely with primary care trusts to design the services together and convince them to create mutually beneficial incentives ahead of full implementation.

So thanks Nigel. It will be easier to engage consultants using the A-Team analogy - selling it as an opportunity to use the policy detritus to build what we want, rather than adding it to the list of initiatives that reinforce the medical profession's role as the great 'done to'.

Dr Hilary Thomas is joint medical director at Royal Surrey County Hospital trust and professor of oncology at Surrey University.