Noel Plumridge is perplexed by the dilemma of paying for payment by results-induced productivity within a closed, cash-limited system (HSJ, 22 February). I.thought the answer to that was price. As the volumes go up so unit prices go down.

Noel Plumridge is perplexed by the dilemma of paying for payment by results-induced productivity within a closed, cash-limited system (HSJ, 22 February). I.thought the answer to that was price. As the volumes go up so unit prices go down.

The intelligent price setter can incorporate reasonable, prospective activity assumptions into the tariff and then leave PbR incentives to do the rest. If there is a variance at year end they can adjust prices in future years.

Noel also has problems with extending pricing into community services, primary care and mental health. For too long these services have been uncounted and unaccountable - isn't it about time we defined objectives, output measures and costed, priced and monitored them.

Finally he notes that the logical conclusion of PbR is to view each clinician as a profit centre, to be accounted for accordingly. What is wrong with that? Is there any other way? As if we didn't need reminding, Sir.Gerry Robinson's televised visit to Rotherham General Hospital.showed that trying to run the NHS as a series of cost centres doesn't work.

Roger Steer, director, Healthcare Audit