The fatal 2008 mistake of a locum from Germany and the financial collapse of an out of hours provider both offer important lessons for CCGs
The Daniel Ubani case
There are few cases of individual care which change the way the health system operates: but a fatal overdose of morphine given to an elderly man by an out of hours doctor has done that.
Dr Daniel Ubani, who normally worked in Germany, was on his first shift as an out of hours locum working for out of hours provider Take Care Now in Cambridgeshire when he gave 10 times the maximum recommended dose to David Gray, who had kidney stones.
Mr Gray’s death in 2008 focused attention on a system which allowed a tired doctor, with little experience and knowledge of the NHS, and limited induction, to treat patients.
‘What comes out of the report is a sense that, where there were failings, the PCTs commissioning services would not necessarily be made aware of them’
The case has led to a general tightening up of regulations around doctors working as locums. Dr Ubani had applied for admission to the local performers’ list in Leeds but had been refused. He then successfully applied in Cornwall, and, on the basis of this, was able to work in Cambridgeshire for Take Care Now.
The death of Mr Gray and the analysis of what had gone wrong focused attention on how out of hours care was delivered, managed and monitored.
A Care Quality Commission report on the case highlighted how reporting on performance was not accurate or comprehensive; flawed governance with incomplete and inaccurate reporting to the PCT around the case; and cases where doctors were not available within 50 miles, and nurses and emergency care practitioners had to cover their shifts. PCTs were generally unaware of this practice of shift covering by other staff.
What comes out of the report is a sense that, where there were failings, the PCTs commissioning services would not necessarily be made aware of them. In part this may have been because there was no requirement for them to be told - something which could be addressed through better specified contracts.
Unequipped to manage
For example, there was no requirement to share information on poorly performing GPs employed by TCN. But in other areas what was specified in contracts seemed to have been ignored - for example, the timescale to respond to complaints specified by PCTs was not reflected in the TCN complaints policy until late 2008.
And some information, such as around national quality requirements, did not accurately reflect actual performance.
But there was also some evidence that the PCT was not best equipped to manage the contract - for example, not understanding activity figures supplied by TCN. And relationships with TCN were not at the point where mature discussions around problems were possible.
The CQC report looked at how Cambridgeshire and other commissioners were monitoring contracts and found that out of hours had not been a high priority for PCTs and were often not reported at board meetings. The national quality requirements were not necessarily understood well by PCT staff and GPs’ views on the quality of service were not regularly sought.
Some of these issues may be overcome by CCGs with their clinical focus and board members who will be aware of out of hours services that are not delivering.
But performance monitoring against specified criteria - whether outcome, process or supplying information - will be key to both raising quality of services and ensuring that penalties can be imposed if they are not met.
After the case, many PCTs tightened up restrictions - for example, by specifying that doctors working for out of hours providers had to be accepted on its local list or one of a nearby PCT. This made it more difficult for doctors to pick a PCT with lighter restrictions to register with - and then to work anywhere on the basis of this.
However, from this April the individual PCT performers’ lists have been replaced by a national list, held by NHS England. The position on language qualifications is also likely to be tightened up for EU doctors from next year, through the GMC.
But CCGs who will commission out of hours services will still need to use their contractual levers to ensure that patients receive good quality care. The then national director for primary care Dr David Colin-Thomé looked at how standards could be improved for the Department of Health after the Ubani case and came up with a list of recommendations. These covered:
- ensuring performance management arrangements are “fit for purpose”, including quality review meetings;
- locally developed indicators which could be linked to incentive payments;
- the importance of considering feedback from different sources - including patients and other stakeholders - and acting on the results of these, including emerging trends;
- out of hours providers should be treated as an integral part of the health economy, and involved in urgent care boards etc;
- robust recruitment and selection processes for clinical staff which cover the skills and knowledge they are likely to need in the local environment; and
- tailored induction processes which are completed before clinicians start work.
Many of these points could be written into contracts, and potentially could be incentivised - or penalised if not carried out.
Capsticks partner James Clarke points out: “Service specification design should never take place in a vacuum - how the specification links in with all of the other parts of the contract, and the procurement process used to put it in place, is vital to securing a stable service which can then be effectively performance managed when necessary.”
The Camidoc insolvency
Clinical commissioning groups procuring out of hours services need to think about the ability of the new provider to run a service for the contracted time - and one element of that is likely to be their financial stability.
A company in financial problems will face additional challenges in providing high quality services, including investing in improvements and meeting unexpected costs. If things worsen, there is a risk that the provider will no longer be able to provide a service, leaving commissioners to struggle to find alternatives at short notice.
Many contracts are now held by private companies or social enterprises, which may be larger than the old GP co-ops and may have more resilience to short-term pressures.
But some of the problems around contracting were shown up a couple of years ago in north London. Camidoc had been providing out of hours services in the area for some years - not entirely without incident as it was criticised for its clinical supervision following the death of a patient in 2005.
However, in early 2010 it was selected as the provider for four large PCTs - Camden, Haringey, Islington, and City and Hackney - after a procurement process. The new contract was meant to start from October 1.
But in the middle of the year, before the contract was formally started, problems emerged. A confidential independent business report for the PCTs, released over a year later to the joint health overview and scrutiny committees of the local councils, reveals that Camidoc was technically insolvent in May 2010, mainly because of nearly £800,000 in pension contributions due to the NHS Pensions Agency.
The report, by accountants Grant Thornton, said that the proposed contract would allow Camidoc to make a small profit but that this depended on a number of sensitivities and risk. A decrease in the volume of cases it handled or a failure to meet the requirements for incentive payments - or incurring penalties - would badly affect its financial position. It was uncertain whether it could continue to trade into the future without either additional payments from commissioners (it had already received extra payments under the old contract) or renegotiated terms.
But the report also indicated some wider governance and capability issues. It suggested Camidoc needed to invest in managerial capacity to allow it to concentrate on improving productivity and profitability, and it needed a cost improvement plan.
In addition, it needed to supply the PCTs with more information, including monthly reporting packs which the PCTs should include in the new contract and a plan for escalating concerns. The report also raised questions about the ability of the Camidoc board to react in a timely manner.
Part of the problem seems to have been the old contract, which was based on a payment per head rather than activity. This contributed to losses for Camidoc, which had been partly offset by additional funding from the PCTs.
In the summer of 2010 - before the new contract came in - the PCTs said they could not confidently and safely ensure continuity of the out of hours service if they entered into a new contract with Camidoc. An emergency provider - Harmoni - was appointed for a nine month period instead while the contract was reprocured and it was paid set up costs as well as an amount comparable to the proposed contract with Camidoc.
In late 2010, Camidoc was declared insolvent with debts which are thought to have been £1.5m. Harmoni had its contract extended before being given a two year contract in late 2012. A group of doctors also put in a bid, amid claims it had scored higher on quality but lower on cost than Harmoni.
While the problems with Camidoc may not have been avoided by better contracting, they do show the need for contracts to include requirements for information and reporting. Poor performance on these indicators may be a warning sign of governance or finance issues within organisations which should sound warning bells with commissioners.
But James Clarke of Capsticks adds that specifications in contracts should be realistic. He says: “I have seen services procured against a specification which contains requirements relating to insurance that are poorly designed and impossible to comply with.
“This puts bidders in a situation where they either have to misrepresent their ability to comply, or to submit a non-compliant bid, or attempt to enter into negotiations post-award leading to procurement risks and ultimately undermining the authority of the commissioner - clearly not a healthy start to any contractual relationship.”