Medical elite faces an attack from Europe: The British Medical Association conference opens today as consultants come under threat. Judy Jones reports

BRITAIN's medical establishment has just had a nasty jolt. For the first time in nearly half a century, the lucrative and highly prestigious post of NHS consultant is threatened with extinction.

The threat originates not from John Major's egalitarian rhetoric, nor from a sudden upsurge of 'patient power', but from the European Commission. Its directorate for the internal market has ruled that the system of specialist medical training and the appointment of hospital consultants in the UK is unfair and discriminatory.

In doing so, it has started a process that should bring about a fall in hospital waiting lists and better patient care.

EC directives came into force in 1977, designed to ensure that fully qualified doctors, whether general practitioners or specialists, could practise anywhere in the EC.

But in spite of the advent of new EC certificates of completion of specialist training, NHS employers and private health insurers continue to place much greater weight on UK certificates of specialist accreditation awarded by the Royal Colleges, following training lasting up to eight years.

The General Medical Council, the statutory body for medical education and training, has kept the list it was legally required to hold of doctors with the EC certificate under lock and key. The medical establishment's justification is that it is protecting patients from potentially inexperienced doctors. Specialist training in most EC countries lasts between three and five years.

However, UK juniors are often left to carry out complex procedures alone and sometimes close to exhaustion. British consultants, critics say, simply want to preserve their monopolistic grip on state and private medicine.

Complaints have increased since last December, when the High Court ruled that the UK higher medical training bodies had been 'perverse' to refuse accreditation to Dr Anthony Goldstein, 39, a Harley Street rheumatologist, when he already had the EC certificate. The GMC has repeatedly refused to comment on Dr Goldstein's charges that 'secret cartels' are used to restrict the number of consultants able to practise in the UK, keeping waiting lists high.

A blanket of official silence has also descended on an admission by the Department of Health that the UK accreditation scheme is in breach of EC law. Department of Health plans for a fundamental overhaul of specialist qualifications and doctors' career structures, drawn up after complaints from the EC, were disclosed by the Independent on 22 June.

The department has told the professional bodies to report their preferred options for change by the end of this month. Health officials believe the most practical solution would be to introduce a new grade called 'NHS specialist', open to those with the EC certificate. For the first time, consultants would have legitimate and fully qualified rivals.

Confidential health department documents say there would be 'significant advantages' in creating a specialist grade. 'There would be significantly higher numbers of fully trained doctors working in hospitals, with the likelihood of improved quality of service to patients.'

Junior doctors' leaders are pressing the Government to scrap the title of consultant altogether. They want a single specialist grade for those appropriately qualified and a single training grade. The juniors' blueprint is expected to come under strong attack from senior colleagues at the British Medical Association annual conference in Nottingham tomorrow.

The conference will hear calls today for a more open debate about health-care rationing given the growing demands of an ageing population on the NHS. Since members of the medical elite seem reluctant to discuss openly their own unlawful restrictive practices, any debate on rationing may seem premature.