NHS 'failing to carry out full checks' on out-of-hours care

NHS trusts have been failing to carry out thorough checks on GPs providing out-of-hours care, a report said today.

The challenges posed by offering care at night and on weekends - such as seeing unfamiliar patients without access to their medical records - means doctors need to be properly assessed for their clinical skills and competence in English, it said.

The report's authors found "limited evidence" of robust checks on clinical skills alongside "misunderstandings" over whose responsibility it was to ensure doctors had good written and spoken English.

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The report, commissioned by the Department of Health, comes after Cambridgeshire North and East Coroner William Morris recorded a verdict of unlawful killing in the inquest into the death of David Gray.

He accused German doctor, Daniel Ubani, of gross negligence following the death in 2008 and said "weaknesses remain" in the out-of-hours system, including the use of overseas and locum doctors.

Today's report said there were "unacceptable" variations in the standards of care offered by primary care trusts (PCTs) around England, who are responsible for out-of-hours GP services.

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

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The report said: "We discovered that most providers did not make an assessment of the clinical skills or competence of their clinical staff."

It added: "The majority appeared not to use a clinical scenario type approach to interviews."

Standard interviews - or no interviews at all - are performed alongside other basic checks, such as the status of a doctor on a PCT's Performers List, which is a list medics approved to work in the NHS.

The report said: "Some providers did not request references, or even if they did, did not chase the non-return or check the provenance of these.

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"Some providers did require staff to have significant experience in primary care or in delivering out-of-hours care but this was not universal.

"Whilst this form of recruitment may mirror that which is usually undertaken in primary care we are concerned that it is not always sufficient for out-of-hours services."

The report said there were "misunderstandings about whether the General Medical Council could conduct language tests in respect of doctors from the European Economic Area.

"This led to uncertainties amongst PCTs of the circumstances in which they should be checking the knowledge of English of applicants to their medical Performers Lists and how this issue should be handled.

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"Where checks of language knowledge were made, different approaches were taken.

"There was also some confusion over whether doctors could be admitted to a list if they needed to improve their knowledge of English.

"The Department of Health needs to issue guidance."

One criticism arising from Mr Gray's case was that Dr Ubani was exhausted when he arrived in Britain for his first overnight shift, having only had a few hours of sleep.

Today's study said providers needed to keep a closer eye on how many hours a doctor was working.

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The review was led David Colin-Thome, clinical director for primary care at the Department of Health, and Steve Field, chairman of the Royal College of GPs.

They called for proper inductions for all doctors who have never worked out-of-hours or in the NHS before.

"Whilst all providers did induct and the majority monitored or shadowed new staff, we were concerned that a clinician could already have treated patients before any concerns over their clinical ability were highlighted through that induction process," the report said.

Overall, the review said the quality of care in many areas was "good" but "we acknowledge that the quality of services varies unacceptably and that there are providers and commissioners who need to improve to prevent those occasions where the care offered falls far below that which is acceptable."

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The Department of Health has accepted all 24 recommendations in the report in full.

Before 2004, GPs covered the needs of their patients during non-office hours, at weekends and on bank holidays.

But a contract negotiated between the then British Medical Association (BMA) and the Government in 2004 allowed doctors to opt out of providing this care.

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

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Dr Colin-Thome said: "The quality of out of hours care for most people is better than it was in 2004, but there is unacceptable variation in how services are implemented and monitored around the country.

"However, I am confident that by implementing the recommendations from our report, the system can be strengthened and vastly improved."

In 2007, a report into the death of journalist Penny Campbell found serious flaws in the out-of-hours system, which led to her dying of multiple organ failure.

She died in March 2005 after consulting eight doctors over the course of four days.