NHS trusts should be getting more value for taxpayers' money from hospital consultants in return for a contract which gave them a 12% above-inflation pay rise, the Whitehall spending watchdog has warned.
The National Audit Office (NAO) said there was still "significant room for improvement" in how trusts managed their consultants despite progress over the past 10 years.
A new contract introduced by the last Labour government in 2003 had yielded benefits, the auditor said, such as ensuring the vast majority have job plans enabling managers to better organise their time.
There had also been no increase in private practice work and consultants' pay progression had been slowed.
However, the new contract was accompanied by new pay bands which were roughly a quarter higher than in the past and consultants' actual earnings had risen 12% in real terms between 2002/3 and 2003/4.
Consultant productivity had continued to fall, although the rate of decline was now less dramatic, and it was unclear how much more work they were doing for the NHS as a result of the contract.
The NAO also said that most trusts were still using locally agreed rates of pay for additional work, ranging from £48 to £200 an hour despite provisions in the new contract for set rates.
Pay progression was still the norm, rather than being linked to performance, it added.
Amyas Morse, head of the National Audit Office, said: "NHS consultants play a key role in the NHS. Given the size of the pay increase given to consultants under the 2003 contract, it is reasonable to expect trusts to have made more progress in improving how consultants are managed and realising the expected benefits of the contract.
"Trusts need to get consultants strongly involved in achieving the trusts' objectives as well as their own clinical goals."