Is this good or bad for the NHS

[TE44]

http://www.telegraph.co.uk/news/newstopics/politics/4975055/Hospital-waiting-lists-will-soar-due-to-European-laws-surgeons-warn.html

I find it quite frightening the hours doctors work, between 2008/2009, 6,080 claims of clinical and 3,743 of non clinical negligence against NHS bodies were recieved.

?769million was paid in connection with clinical negligence during 2008/2009.

How many of these complaints were due to doctors over worked, I've no idea, but I can't imagine you are at your best

when you are exhausted.

[KidKruger]

Your performance inevitably goes down as your hours go up, whatever the industry/sector - doctors included.

And you are exactly NOT at your best when you are exhausted.

The huge hours doctors work may not actually be worth the proportion of the ?797 million that may be attributed to payment of claims against faults caused by exhaustion.

[SteveT]

Until we have the figures (of the proportion) it is merely speculation.

[Marmora Man]

In 2008 / 09 there were approximately 16 million patient episodes - of which 5 million were daycase treatments. This does not include GP episodes - which will be significant. SOURCE NHS Information Centre.

TE44 suggests there were 10,000 cases of negligence in 08/09. As a rough proportion this equates to 0.05% error rate. Which is pretty good in an organisation that relies heavily on humans and is therefore subject to human error.

?769 million represents less than 1% of the NHS budget - others will have a view as to whether this represents value for money or not. For me it seems about right - it would cost a lot more than ?769m to reduce the already tiny error rate in any substantial fashion.

[TE44]

Marmora man, I can see what you're saying in proportion, where peoples lives or deaths become a statistic. The victims or families of victims who have suffered through human error in the NHS, often have a long wait for answers, to a very lengthly procedure.

"The Royal College of Surgeons wants trainee surgeons on a 65-hour working week in order to produce safe, properly trained doctors and cover the workload required by hospitals."

I cannot understand this, I do not have the figures, I do not believe over working and pressurising junior doctors will

produce a safe enviroment.

[Marmora Man]

TE44 - have you read the Book Outliers? In it the author suggests that any skill requires 10,000 hours of practice. The skill could be violin playing, ice hockey, cricket or surgery.

I have worked in / around health for 18 years.

Prior to the imposition of the 48 hour working time directive junior doctors (now known as Foundation 1 & 2 doctors) would routinely work 65 hours a week or more under the supervision of more senior and experienced doctors. This gave them real direct experience of a very wide range of symptoms and medical problems. Coincidently this meant that their three years of training gave them about 10,000 hours of practical experience. The supervision meant that the risk of errors were detected, controlled and minimised. The acknowledged tiredness that junior doctors experienced meant that they became used to making accurate diagnoses under pressure and stress - something to be appreciated when they are dealing with a major medical incident in the middle of the night.

They would then move on to specialised training as surgeons, physicians etc in one of many sub specialties, again supervised by senior practitioners - and again clocking up about 10,000 hours of practical experience before gaining "Consultant" status that meant they have been tested by exam and peer review as ready to practice unsupervised as a doctor.

Reducing the hours that junior / training doctors can put in directly affects their knowledge and skills base. There are two options:

a. Increase the training time to give them that experience but this would require a massive expansion in the number of doctors if patient care isn't to be compromised. The NHS cannot / will not fund this.

b. Accept that, in the future, doctors will have less experience than in the past. This is the route that gov't and the NHS have chosen. It is also why the Medical Royal Colleges - established to develop and improve the quality of doctors are complaining and campaigning for opt outs. I support the Royal College of Surgeons and others in their campaign - there is no doubt that patient care and medical cover has been and is being compromised in order to meet the European Working TIme Directive (EWTD) - also that the EWTD is being flouted, with implicit consent of hospital management, to ensure patients do receive the care and cover they need.

[TE44]

No MM, Haven't read the Outliers.

"It has been estimated that approx 1 in 15 UK doctors is likely to suffer some from some form of dependence" (ethics department, BMA)

I don't know who they are quoting or where they got there figures, it is very difficult to get figures on doctors allowed to continue in there work, who have dependency problems.

It seems common knowledge that many junior doctors use alcohol and other substances, and I know that help is offered to them

and decisions made whether they can continue working with there habit.

I cannot see why by acknowledging there tiredness this would enable them to make accurate diagnoses. Yes of course there is pressure and strain when dealing with life and death but surely a refreshed rested mind would be more able in dealing with

these pressures.

In fact it is contradictory to what we are told from our GP's, sleeping tablets being so commonly prescibed, because lack of sleep can be so debilatating.

MM Do you know if there is public access to the number of doctors/juniors who have suffered from the three most common

disorders (depression, anxiety and alcooholism)

http://docs.google.com/viewer?a=v&q=cache:K9yY7UWppQ8J:www.bma.org.uk/images/Doctor%2520patients%2520new%2520layout%25202_tcm41-147309.pdf+BMA+action+over+alcohol+consumption+doctors+and+nurses&hl=en&gl=uk&sig=AHIEtbQNaUE0Q0cg7JP7kOIaGaV5u8XFpA

[Marmora Man]

I have no idea how you might access info you seek - but the BMA may have information. You seem to have an "agenda" - have you or one of your family been affected by a decision or decisions made by a possibly tired doctor?

I think you overestimate the impact of long working hours. 1 in 15 doesn't seem to be a significantly higher figure than alcohol and other substance dependence in the wider population.

In my own experience at sea I routinely worked a 90+ hour week for up to three months at a time - then a 5 week break, working a 40 - 60 hour week for three of the weeks and a two week holiday then back to sea and long hours again. I learnt to get by on 4 hours sleep a day with occasional 30 / 45 min cat naps as well. I was probably performing at 95% optimum but I could do that for weeks on end - I'm sure junior doctors did the same. Remember they are supervised and have access to other, more senior, rested and experienced consultants.

[TE44]

No MM I have no agenda, I'm just curious if there is a connection between long hours, and the issues I have already mentioned above. I think it is sad if junior doctors are struggling and feel they cannot turn to there seniors for help, as stated in the link I put up.

[jollybaby]

As MM said the hours have really come down over the past few years. Up until around 5/6 years ago most on call rotas involved included days where you started work in the morning, worked overnight - maybe a couple of hours sleep if lucky and then worked the next day. This was then repeated 4 - 5 days later when your next on call came around. This wasn't particularly fun but you got through it with the help of your colleagues and nescafe. If you took annual leave you then had to do a 1 in 2 or 1 in 3 on call stretch to make up for the on call you missed.

Since then there has been a huge change in practice with most acute specialities working full shift rotas - with blocks of night shifts and then time off to compensate. I don't work in an acute specialty any longer and don't work night shifts in the hospital. My on calls are from home(usually giving advice over the phone - although I do go into hospital if a patient is very unwell) and I do a very healthy one night on call every 16 days and one weekend every eight. The rota has now got even easier thanks to EWTD as I am now entitled to a half day off after every night on call and then a full day after every weekend.

I know there are some specialities whose rotas are much less favourable than mine but our hours of work really have got a lot better over the past few years and in a way your thread is about 5 years too late. Also you comment on surgeons in particular, but it has already been recognised that operating on routine cases in the middle of the night is not best practice.

Now as for the impact on our training there are definite advantages and disadvantages of both ways of working. In the old system, although you were tired, you worked very closely in a team. You were usually on call with your consultant and your registrar. The patients admitted overnight often stayed under your team's care until discharge which allowed for continuity of care. It was busy but you were had exposure to lots of different situations and became quite adept quite quickly at stabilising the sick patient even at a relatively junior level. Admittedly there were times when you were tired and undoubtedly I have made some mistakes due to fatigue but overall I think what I gained in experience, and learning how to prioritise has made up for it.

Whilst the hours are reduced with shifts - there are potential problems. Handover is an issue - for example a patient may be admitted by one group of doctors overnight, looked after by another team on the acute assessment unit and then handed over to another team when they are transferred to the ward. It's easy to see how information can be lost through this type of system. From a learning perspective too it is far more rewarding to be able to stay involved in the care of the patient throughout their stay. Night shifts inevitably mean day shifts off work - and loss of learning experiences such as clinics/operating and procedure lists. I have been in jobs where I worked a week of evening shifts, followed by a block of night shifts and then a week off to compensate. By the time you get back to the day job you feel completely out of touch.

Fewer hours does equal less clinical experience. Our current foundation doctors (equivalent of old junior house officers) do not do any out of hours work - which I'm not convinced is at all in their best interest. However the rota slots still need to be covered and so one way of doing this is cross covering specialties which again I'm not convinced is a better way of working.

As for dependency and stress amongst doctors - again as MM said the figures you quote don't seem that out of line with that of the general population but I think it is well recognised that it is well recognised that there is a high level of stress amongst doctors. I don't think that's purely down to the hours - but also the nature of the work and the kind of personality that it tends to attract. I'm more stressed now than I was as a very junior doctor despite working less than 2/3 the hours - though I suppose that's the increased responsibility both at work and in the home.

So all in all - would I want to return to the old hours- NO (if I'm beginning to look too much through rose tinted glasses I put on an episode of 'Cardiac Arrest' to remind me). Do I want more experience but not to take twenty years to complete my training - YES - the problem is these are not entirely compatible and I've a feeling that once I reach consultant grade in a year or so I will be much less experienced than some of my predecessors.

[Huguenot]

I can see MM's point.

The population can't claim for more experienced doctors, shorter working hours, continuity of care and lower taxes all at the same time.

I also agree that 1 in 15 doesn't seem so unusual, and that a 0.05% error rate is a success story not a failure.

I do take umbrage at the penalty fines imposed, and I feel 1% is extraordinary. We shouldn't be suing doctors in public service, there is no 'punitive' element in fining taxpayers and compensation should only reflect the cost of make good not incremental benefits.

If you want to sue your doctor go private. It's not a public service it's a proft making entity and both punitive and compensatory damages claims have a clear benefit impact on treatment.