It may be time for different salaries for different specialties in different locations to plug extreme rota gaps, say Matt Morgan and Peter Brindley

Happy 70th Birthday, NHS. We are proud of you and we love you. As a septuagenarian, in theory, you can now spend your days travelling the bus for free and sneaking into afternoon movies. Instead, Britain still needs you working, and harder than ever. As such, please excuse these two young whippersnappers, but we think it is time for “the talk.” What do you want going forward? What are you prepared to give up? And what sort of legacy do you wish to continue? We know that this is a tough discussion, and we know we’d all rather ignore it. We only bring it up because we care. We put it off as long as we could.

We wholeheartedly stand behind your principle of equality of access despite socioeconomics or postal code. Alongside education, healthcare is a magnificent way to provide opportunity, and these two middle class lads were grateful beneficiaries of your hard graft. However, you have been struggling to keep the lights on for some time. This is in part due to the rapid inflation of available treatments and diagnostics. With the risk of stating the bloody obvious, things have changed a tad since 1948. Back in the day, your doctors battled the inevitability of death with a scalpel, a brace of antibiotics, and a trusty stethoscope. You now confront 60 000 different conditions, offer 4000 procedures, and stock 6000 drugs. This was hardly what you signed up for. You look tired.

You are also one of the country’s largest employers, and if one thing has remained constant it is that British workers are often unhappy. You need, and we need, a workforce that is fit for purpose. Not only the right numbers, but in the right specialties, and in the right places. Both town and country have problems: smaller, rural hospitals struggle to provide comprehensive services, while so called ivory towers are drowning in volume. We have a suggestion, and this is where it gets awkward. After all, if there’s one thing you don’t usually do in Britain, it is talking about money. Here goes . . .

Sometimes you are penny wise and pound foolish. Please do not wait for a crisis before you spend. Sometimes you are just too generous. Please do not expect to be all things to all folk. Regardless, this is tough stuff, so let’s narrow the conversation to where we feel slightly more qualified to comment. Among other issues, it is time to review the one size fits all model of NHS consultant pay. The NHS is unlike many other countries, including those with a single payer system. It pays the same to a consultant cardiac surgeon, a consultant in wound healing, a forensic psychiatrist, and an occupation health doctor. Or at least you claim you do. You are a bit sneaky.

Part of your strategy to attract people lies in what is euphemistically called creative job planning. With all respect, this system is already a bit Animal Farm, where “everyone is equal, but some are more equal than others.” For example, you offer posts with a high number of sessions attached. You also try to tempt folks with those on-again, off-again pay awards. A few are making “loads of money,” while others collect the minimum. We suggest that this strategy to deal with market forces could be more transparent. Simply accept that, where extreme shortages are impacting the NHS’s ability to deliver safe care to all, you could pull the salary lever. Like our medical cousins around the world, it may be time for different salaries for different specialties in different locations. There, we said it, and now we can’t take it back.

Before the outrage begins, let’s be very clear. This is in no way to argue that different specialties have different worth. Moreover, each specialty has equal potential to enhance or mess up a patient’s life. Pay is not delivered according to moral or health worth in any sphere of life. If it was then bankers would be handing their Porsche keys over, and teachers would be driving them away. Also, we are not saying that pay is determined by “rarity”; otherwise a small specialty such as cardiac surgery would be paid far more than larger groups such as psychiatry.

Perhaps we need the courage to contemplate the contrary. In specific geographical areas, where psychiatry is in dire straits due to staff shortages, psychiatrists could be paid more than cardiac surgeons. We shall pause to let you gasp. However, this general idea of geographic incentives approximates what they do in Canada and Australia in hopes of caring for the North and the Outback, respectively. Admittedly, it hasn’t fully solved their problems, but the extra costs it incurs may be offset by reducing treatment delays and locum costs.

You might argue that “tiering” professionals breeds resentment and false incentives. However, you have lived with this system all your days. Two tiered UK healthcare means that you already have private medicine, and to a far greater extent than other countries. Moreover, London pay is sometimes weighted, just as the Highlands and Islands can get special allowances. Regardless, this may help level out the playing field where those in specialties with long waiting lists find themselves with less private work. This is because public staff shortages can be mitigated using differential pay.

Presumably what is good and bad for doctors applies for nurses too. Presumably, we need to get that thorny conversation sorted in short order. After all, next comes that even more contentious subject: what services should be covered and what should not. This is the part in the conversation where we typically all look at our shoes.

Overall, we are not arguing that any new system would be perfect. We’re not even arguing that it is more “right” or “moral.” Moreover, in your seven decades you’ve probably heard every overly simplistic solution to every overly complex problem; we wouldn’t be surprised if you’ve had it up to here. Like you we are just fighting to remain true to your vision of healthcare for all. The NHS is a beloved national treasure. We want to keep you around while also keeping patients safe and staff engaged. Life is getting tougher, and you are looking frail. It’s time to have a tough chat about pounds and pence and common sense. We’d like to wish you another 70 years, but right now that seems hard to imagine. Perhaps not what you wanted to hear on your birthday, but it really is because we care.

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @dr_mattmorgan

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Competing interests: None declared.