Published: 31/01/2002, Volume II2, No. 5790 Page 23

John Yates' analysis of consultant surgeons' activity (Wait Watcher, 10 January) is convincing and compelling. The analysis and arithmetic are sound; the reality is woefully lacking.

I am writing this in my (shared) office because my NHS elective operations, and those of all my surgical colleagues, have been reduced by half since December.

This is proposed to continue until the end of March to abolish trolley waits in the accident and emergency department, in order to return data showing satisfactory performance.

It is almost impossible to keep orthopaedic surgeons out of theatres - day, night or weekend.

They share a compulsive need to operate, in the NHS and independent sector. The maximum part-time contract is flexible because of variations in clinical needs. The part-time commitment is 34 hours per week, yet the best evidence suggests most consultants work an average 54 hours. Demands to attend management or educational meetings at 8am or leave them at 10pm, are balanced by being able to use non-fixed sessions for non-NHS work, research or recreation.

The annual NHS consultant salary of£87,280 quoted by Professor Yates assumes the recipient will have reached the maximum increment five years after appointment, and then received the full quota of discretionary points. But these may take a further 15 years to accrue. The fanciful£250,000 annual private salary is restricted to a very few surgeons, about 1 per cent of all NHS consultants. And it represents turnover, not income.

After practice expenses, it is likely to be half that figure.

Comparing other professional groups, the income level in private practice represents the value governed by market forces, and consultants reduce NHS costs by contracting to work for a rate that subsidises the NHS.

If all the orthopaedic surgeons in an average NHS hospital offered to double their fixed clinical commitments, there would be neither the anaesthetists, junior doctors, nurses, theatres nor beds to accommodate the increase in productivity. The cost of the prostheses alone (say£1,000 for a hip) has not been included in the equation. Clinical time is now compulsorily assigned to audit and continuing education.

More patients with high expectations now want interventional treatment at an older age. They want longer, detailed, informed, quality consultations with the specialist.

NHS productivity will therefore continue to fall while consultants' activity in the independent sector will probably remain constantly proportional to the number of consultants.

The constraints on improving NHS productivity lie within the NHS. When the resources and staff are available, orthopaedic surgeons will fight each other to get into theatres to operate.

Peter J Robb Consultant ENT surgeon Epsom Surrey