Peter Kennedy (Psychiatric Bulletin, August 2003, 27, 281–282) has concerns about the quality and cost of locum consultants. Quality would be best assessed by the Royal College of Psychiatrists, as with CCSTs, perhaps by a retired consultant. The lack of a national database represents a failure of management at the Department of Health, as does its failure to establish a register of those other expensive wanderers, patients with Munchausen syndrome.

Do I detect a note of envy at the £180k that locums receive? Fewer would be needed if three sessions extra were paid to over-worked general consultants. My impression is that home graduates tend to do less demanding jobs in liaison psychiatry, cognitive–behavioural therapy, and eating disorders, leaving the ‘dirty jobs’ to those qualified abroad. The pits of medicine, namely psychiatry, geriatrics and inner-city GP posts, have traditionally been filled by graduates of South Asia (Passage from India, Guardian, 27 August 2003). Recruitment remains difficult, due to under-financing and bed closures, against a doubling of the incidence of schizophrenia in London (Boydell et al, 2003). If a similar increase were to be found in epilepsy or diabetes, then extra resources, both in hospital and community, would be made available.

How much are consultants worth? The answer is £450–500k, which is the payment at direct treatment centres for surgical waiting lists.