ONE important factor in the difficulty of recruiting NHS consultants to the Highlands ("Remote hospital struggling to recruit staff ‘lacks imagination’", The Herald, July 19) is not usually mentioned, notably because it is considered in bad taste to discuss it. This is the role of private practice. In short, all the city consultants have plenty private practice income to add to their NHS salary, but in the Highlands and Islands there is no such added extra. Surgeons and physicians, who might enjoy working and living outside the city, instead cling to city practice for financial reasons.

It might be thought that this differential in earnings is inevitable, but it was not always the case. For the first 50 years of the NHS, if a city consultant wished to do private practice, then a smaller salary had to be accepted – to level things up. Most of the consultants did not take this private practice option and worked full-time for the NHS. Consultant salaries, for instance in Oban or Glasgow, were therefore the same. This worked well, and recruiting staff to the north or Borders was not difficult; there were enough applicants who preferred rural work to a city life-style.

When the Thatcher governments changed the salary structure to allow all consultants to do private work, without any cut in salary, then the situation changed radically. To seek a rural post lacking in private practice meant a serious lowering of financial prospects.

The earlier system suited Scotland admirably and in the vote on the Conservative Government's new contract, the Scottish consultants nobly voted against it, aware of the likely problems posed to rural hospitals (and academic medicine). But the national doctors' libertarian vote prevailed, and the meek Scottish BMA gave in. The damage commenced slowly and the present arrangements for private practice, seldom discussed, largely explain the crisis.

David Hamilton FRCS,

Retired consultant surgeon,

142 North Street, St Andrews.