OBJECTIVES: To evaluate the changing role of an open-access consultant-led paediatric echocardiography service for the detection and assessment of cardiac disease in children. DESIGN: A retrospective analysis comparing two patient groups undergoing echocardiography over two corresponding six month periods in 1989 and 1994. SETTING: A tertiary referral centre. MAIN OUTCOME MEASURES: Patient demographics, indication for echocardiogram, source of referral and findings on scan in new referrals, subsequent follow up arrangements. RESULTS: The total workload increased by 51% over 5 years but in 1994 fewer neonates were scanned. Patients were referred by hospital paediatricians, community paediatricians, and general practitioners and the number of "new referrals" as a percentage of the total number of patients scanned remained constant. The number of children referred with asymptomatic murmurs who had "normal" echocardiograms increased. Fewer patients were referred directly for surgery in 1994, but the number of children referred for interventional catheterisation rose. CONCLUSIONS: Open-access echocardiography has an expanding role in the tertiary referral centre despite increasing availability of echocardiography facilities in local hospitals and increased demand in local outreach clinics with paediatricians. Asymptomatic murmurs continue to be the single most common reason for referral of "new patients" and many scans are used to confirm the clinical suspicion of a "normal" heart. The appropriateness of using echocardiography as a screening procedure must be questioned where it would be more logical to refer only the children who present diagnostic difficulty. None the less these data confirm the impression of increasing demands on the paediatric cardiologist, and thus may be useful in planning consultant services within the specialty.