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| >> Service Provision Guidelines Workload of a Consultant DermatologistGuidelines produced by the British Association of Dermatologists, October 1995 and approved by the CCSC of the BMA IntroductionWhen a consultant takes up a post he or she is normally given a job description and a programme of duties. The degree of detail varies widely between different employing authorities. It should be noted that time devoted to private patients or any activity for which special NHS fees are payable, such as domiciliary consultations, cannot be computed within the contract. All consultants are required to have a job plan agreed with the general manager which will then be reviewed annually. Job plans include a work programme which shows the time and place of the consultant's weekly fixed commitments. TerminologyA consultant's contract is based on notional half days (NHDs) and in the description of contracts it is important that there should be no confusion between the term 'NHD', which is regarded as the equivalent of 3.5 hours, and the term 'session', which has frequently been used loosely to indicate the time devoted to an operating list or an out-patient clinic. If the word 'session' is abandoned and the 'NHD' substituted, it immediately becomes clear that an NHD often does not cover an operating list or an out-patient clinic, since these may both often engage a consultant for more than 3.5 hours. Description of ContractsWhilst consultants had the option until 31 March 1980 to retain their original contract, new consultants and those wishing to change have three types of contract from which to choose. These carry the same titles as before:
Holders of whole-time and maximum part-time contracts are expected to devote substantially the whole of their professional time to the NHS which is regarded as not less than ten NHDs. However, in interpreting this obligation, the Department of Health has accepted that it can only operate in the light of a consultant's ethical obligation to all his/her patients when emergencies arise and that maximum part-time consultants must enjoy sufficient flexibility to make arrangements to carry on private practice. This right is recognised in the contract, and, in return, a part of the aggregate whole-time salary is forfeited. Thus, for the maximum part-time contract holder, the programme will be regarded as a basic commitment of not less than ten NHDs per week computed in the flexible way as described later. Travelling time between home and place of work may be included in the computation. Subject to the requirement to give the NHS priority, there is no limit to private practice earnings. There is a right for the maximum part-time contract holder to change to a whole-time contract and vice-versa. This option does not apply as of right to nine session contract holders. Those holding a whole-time contract are permitted to engage in private practice, up to a limit of 10% of their gross whole-time salary (including any distinction award) for that financial year. Nine NHD contracts and contracts for a lesser number of NHDs are not subject to the requirement to give the NHS priority. They permit unlimited private practice earnings as long as the NHS commitment is honoured. Travelling time to and from work may be included in the computation of the programme. When the workload changes substantially after the appointment, it is open to those who hold part-time or whole-time contracts to seek reassessment of the contract with their employing authority by taking on a further NHD. This arrangement is deemed to be temporary and the extra salary is not superannuable. Job PlanAll consultants should have a job plan agreed with their general manager. A job plan is a detailed description of the duties and responsibilities of a consultant and of the facilities available to carry them out. It incorporates a work programme showing the nature, location and timing of the consultant's fixed commitments. The Terms and Conditions of Service state that when drawing up job plans, "the authority shall take the following duties into account: out-patient clinics, ward rounds, operating procedures, investigative work, administration, teaching, participation in medical audit, management commitments (for example as a clinical director), emergency visits, on-call rota commitments and so on". It should be noted that time devoted to private patients and category 2 work, cannot be included in the job plan. A model format for a job plan, including a recommended outline work program, is an annex to the circular HC(90)16. The recommended outline form of job plan gives a general description of the nature of the post and the work it entails. Detailed general guidance on the completion of job plans is given in the "Consultants' Guide for the '90's", issued by the Central Consultants and Specialists Committee. Consultants are strongly advised to read the "Consultants' Guide for the '90's" in addition to this specialty advice before completing their job plans. Part of the job plan is the work programme, which is divided into two sections:-
Fixed CommitmentsOnly fixed commitments should be included in part (a) of the work programme - the weekly timetable. Fixed commitments are regular scheduled NHS activities. They are formally defined as those that substantially affect the use of other NHS resources, such as other staff or facilities. Examples of fixed commitments include operating lists and out-patient clinics. Some work may or may not be a fixed commitment depending on whether it is a regular scheduled activity or not. Fixed commitments are assessed in terms of notional half days (NHDs), which are regarded as the equivalent of a period of three and a half hours flexibly worked. Depending upon the type of contract the consultant holds, along with several other factors, the number of fixed commitments should be as follows:-
In deciding upon the number of fixed commitments, all other components of the job plan must be taken into account. It is recognised that the "normal" number of fixed commitments may be varied with the agreement of the consultant and the general manager, in the light of all other factors which are covered by the job plan. Thus, for example, if a consultant has onerous on-call commitments, with few junior staff, it may be appropriate to make a case to reduce the number of fixed commitments. A Guidance on Fixed Commitments for Consultant DermatologistsIt is suggested that a total of five and a half NHDs as fixed commitments are appropriate for consultant dermatologists, although the type of hospital, number of sites, location of hospital and numbers of junior staff are also factors which need to be taken into account. B NHS Duties of a Consultant DermatologistThe workload varies considerably amongst dermatologists depending on local needs and the particular interests of the dermatologist. For example, some dermatologists spend a good deal of time on surgical procedures, whilst others do not. Similarly skin histopathology interpretation is an important part of some dermatologists' workload. Research, committee work, and teaching, particularly undergraduate teaching, will not be part of every consultant's workload, but some will spend a considerable proportion of their time in one or more of these activities. The following suggestions refer to whole-time and maximum part-time consultants. Other part-time consultants would have their workload reduced on a pro rata basis. 1 Out Patient Clinics Dermatology is predominantly an out-patient specialty, and most consultants would probably spend three to five NHDs every week in the out-patient clinic. It is suggested that in one clinic, taking one NHD, the single handed consultant would see a maximum of either 10 to 12 new patients or 15 to 20 follow up patients, or a mixture of new and follow-up patients, on a pro rata basis. These numbers would need to be reduced if this were a teaching clinic, or if surgical procedures were performed during the clinic. Around 30 minutes should be allowed for dictating letters and checking laboratory reports in each clinic. a More patients will be seen if there are supporting medical staff, such as clinical assistants or trainee dermatologists, but such doctors cannot be expected to see the same number of patients as the accredited consultant, and the consultant will continue to have a supervisory and teaching role, so that the presence of such medical assistants at the clinic may mean that the consultant will see fewer patients on his or her own list. Clinical assistants or trainees should not work in isolation, away from the consultant. A limited number of surgical procedures, such as cryotherapy, curettage, simple excisions and biopsies may be performed during the out-patient clinic, provided this does not increase the duration of the clinic to more than 1 NHD. More complex surgical procedures, including larger excisions, would normally be brought back to a special theatre session. 2 Theatre or Special procedures All dermatologists require access to a suitably equipped biopsy theatre for minor operations, and some, but not all, will have one or more NHDs devoted to surgical work, usually as a fixed commitment. Consultants with another special interest or expertise e.g. in photobiology, histopathology, allergy testing etc. may provide a special service for their colleagues, and may have one or more NHDs devoted to this special interest. 3 Ward Work All dermatologists should have access to beds and day-care facilities, and should be supported by specially trained dermatology nurses. A consultant might be expected to undertake two ward rounds each week and this might account for one NHD. 4 Management and Administration All consultants must now expect to be involved to some extent in these activities, but these will vary, depending on the interest and seniority of the consultant. Most consultants might expect to spend one NHD each week in these activities. 5 Research All consultants might be expected to take an interest in research, but the time they can personally spend in research activities will vary. A teaching hospital consultant might reasonably be expected to spend one NHD each week in research. 6 Teaching and Training This is an important part of a consultant dermatologist's workload, since in addition to teaching of undergraduate medical students, there is a need for teaching and training of other hospital doctors, GP's and nurses. For units which have trainee dermatologists there is an additional workload for the consultant, which is likely to increase with the implementation of the Calman Report, and the use of Log Books to monitor the progress of the trainee staff. A consultant dermatologist might therefore expect to spend between one half and two NHDs each week on teaching and training, according to local circumstances. 7 Medical Audit A consultant dermatologist is expected to spend half a NHD each week in audit activities. 8 Continuing Medical Education (CME) Activities which may be included in CME have been defined elsewhere, and each consultant might expect to spend one half NHD each week in CME. 9 Committees It is essential that there is medical representation on appropriate local and national committees and a consultant dermatologist might spend time in these activities in addition to routine management work. From a half to one NHD might be spent in such work. 10 On Call and Travelling On-call commitments for dermatologists are difficult to standardise. Some consultants have to spend a considerable time travelling from one hospital to another, and some consultants are expected to provide on call service for ward referrals and emergencies in a number of different hospitals. Other consultants may be based only at one hospital with good supporting junior staff, and their commitments may be much less in this respect. It is suggested that between a half and one and a half NHDs might be taken for travelling time and on call work, according to local circumstances. C Facilities Considered Desirable for a Consultant DermatologistDetails set out underneath are intended as a guide to standards below which it would be difficult to provide a quality service that is safe and in the best interests of patients.
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