Or, in simple terms, why should the NHS pay a nurse in Workington almost as much as a nurse in Wimbledon? She'll only fritter it away anyway.

When reading newspapers, a sound piece of advice is to beware of headlines that end with a question mark. When a reporter asks, in bold 124-point type: 'Is Elvis alive and well and living in Essex?' you can be pretty confident the answer is no.

The advice is especially relevant when looking at the Department of Health's 'early draft plan' for the NHS workforce after 2008, recently revealed in an HSJscoop (news, pages 5-9, 4 January 2007). You know, the one that suggests by 2010-11 the NHS in England will have 3,200 medical consultants too many and another 16,200 allied health professionals and scientists for whom the supply is to be 'managed down', but a shortage of 14,000 nurses and 1,200 GPs.

Here we offer answers to difficult questions. Here's a selection from this week's inbox:

Do they mean it is about local pay for nurses?

It's been a DoH ambition for ages, especially since a review of public sector pay identified national pay scales as a problem about five years ago. Essentially it said the public sector pays too much in poor areas and when labour markets are slack; not enough in expensive areas and when labour markets are tight. Or, in simple terms, why should the NHS pay a nurse in Workington almost as much as a nurse in Wimbledon? She'll only fritter it away anyway.

What about local pay for doctors? Are they different?

Don't be silly.

Does the DoH report reveal that NHS workforce planning is still rubbish?

Certainly not. It tells us next to nothing about the quality of workforce planning in the NHS, whether it's actually improved since A Health Service of All the Talentswas so critical all those years ago. The projected shortfall of 14,000 nurses might be down to lacklustre NHS recruitment and retention practice rather than poor workforce planning. After all, we've been training them like there's no tomorrow, so where have they all gone?

And look at the allied health professional numbers. The NHS is projecting a surplus of 16,200: about 10 per cent. That may well be deliberate. It's entirely consistent with the notion of training lots of new people, flooding the market and using the threat of unemployment to drive down pay costs.

Isn't that a bit cynical? Would they really do that?

Get real. Why would we anticipate anything else? We're in a competitive healthcare market now. Besides, the civil servants are still smarting from the drubbing they got over their feeble budgeting for the consultant contract and Agenda for Change. They'll enjoy demonstrating that they were playing with a full deck from the outset.

I don't quite follow. Surely they screwed up the costings for pay reform in a big way? Isn't that behind lots of the deficits?

Well, that's what NHS chief executive David Nicholson as good as admitted to the House of Commons last November. He blamed opaque accountancy. But even if they did (and in truth the cost overruns were as much down to local negotiating weakness as feeble central budgeting), the DoH was playing a long game.

Here's how it goes: back in 2000 or so the NHS needed more staff in a hurry to meet promises on shorter waiting times. So the DoH concocted a cunning plan:

  • improve NHS pay, quickly, as a boost to recruitment and retention;
  • recruit overseas, encouraging both individuals (to fill vacancies) and firms (by opening up NHS-funded provision to overseas competition) to provide extra capacity;
  • destabilise the NHS culture of professional silos and encourage 'workforce flexibility';
  • meanwhile, quietly flood the market with trainees, to transform the labour market and gradually make the other three measures superfluous. And it worked. Just as well, because now Gordon Brown wants his money back and is clamping down on pay inflation.

By the way, there's no connection between deficits and pay, or between deficits and private finance initiative schemes. Is that clear? To put the record straight, deficits are about the quality of local management.

So was it the workforce development confederations that made a mess of the training numbers?

Oh no. They did their job brilliantly, commissioning unprecedented numbers of training places and protecting the training funds from cash-strapped local health economies. For a while. Then Alan Milburn cut their throats.

And what about 'workforce flexibility'? You know, role redesign? The changing workforce programme? The career climbing frame?

Forget all that stuff. That's not what 'flexibility' means nowadays. Who needs new job roles once the recruitment hotspots have been sorted? Flexibility is about working when you are wanted, and having something else to fall back on when you are not. Like working in a call centre, say, or minicabbing. Do try and keep up.

You make my profession sound more like a commodity.

Actually we'd prefer you didn't think of it as a profession. Think of it as a silo. You know, one of those grain stores that people slither into and then can't escape from.

If you mean that, why are the workforce plans still described firmly in terms of so many doctors, so many nurses, and so on?

It's to do with the colleges. They have a business to run as well, you know. It's the only way they can recruit.

OK, then. Why doesnt the NHS take some of those extra therapists we've trained, and design structures using more therapists and fewer nurses? Or more therapists and fewer doctors?

I'm not sure about the 'fewer doctors' bit.

Or care models with more consultants and fewer GPs? GPs are now more expensive than hospital consultants, aren't they?

[Disconnected. Please refer to your service provider.]

Noel Plumridge is an independent consultant and former NHS finance director.