Recommendations for out of hours provider contracting offer wider lessons for PCTs, says Lucy Johnson

The recent inquest into the deaths of David Gray and Iris Edwards raised a number of issues about the arrangements for the provision of GP care to patients out of hours.

Coroner William Morris concluded that Dr Daniel Ubani, a locum doctor based in Germany, was incompetent in his dealings with patients over the weekend of 16 February 2008. He returned verdicts of unlawful killing in respect of David Gray and natural causes in respect of Iris Edwards.

EU law requires that national authorities such as the General Medical Council recognise professional qualifications awarded in other member states. As a German doctor, Dr Ubani was therefore able to gain admission to the GMC register.

The main issues that emerged at the inquest were:

  • the differing levels of experience between UK doctors and those from other EU countries, especially regarding familiarisation with the NHS and differing prescribing practices;
  • the assumption on the part of some providers that GMC registration and entry onto a GP performers list was a sufficient indicator of quality of experience;
  • the regional variation in entry requirements;
  • the process for selection, recruitment and induction of doctors for out of hours work;
  • the robustness of out of hours contracts and performance management;
  • the importance of separation of high dose ampoules of diamorphine to avoid incorrect selection.

Steps for PCTs

To avoid problems in future, primary care trusts should consider reviewing the following:

  • Contracts with out of hours providers - are obligations relating to clinical governance and risk management and to processes for recruitment and induction of doctors robust?
  • Contractual monitoring and performance management arrangements - are sufficient proactive checks being carried out to ensure services are being delivered appropriately?
  • Criteria for entry onto medical performers lists, in particular relating to language testing; whether referees have sufficient knowledge of working in the NHS; intention to work in the local area; whether any other applications have been withdrawn; CVs and references are being checked by a clinician.
  • Arrangements for availability and storage of high dose opiates for use out of hours.

The Ubani case also raises a wider issue of how PCTs performance manage their providers generally.

The coroner made a series of recommendations to the health secretary, NHS East of England and the Royal College of GPs:

  • Guidance should be issued to PCTs requiring them to risk assess every non-UK based doctor involved in out of hours services care, including an assessment of their experience in the NHS and whether the doctor gained accreditation in his home state via the acquired rights system or through examination.
  • There should be a national protocol for PCTs to follow when deciding whether to admit performers to the list.
  • When considering applications to the medical performer’s list, PCTs should check GPs have sufficient knowledge of the English language; establish an intention to deliver services in the PCT’s area; check whether an applicant has failed to progress applications to other PCTs; ensure an appropriately qualified person is responsible for robustly applying regulation 6 of the performers list.
  • PCTs should ensure out of hours providers remain responsible for assessing the quality of the doctors they engage and not delegate it.
  • PCTs should ensure that all contractual arrangements with out of hours providers include a thorough induction and robust clinical governance and risk management structures.
  • All the contracts should be regularly monitored.

The Department of Health has published a report, General Practice Out of Hours Services, following a review by the DH and the Royal College of GPs.

The health select committee has recommended that until the GMC is permitted to test language ability, strategic health authorities and the Care Quality Commission must ensure PCTs carry out language tests.