The government is determined to ensure consultants pull their weight in their NHS work - but how tough will the crackdown really be, asks Kaye McIntosh

The diagnosis is uncompromising, the treatment severe - and the prognosis uncertain. The government's NHS plan is going to try to stop consultants spending too much time with their private patients.

The British Medical Association may see the proposals as 'an ill-conceived, vindictive attack on new consultants' freedom'. But private practice has been under attack for some time.

Everyone remembers when Nye Bevan said, in a bid to persuade doctors to sign up to the NHS, 'I stuffed their mouths with gold.' There have been suspicions ever since that some consultants have exploited the contract which allowed them to work in both the private and public sectors.

The plan is clear about the solution: 7,500 more senior doctors will be appointed by 2004, but in return they will 'be contracted to work exclusively for the NHS for perhaps the first seven years of their career, providing eight fixed sessions, and more of the service delivery out of hours'.

The government is refusing to buy out private practice, claiming 'it would probably cost at least£700m'. Instead it insists that existing full-time consultants will have to work seven fixed sessions a week and, for the first time, prove they are doing their jobs: 'The right to undertake private practice will depend on fulfilling job plan and NHS service requirements.'

The threat is, if doctors don't play along, ministers 'will look to introduce a new specialist grade for newly qualified hospital specialists to secure similar objectives'.

If the doctors agree, they will be compensated with better pay for newly appointed consultants. The number of senior doctors qualifying for merit awards will rise from under half now to two-thirds. And the Department of Health will fund centrally specialist registrar posts - the grade just below consultant. A DoH spokesperson says 'no additional funding' will be needed for this.

There is very little evidence to back up - or refute - the suggestion that doctors abandon their duties to earn a fortune on the side.

An inquiry by the health select committee earlier this year said it was 'extremely surprising' that there were no accurate and independent figures showing the average hours worked by the 23,000 NHS consultants. But an Audit Commission survey suggested that fewer than 70 per cent of consultants were attending most (90 per cent) of their fixed sessions - even after adjusting for accepted leave.

Professor John Yates of Birmingham University's health services management centre suspects that many consultants see paying patients in NHS time. Much of the evidence on how much time surgeons spend operating on patients is his; and many doctors have attacked his conclusions that the medical profession could do better.

But Professor Yates insists private practice damages the health service.

'This is not work done in their spare time.' Many surgeons, he says, 'work two, three four days a week in the private sector when they should be in the NHS'.

Consultants resent the suggestion that they might be abusing the flexible contract. British Medical Association consultants' committee chair Dr Peter Hawker stands by his words when the plan was launched, that it was a 'vindictive attack'.

The scene is set for a major battle with the government. Dr Hawker says he wasn't warned about the proposal, despite negotiating reform of the contract with the DoH for the past year. 'I don't think this was thought through.

I don't think they have realised how offensive it is to consultants - people see this as a final straw.'

Setting the number of fixed sessions consultants should work is fine, a lthough he warns it will be difficult to categorise emergency work and time spent seeing patients on the wards.

The BMA's junior doctors committee is vehemently opposed to the introduction of a 'sub-consultant' grade. It even succeeded in pushing through a motion calling for the resignation of Royal College of Obstetricians and Gynaecologists president Professor Robert Shaw at the BMA's annual representatives' meeting in June, because he had backed the grade. Consultants will decide what line to take at their next committee meeting in September. But Dr Hawker says 'the optimist in me' hopes ministers are saying 'we will negotiate hard but we will look at it'.

Professor Yates doubts if ministers will persist with the tough stance of the NHS plan. 'It is a proposal that is part of a negotiation package between the government and the medical profession.

'It has not been discussed with the medical profession - and their track record of negotiating hard is something to behold.'