As Charlie Munger once said: show me the incentive and I'll show you the outcome.
NHS consultants earn the same basic pay regardless of specialty, regardless of how much work they deliver. A neonatologist who chose the specialty out of vocation gets the same as a surgeon who chose the specialty for its private practice income potential. Therein lies both the tension and the opportunity.
The socialist-capitalist hospital
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust is seeking a private sector partner to grow its in-house private unit. Last year it generated £6 million in revenue doing hips and knees. The trust describes the market opportunity as clearly significant, emphasising its brand and unique positioning.
Brand. Opportunity. Market. Socialist talks capitalism.
Some questions follow. If the revenue was £6 million, what was the profit? Where did all those extra hips and knees come from? The NHS waiting lists. Who are the surgeons? The trust's own 40-strong NHS consultants, earning private fees in a private bit of the NHS building. The socialist NHS provider cannot crack its orthopaedic waiting lists, but is happy to provide for the market opportunity.
The incentive is the money. It always was.
The on/off drug
When deficits bite, leaders turn to waiting list initiatives. WLIs are the on/off drug of the NHS. When there is money, WLIs are on, consultants say yes, work gets done. When the money runs out, WLIs are off. Consultants refuse.
Incentivise the wrong thing and the humans still respond to the money. Set up WLIs to clear waiting lists and you create an incentive to have waiting lists. One surgeon went rogue and created his own.
Is there a way of incentivising consultants to deliver more without the on/off WLI, paid consistently and properly, as a matter of routine?
The proposal
At STRASYS, the Decision Intelligence engine for healthcare, we have built the analytical infrastructure to make this possible. The Consultant Workforce Optimisation System starts with the question no Medical Director can currently answer: how many consultants do we actually need in each specialty, and what should each be delivering?
The proposal: instead of adding more consultants, and instead of not replacing those who leave and retire, the employer offers the same total money to fewer consultants to deliver all the work.
Offer 25%, 50%, 75% more pay for proportionally more work per consultant. The work that is low risk and simpler to deliver stays in-house rather than being lost to external private providers, daily adding to the deficit.
Fewer doing more, for more pay.
The programmed activity structure already exists to pay consultants more than the standard 10 PAs. The proposal is not just more PAs. It is more patient throughput in each PA, in the extra PAs, in return for significantly more pay. Productivity up. Pay up. Waiting lists down. Headcount right-sized. Income up. Salary costs down.
The Strasys Value Index quantifies what this looks like at trust level: the gap between current value generation and what is achievable when consultant capacity is optimally deployed.
How radical
This has never been done before. It will not work as a national edict. It has to focus on key specialties first.
If a service asks for more consultants: stop. Do the job planning analysis. Map actual direct care PAs to demand. Reveal the soft and flexible sessions that have accumulated. Optimise through team and organisational need. Offer more regular pay through the existing PA structure with detailed activity measures. Allow for those with measurable research and teaching careers. The number of consultants will eventually go down.
The radial final step: place those not needed where they are needed, in other organisations. Those poorly served parts of the UK with seemingly unattractive hospitals that always struggle to recruit would recruit and retain overnight if they offered much higher pay for the work. Because the incentive is the money.
Naeem Younis, STRASYS CEO, argues that the BMA will ask consultants to work less for more. STRASYS's counter-proposal: work more, get paid much more, and in doing so, fix the waiting lists, fix the finances, and fix the distribution problem that leaves some communities permanently underserved.
Consultant Workforce Optimisation
Forensic data triangulation to identify trapped clinical capacity and release it.
Key Definitions
- Consultant Workforce Optimisation System (CWOS)
- A STRASYS product using forensic data triangulation to reveal programmed activity variation and trapped clinical value. Applied to the incentive proposal, CWOS identifies which specialties have the greatest gap between current and achievable throughput per consultant.
- Strasys Value Index (SVI)
- A STRASYS product measuring trust-level value generation relative to population need. Quantifies the financial impact of consultant workforce optimisation, showing what each trust could achieve if consultant capacity were fully deployed.
- Decision Intelligence
- The discipline of converting complex healthcare data into structured, actionable decisions for NHS leaders. STRASYS coined and owns this category in UK healthcare.
Frequently Asked Questions
The evidence already exists. Consultants respond to financial incentives in private practice, in waiting list initiatives, and in insourced/outsourced work. The proposal formalises this: instead of ad hoc WLI payments, build higher throughput expectations into regular contracts with proportionally higher pay. The incentive structure already works in the private sector. The question is whether the NHS will adopt it.
CWOS starts with detailed activity analysis per consultant: how many direct care PAs, what throughput per PA, how much is spent on non-clinical activity, and where soft sessions have accumulated. This data is the foundation for any pay-for-productivity negotiation. Without it, the employer has no basis to set throughput expectations or justify higher pay.
The proposal explicitly allows for those with measurable research and teaching careers. The analytical framework separates direct clinical care PAs from supporting professional activities, ensuring that genuinely productive academic work is protected while PA accumulation that serves neither research nor patient care is identified.
Hiring more consultants within the current model adds cost without proportional output gain. The variation in delivery across existing consultants means there is significant trapped capacity. CWOS reveals trusts where fewer, better-incentivised consultants could deliver more total care than the current headcount. Each new consultant carries a lifetime cost of approximately £7.5 million in salary and pension alone.
Yes. Hospitals in underserved areas struggle to recruit because pay is nationally standardised. If trusts in Blackpool or Sunderland could offer significantly higher pay for higher throughput, they would attract consultants who are currently chasing private practice income in London and the South East. The incentive is the money. Geography becomes less of a barrier when the financial offer matches the opportunity.
This article is adapted from the Friday Fish and Chip Paper, Dr Nadeem Moghal's weekly newsletter on LinkedIn.
Dr Nadeem Moghal
Chief Medical and Innovation Officer