A 10-PA consultant should work 5 PAs in the clinic, operating theatre, seeing ward patients etc, with 2 PAs of patient administration and 0.5 PA for MDT. A newly appointed consultant on 8.5 DCC and 1.5 SPA (ie with no teaching, research and trainee supervision or department management) may do an extra 0.7 PA in clinic or operating (with an extra 0.3 patient admin) initially pending job planning review.
Consultant work programme/specimen job plan
The work programme/specimen job plan above is for a consultant dermatologist working in a district general hospital. The standard contract for a full-time NHS consultant is 10 PAs per week, typically divided into 7.5 PAs for direct patient care including ward work and 2.5 PAs for supporting activities (SPAs) (7:3 ratio in Wales).
The balance between formal clinics, surgery, specialist clinics, ward work and supervisory activity will vary. Direct patient contact time must be accompanied by appropriate clinical administration time (1 clinical PA requires 0.4 PA administration time). Numbers in clinics should be adjusted to ensure completion within 4 hours (3.75 in Wales), including clinic teaching and immediate clinical administration.
The BMA and the RCP give 2.5 SPAs (3 in Wales) as the ‘typical’ requirement, with 1.5 typically needed for the purposes of revalidation. Additional time is required for training, the lead dean stating that StR supervision requires 0.5 SPA and FY1/FY2 supervision 0.25 SPA weekly. New jobs should detail the proposed SPAs and existing consultants may need to justify SPAs at the job plan review.
Work for national bodies should be acknowledged and programmed and may require a negotiated reduction in the clinical elements of the job plan. On-call commitments will vary with local policies and staffing levels. Those working part time or in academic posts must revalidate. Adequate SPA time must, therefore, be available while maintaining a sensible balance in a part-time contract. Hospital consultants involved in teaching and research need additional time for these activities, which will reduce the clinical elements of the job plan.
New to follow-up ratios
1 new to 1.6 follow-up patients is achievable for general dermatology clinics (not counting patients attending for patch testing, phototherapy, surgery and other specialist treatments).
The recorded new to follow-up ratio in 2011–12 for dermatology in England was 1:2.4. Due to recording problems these appointments are likely to include many patients attending for patch tests, phototherapy and skin biopsies. Commissioners using current inaccurate recording methods should expect to commission for these figures. These correspond to 4,000 new patients and 9,600 follow-up patients ie 13,600 new and follow-up patients/250,000 population.
Typical clinic sizes
A consultant with no travel to other centres, no inpatients, ward rounds or on call, no specialist clinics, no clinic teaching and no junior supervisory role, should undertake two new, two follow-up (or equivalent mixed clinics) and one skin surgery clinic per 10-PA week. With 12 new patients (20 minutes per consultation), 16 follow-up cases (15 minutes per consultation) or up to seven surgical cases per clinic, 24 new patients, 32 follow-up patients and seven surgical procedures are seen per week.
Some clinics (eg those seeing allergy cases or complex specialist disorders) will require longer consultations of up to 45 minutes per patient. Therefore, these are maximum numbers; actual numbers and new to follow-up ratios vary according to case type/complexity, with a ratio of 1:1.6 reported for psoriasis. People attending phototherapy, day care, treatment visits, surgery or investigations should not count or be coded as follow-up cases. Intermediate services take simple cases, resulting in more complex cases in secondary care adversely affecting new to follow-up ratios.
In areas where independent providers have been commissioned to see low cost, high profit cases, cherry picking will lead to those cases seen in local hospitals containing a higher proportion of complex cases. This will result in average longer consultations, higher costs and economic disadvantage to the units and the patients attending.
In a 42-week year, a consultant will see a maximum of 1,008 new and 1,344 follow-up patients and perform 280 operations. A population of 250,000, therefore, requires a minimum of 4 whole-time equivalents (WTE) consultants (ie one consultant per 62,500 based on DH 2009–10 figures). This does not allow for patch testing and phototherapy clinics, teaching students, supervising or training any grade of staff, ward referrals, inpatient care, on-call work, travel or MDTs.
Reductions in clinic numbers are required for consultants supervising and training other doctors and medical students. The impact varies (typically one patient slot/individual) but may mean up to a 30% reduction in patient numbers.