In my conversations with many urologists, indeed many doctors, it is a commonly held perception that there is a relentless rise in medical negligence litigation leading to a ‘crisis in litigation costs’ [1]. The analysis by Lane et al. [2] of 20 years of claims in urological practice in the NHS is therefore timely. It identified 2585 claims against urologists over 20 years, with a sevenfold increase from approximately 50 per year in 1996/1997 to approximately 350 in 2016/2017. Damages increased from £0.2m to £7m.

Does this sevenfold increase in litigation provide evidence for a litigation crisis in the NHS? Are patients becoming ever more litiginous? Or are there other explanations for the rise in litigation?

Two considerations paint a less alarming picture. Firstly, the prevalence of urological conditions and of treatments are rising, year on year [3]. Over 20 years, rates of radical prostatectomy and ureterorenoscopy have almost quadrupled, and those for nephrectomy are not far off having doubled. We are doing more to more patients and it should therefore come as no surprise that claims should also increase.

Secondly, UK consultant urologist numbers have increased substantially over in 20 years, from 520 in 2002, 800 in 2010 and, as of September 2019, to 1158 [4] (according to BAUS). Applying the data for total number of claims year on year from the study by Lane et al. as a rough estimate, the annual litigation risk was approximately 0.2 cases per urologist in 2002 (100 cases spread over 520 urologists), 0.2 cases per urologist in 2010 (150 cases amongst 800 urologists) and 0.28 cases per urologist in 2019 (325 cases amongst 1158 urologists). For the individual consultant urologist the chances of being sued in NHS practice have risen – but only 1.5-fold.

This relatively small rise in litigation for the individual urologist, spanning almost two generations of consultant practice (if a generation equates to roughly 20 years) may not be so dramatic, especially when seen in the context of the rise in urological activity. The shorter apprenticeship of younger generations of urologists has perhaps not translated into a greater litigation risk. An analysis of litigation risk based on year of first consultant post would be interesting.

Other factors may account for a less than dramatic rise in litigation. Guidelines (National Institute for Health and Care Excellence, BAUS, European Association of Urology) are now ingrained in practice. Adherence can be a shield against litigation [5]. Consultant-led, and often delivered, care may have offset the trend in litigation yet further.

What the study by Lane et al. does not tell us is the scale of or trends in litigation in private practice, which is indemnified by other insurance carriers. Furthermore, while it provides a glimpse into urological litigation, it is only a glimpse. NHS Resolution data do not allow a more sophisticated analysis of the causes of litigation beyond ‘intra-operative’ or ‘postoperative’, for example, so we are left with limited direction with which to modify our behaviour in order to avoid litigation (watch this space and this journal). It simply tells us we have a problem, but not what specific actions or inactions lead to litigation or what the practical remedies are likely to be.

Lane et al. conclude that ‘Intraoperative related claims represent a small proportion of the overall claims in surgery … arguably these could be some of the most avoidable through training and mandatory pre-operative checks’. I’m not sure I agree. Error prevention in the intensity and ‘heat’ of surgery may be less effective than focusing on the ‘slower’ phases of care – those preceding and following surgery.

With this in mind, it is notable that in the 10 years from 2009 to 2019 there were 88 successful consent claims. The judgement of the UK Supreme Court in Montgomery vs Lanarkshire Health Board was in 2015, and it is widely believed that this has and will continue to increase the risk of consent-related litigation. These 88 claims are a warning shot. My own experience as an expert witness is that consent claims are on the rise. Consent is the low hanging fruit of litigation prevention. Avoiding litigation through focusing on alternatives, risks and outcomes is easy. It does not require years of training to attain technical surgical skills. It is not impacted upon by other factors that might increase litigation risk (e.g. the high anaesthetic risk patient). It is simply about the use of words and the giving of information. Avoiding litigation through adequate consent is therefore achievable, if simple rules are followed [6]. Adequate consent takes time, but so too does defending an allegation of inadequate consent, especially at the General Medical Council.

There is no doubt that the NHS is facing a ‘crisis in litigation costs’ [1]. The House of Commons Committee of Public Accounts [7] predicted that spending on clinical negligence would consume 4% of Hospital Trusts’ income in 2020, money that would otherwise be spent on patient care. However, this crisis is not pan-specialty. Fifty percent of the value of claims managed by NHS Resolution in 2018–2019 relate to high-cost obstetric cases while representing just 10% of claims (e.g. for a lifetime of care from brain injury at birth) [8].

Urological litigation is nowhere near as costly because we are not faced with the need to make the rapid decisions required of obstetricians in the often frenetic environment of the labour ward. There is no room for complacency in urological practice. We all bear the burden of litigation costs, whether financial as tax payers, reputational as a profession, or personal as the second victims of errors in care. We can do our bit to reduce litigation risks by focusing on the shield of guidelines, attention to detail in consent, and perhaps simply, as Joe Smith, who founded the Department of Urology in Oxford and was President of the Medical Defence Union, used to say, by being honest with and nice to patients. As a patient it is difficult to sue a doctor you like, who you think is genuinely interested in looking after you and who comes across as being an honest, caring professional. This approach to care should impact positively on the risk of litigation and can only be for the good for our patients, our health service, our specialty and ourselves.

在我与许多泌尿科医生，实际上是许多医生的交谈中，普遍认为医疗疏忽诉讼不断增加，导致“诉讼费用危机”[ 1 ]。Lane 等人的分析。[ 2 ] 因此，NHS 在泌尿外科实践中 20 年的索赔是及时的。它确定了 20 年来针对泌尿科医生的 2585 起索赔，从 1996/1997 年的每年约 50 起增加到 2016/2017 年的约 350 起，增加了七倍。损失从 20 万英镑增加到 700 万英镑。

这七倍的诉讼增加是否为 NHS 的诉讼危机提供了证据？患者是否变得越来越爱打官司？或者对于诉讼的增加还有其他解释吗？

有两个考虑描绘了一幅不那么令人震惊的图景。首先，泌尿系统疾病和治疗的患病率逐年上升 [ 3 ]。20 多年来，根治性前列腺切除术和输尿管肾镜检查的发生率几乎翻了两番，而肾切除术的发生率几乎翻了一番。我们正在为更多的患者做更多的事情，因此索赔也应该增加也就不足为奇了。

其次，英国泌尿科顾问医生人数在 20 年间大幅增加，从 2002 年的 520 人、2010 年的 800 人以及截至 2019 年 9 月的 1158 人 [ 4 ]（根据 BAUS）。应用 Lane 等人研究中的逐年索赔总数数据。粗略估计，2002年每位泌尿科医生的年度诉讼风险约为0.2例（520名泌尿科医生100例），2010年每位泌尿科医生0.2例（800名泌尿科医生150例），2019年每位泌尿科医生0.28例（325例） 1158 名泌尿科医生）。对于个体咨询泌尿科医生而言，在 NHS 实践中被起诉的机会增加了——但只有 1.5 倍。

对于个体泌尿科医生而言，这种相对较小的诉讼增加，跨越了近两代顾问实践（如果一代相当于大约 20 年）可能并不那么引人注目，尤其是在泌尿外科活动增加的背景下。年轻一代泌尿科医生的学徒期较短，也许并没有转化为更大的诉讼风险。基于第一个顾问职位的年份对诉讼风险的分析会很有趣。

其他因素可能会导致诉讼数量的急剧增加。指南（国家健康与护理卓越研究所、BAUS、欧洲泌尿外科协会）现已在实践中根深蒂固。依从性可以成为防止诉讼的盾牌 [ 5 ]。顾问主导的、经常提供的护理可能进一步抵消了诉讼的趋势。

莱恩等人的研究是什么。没有告诉我们是私人执业中诉讼的规模或趋势，这是由其他保险公司赔偿的。此外，虽然它提供了泌尿外科诉讼的一瞥，但这只是一瞥。例如，NHS 决议数据不允许对“术中”或“术后”以外的诉讼原因进行更复杂的分析，因此我们在改变行为以避免诉讼方面的方向有限（请看空间和这个杂志）。它只是告诉我们我们有问题，但没有告诉我们哪些具体的作为或不作为会导致诉讼或实际的补救措施可能是什么。

莱恩等人。得出的结论是“术中相关索赔仅占手术总索赔的一小部分……可以说，这些可能是通过培训和强制性术前检查最可避免的一些索赔”。我不确定我是否同意。在手术强度和“热度”方面的错误预防可能不如专注于“较慢”的护理阶段（手术前后的那些阶段）有效。

考虑到这一点，值得注意的是，在 2009 年至 2019 年的 10 年中，有 88 次成功的同意声明。英国最高法院在蒙哥马利诉拉纳克郡卫生委员会案中的判决是在 2015 年，人们普遍认为这已经并将继续增加与同意相关的诉讼风险。这 88 项索赔是一个警告。我自己作为专家证人的经验是，同意要求正在上升。同意是诉讼预防的简单果实。通过关注替代方案、风险和结果来避免诉讼很容易。它不需要多年的培训来获得技术外科技能。它不受其他可能增加诉讼风险的因素（例如高麻醉风险患者）的影响。它只是关于语言的使用和信息的提供。因此，如果遵循简单的规则，通过充分的同意避免诉讼是可以实现的 [ 6]]。充分同意需要时间，但为不充分同意的指控辩护也需要时间，尤其是在综合医学委员会。

毫无疑问，NHS 正面临着“诉讼费用危机”[ 1 ]。下议院公共账户委员会 [ 7 ] 预测，到 2020 年，临床疏忽支出将消耗医院信托收入的 4%，否则这笔钱将用于患者护理。然而，这场危机并不是泛专业的。2018-2019 年 NHS 决议管理的索赔价值的 50% 与高成本产科病例有关，而仅占索赔的 10%（例如出生时脑损伤的终生护理）[ 8 ]。

泌尿外科诉讼远没有那么昂贵，因为我们不需要在产科病房经常狂热的环境中做出产科医生所需的快速决定。在泌尿外科实践中没有自满的余地。我们都承担诉讼费用的负担，无论是作为纳税人的财务，作为职业的声誉，还是作为护理错误的第二受害者的个人。我们可以通过关注指导方针的盾牌、对同意细节的关注，或许只是像乔·史密斯（Joe Smith），他在牛津创立泌尿外科并担任医学防御联盟主席，来降低诉讼风险。比如说，对病人诚实和友善。作为病人很难起诉你喜欢的医生，您认为谁是真正有兴趣照顾您的人，谁是诚实、有爱心的专业人士。这种护理方法应该对诉讼风险产生积极影响，并且只会有利于我们的患者、我们的医疗服务、我们的专业和我们自己。