The Survey of Manpower Resources and Activity conducted for the Society of Cardiothoracic Surgeons of Great Britain and Ireland by Professor H R Matthews in 1995 has given a detailed insight into the working patterns of cardiothoracic surgeons and cardiothoracic units. At that time there were 180 consultants working in 47 units. Thirty one percent of surgeons performed cardiac surgery only, 44% undertook cardiac and thoracic surgery, 20% performed thoracic surgery only and 6% performed paediatric cardiothoracic surgery. Thirty eight percent were employed full-time and 58% were employed maximum part time.

The majority of consultants worked in excess of their contracted hours, the mean number of hours worked being 45.7 hours a week (excluding on call). The on call commitment was also onerous and 44 consultants were on call more frequently than 1 in 3. These were mainly surgeons in the specialities of thoracic surgery and paediatric cardiac surgery where there were only 2 or fewer surgeons in a unit. The Working Party felt that a 1 in 3 on call rota was the minimum acceptable, and where possible a 1 in 4 rota or better should be organised. Those surgeons on call more frequently than 1 in 4 should be remunerated accordingly. However, it was appreciated that in small specialities it would be necessary for some surgeons to continue to be on call 1 in 2, but a continuous 1 in 1 rota was not acceptable, and such units should probably close.

It was clear that Trusts had been encouraging surgeons to undertake more operations and work longer hours but this had not often been adequately rewarded. Whereas many older surgeons grew up with a philosophy of trying to do as many operations as possible and consequently working very long hours, this was no longer acceptable since the pattern of the cardiothoracic surgical workload was changing. Newly appointed consultants who had been used to the limited number of hours a week now worked by junior doctors, would be less likely to work such excess hours when appointed to consultant posts. There were increasing demands on cardiothoracic surgeons and, in particular, the Calman training reorganisation had resulted in many units having relatively inexperienced registrars. The previous system of having experienced senior registrars able to contribute greatly to the throughput of the unit, was now unusual. At the time of the Matthews report in 1995 many surgeons had their senior registrar operating simultaneously in an adjoining theatre. Because of training requirements and risk management this was now becoming an unacceptable practice and consultants would be expected to assist or be immediately available to help any trainee who was not accredited when operating. This would inevitably result in either a reduction in the number of operations per consultant or an increase in the consultant workforce. The latter was unlikely to happen quickly and therefore the number of operations performed in each unit would be likely to drop and Trusts should be aware of this when planning contracts.

Furthermore, the requirement for continuing medical education (CME) would make further inroads into a consultant's time as will management. There were increasing demands for involvement in audit, with the introduction of more complex databases and additional registers to complete. The reduction in doctors' hours and the reduced years of training, brought about by the introduction of the Calman regime, were likely to result in newly appointed consultants being less experienced. It was therefore considered likely that established consultants would increasingly have to spend a proportion of their time helping and standing by for these new consultants and this would further increase the load on cardiothoracic surgeons.

Having taken all these factors into account and with guidance from the "model workload document from the central consultants and specialists committee of the BMA" (CCSC272 1996-97) the following timetable for maximum part time or whole time consultants is proposed. The number of fixed commitments should be between 5 and 7 notional half days (NHDs) and therefore for the sake of this example 6 fixed commitments are recommended. It should be stressed that a notional half day is the equivalent of 3½ hours flexibly worked.

* This is for a 1 in 4 or 1 in 5 commitment. If the on call is more frequent, extra NHDs should be paid accordingly, e.g. 3 NHDs for a 1 in 3 rota and 4-5 NHDs for a 1 in 2 rota (CCSC272, 1996-97)