Q&A: NHS consultant bonuses
The bonus scheme for consultants is under attack. Critics claim the system needs overhauling as checks are not being carried out and a loophole means the money cannot be withdrawn even if performance deteriorates. How does the system work?
How do the bonuses work?
The scheme dates back to 1948 when the NHS was created. They are available to consultants and are designed to reward excellence in research, teaching and, of course, clinical care.
They are paid on top of the basic salary - which currently stands at £89,400 on average - and for the top-performing doctors are worth an extra £75,000 a year.
Consultants nominate themselves for the awards with a final decision being made by the local NHS trusts or, for the larger awards, a national committee.
Once a doctor is awarded a bonus given they continue to get it in subsequent years. However, the awards are subject to five-yearly checks.
Why can't the bonus be taken from them?
There is a loophole in the system which means the five-yearly checks can only remove the award in name only.
The clause was inserted right at the start of the health service as a way of enticing hospital doctors into the newly created free NHS.
It means the extra money once given cannot then be removed even if a recipient's standards slip.
For example, a doctor getting the top £75,889 award could get the gold star removed from the records, but would still be given the money each year.
The loophole has created a culture where the five-year checks are not rigorously enforced with some doctors not even taking part in the process at all.
It has meant that in practice very few doctors have had the award withdrawn, even in name only.
Critics argue that the awards have effectively become "lifetime" bonuses.
How many doctors are getting the awards?
The numbers getting them are rising year on year. Nearly 20,000 in England - that is more than half the entire workforce - get some level of payout.
The trend pushed the bill for the bonuses through the £200m barrier last year.
While many awards are for sums under £10,000, there are still more than 5,000 consultants on payouts of more than £35,000.
The numbers in Scotland, Wales and Northern Ireland are much smaller. In Scotland, for example, just 12% of consultants have qualified for them.
What is the government doing about it?
Ministers have tried to reform the bonus system previously. The most recent attempt came during negotiations seven years ago over the new contract, but as yet significant reform has proved hard to get doctors to agree to.
However, as soon as the coalition government was formed, Health Secretary Andrew Lansley pushed for a review of the system in England. The other parts of the UK, which have similar schemes, followed suit.
The independent doctors' pay body is now looking at the issue and will make recommendations next summer.
The BBC understands this pay protection loophole is one of the things they are looking at.
However, they face a fight from the medical profession. Many doctors privately feel it is impossible to justify in the current economic climate when public sector workers are facing pay freezes.
However, the British Medical Association, the doctors' trade body, remains a staunch defender. It says the bonuses are an important part of the overall pay system.
Just how much do consultants really earn?
It is hard to get accurate figures. Even the NHS Information Centre, which records every small detail of health expenditure, is unsure.
With the bonuses, overtime payments and extra sums for taking on managerial responsibility it is not uncommon for the basic salary to be doubled.
In fact, figures obtained by the BBC Panorama programme suggested some consultants were earning more than £300,000 a year from the NHS.
On top of that, there is the lucrative private market, something which is not readily available to the other big earners in health, GPs.
It is estimated about half of consultants do some form of private work, with surgeons the most likely to profit.