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Concern over out-of-hours care

By Jenny Wivell

Updated on 02 October 2009

A health watchdog warns there is nationwide concern over the quality of out-of-hours GP care.

Stethoscope (credit:Getty Images)

The Care Quality Commission's stark warning comes as it publishes a report into the death of a man who was treated by an out-of-hours doctor shortly before he died.

In February last year, David Gray, 70, was accidentally killed by a German doctor working his first out-of-hours shift in Britain.
Mr Gray was given 10 times the normal dose of diamorphine by Dr Daniel Ubani. The foreign doctor admitted being exhausted and having had only a few hours' sleep before beginning work for a Cambridgeshire health trust.
Today's interim report is not the first time concerns have been raised over out-of-hours care. In 2007, a report into the death of journalist Penny Campbell found serious flaws in the system. She died of multiple organ failure in March 2005 after consulting eight doctors over four days.

The investigation into Campbell's death was critical of private company Camidoc, which was commissioned by the NHS to supply out-of-hours doctors. It also identified weaknesses in the arrangements for out-of-hour care nationally.
Today's report examines the work of another private firm, Take Care Now. The company employed Dr Ubani and assigned him to work under the NHS Cambridgeshire contract.

The firm currently has four other contracts with primary care trusts (PCTs). These are NHS Worcestershire, NHS Suffolk, NHS Great Yarmouth and Waveney and NHS South West Essex.
The firm's chief executive, David Cocks, released a statement this morning saying -

"We welcome the CQC's interim progress report and are continuing to work with the CQC in its ongoing investigation."

The report says there are fears PCTs across England may not be effectively monitoring out-of-hours performance and risk failing to spot patient safety concerns. Investigators said that PCT monitoring varied across all five trusts served by Take Care Now, leading them to believe "this might be a widespread problem".

Professor Steve Field, of the Royal College of GPs, said the quality of out-of-hours GPs was linked to the quality of the system which operates the service.
The CQC recommended that "all PCTs should scrutinise out-of-hours services more closely".
"They should look in detail at the services that they commission, including the efficiency of call handling and triage, the number of unfilled shifts, the proportion of shifts covered by non-local doctors, the induction and training those doctors receive and the quality of the decisions made by clinical staff."
CQC Chief Executive Cynthia Bower said: "As commissioners of these services, PCTs need to ensure people receive safe, quality care around the clock.

"Our visits to the five trusts that commission Take Care Now's services showed they are only scratching the surface in terms of how they are routinely monitoring the quality of out-of-hours services."
The chairman of the Royal College of General Practitioners, Professor Steve Field, said:

"Providers need to ensure their doctors are competent to the level of UK trained graduates, have good English skills, not overly tired after working long shifts and are orientated to the local conditions. There needs to be safeguards and reviews in place, at both the clinical and strategic level.

"What happened in Cambridgeshire was a terrible tragedy and we need to ensure this never happens again. All patients deserve the best care, wherever they live in the UK."

Dr Ubani was given a nine-month suspended sentence in Germany for causing death by negligence in the UK. An inquest will be held in Cambridgeshire later this year or early in 2010.

The CQC has shared its findings with the Department of Health, which is writing to PCTs across England asking them to make it a priority to review their monitoring arrangements for out-of-hours services.

Out-of-hours responsibility

More than nine million patients receive out-of-hours care in England every year.

Before 2004, GPs covered the needs of their patients during non-office hours, at weekends and bank holidays.
A contract negotiated between then British Medical Association (BMA) and the Government in 2004 allowed doctors to opt out of providing this care.

In return for giving up £6,000 a year in salary, they could hand over responsibility for patients from 6.30pm to 8am on weekdays, and on all weekends and public holidays.

Nine out of 10 GPs chose to do so, with primary care trusts (PCTs) taking on the role of providing cover.

They now commission out-of-hours services from a range of organisations including private firms, GP co-operatives and in-house teams at the PCT.

Earlier this year, the Royal College of GPs called for a review of the use of overseas doctors in out-of-hours care in light of David Gray's death.

Last year, the NHS Alliance group of NHS staff said family doctors should take back responsibility for providing out-of-hours care as patients had lost confidence in the new arrangements.

In March 2007, the Commons Public Accounts Committee (PAC) condemned the Government's preparations for the handover from GPs to PCTs as "shambolic".

The PAC report put the cost of the new out-of-hours service at £70m a year higher than predicted.

It said the Department of Health "failed to explain" whether the service should cover just urgent cases or any request for help around the clock.

In May 2006, a report from the National Audit Office (NAO) also found less than 10 per cent of primary care trusts (PCTs) could show they met Government targets on assessing patients within 20 minutes of receiving an urgent out-of-hours call.

The NAO said a significant number of PCTs had no data on whether they were meeting the Government's targets on out-of-hours care.

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