Health: Trainees carry out surgery unsupervised

One-fifth of out-of-hours surgery in hospitals is carried out by unsupervised junior doctors, a survey has found.

Jeremy Laurance, Health Editor, reports on the dangers of an ill-organised and under-resourced service.

Hospital patients are being compelled to undergo surgery late at night or in the early hours of the morning when senior staff are absent and back-up services are thin on the ground because they cannot be fitted in during the day.

Thousands of cases designated as emergencies and operated on at night could have waited until the following day when staff were fresh, senior surgeons were available should anything go wrong and the hospital was fully functioning, the survey by the National Confidential Enquiry into Perioperative Deaths (deaths within 30 days of operation) found.

The health minister Baroness Jay said that the findings were "disturbing." She added: "Patients clearly have a right to expect that doctors will not perform procedures that are beyond their competence."

The survey of 355 National Health Service hospitals monitored for seven days found that about 3,500 weekday operations were performed between 6pm and 8am, 6.1 per cent of the total, of which 428 were performed after midnight (less than 1 per cent). Extrapolated to the 400-plus hospitals in England and Wales, the findings imply that about 200,000 operations are performed out of hours every year, about 25,000 of them after midnight.

More than nine out of ten were designated emergencies but very few "emergencies" - including the most common, removal of an appendix - are so urgent that they cannot wait, the report says.

One in five operations out of hours was performed by an unsupervised senior house officer - usually a junior doctor with two years' clinical experience - and one in two was attended by an unsupervised SHO anaesthetist.

Evidence suggests that patients operated on at night or by unsupervised junior staff are at greater risk. Earlier reports from NCEPOD, established 10 years ago by the surgical Royal Colleges, found a disturbing number of patients who had died following out-of-hours operations, although the current study did not indicate excess deaths. Research on day cases has shown that patients operated on by fully trained consultants suffer fewer complications.

Professor John Blandy, chairman of the inquiry panel, said the number of operations performed out of hours was less than expected, especially during the "wee, small, dangerous hours" after midnight, but there was no room for complacency. Real emergencies were very rare. "Many of these patients could have been admitted and operated on during the day but there was no time," he said.

Surgeons quoted in the survey illustrate the pressure the NHS is under. A patient with a hand injury had to wait 30 hours before being operated on at 1am because of "lack of operating time - theatre busy with general surgical cases."

Dr Stuart Ingram, one of the report's authors, said the findings of the survey supported the call by the Royal College of Surgeons earlier in the summer for emergency work to be concentrated in half the present number of hospitals with the remainder doing routine work.