Making Out-Of-Hours Care Safer: Overseas Clinicians' Registration And Quality Data Need Attention

Main Category: Primary Care / General Practice
Article Date: 10 May 2009 - 0:00 PDT

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The death of David Gray, caused by a 100 mg diamorphine overdose (10 times the usual dose) injected by out-of-hours GP Dr Daniel Ubani, will clearly be devastating to Mr Gray's family. While medicine remains practiced by humans, there will always be room for error. Yet our knowledge that medical errors can harm or kill should drive us to learn as many lessons as possible - and to learn the right lessons.

Does EU doctors' primary care expertise measure up?
This case highlights issues around the knowledge and expertise of some European doctors who, under EU rules, are entitled to practice in the UK without further assessment or training here.

EU rules to support the free movement of labour across national boundaries require "equivalence" to be given to EU-qualified doctors, so that they can join the UK General Medical Council and PCT Performers' lists. However some of these EU-qualified doctors acquired their rights to practise without any specific training in general practice. This is because they had already begun their professional practice in their country of professional origin before that country introduced general practice training regulations.

By contrast, doctors of non-EU origin are required to undertake thorough clinical and English language assessment and training - a process that takes several months.

This case also shows that some EU doctors are unfamiliar with diamorphine, which is commonly used for pain relief among UK cancer patients.

The NHS Alliance Urgent Primary Care Network believes that this case raises key issues about the potential impact on patient safety of these rules. The Care Quality Commission review following this case needs to look closely at the implications of these issues. Unless out-of-hours providers feel they can be reliably assured over issues of training, language and hours worked, perhaps they should err on the side of patient safety and not use any temporary GPs - from the EU or anywhere else.

The NHS Alliance Urgent Primary Care Network have also written to all their members (who include a large number of out-of-hours providers), warning them of the implications of this case. They advise that 100 mg ampoules of diamorphine should not be carried unless there is a particular reason to do so, such as a visit to a seriously-ill patient who is treated with a syringe driver (which delivers controlled dose of a drug over a period of time).

Edmund Jahn, managing director of out-of-hours provider Harmoni and the NHS Alliance Urgent Primary Care Network, said, "This tragic case should, and no doubt will, make out-of-hours providers review carefully the use of doctors whose experience is in a foreign health system, working for an out-of-hours service at short notice and with minimal checks. EU-qualified doctors can be a useful element in the mix, but only if out-of-hours providers can assure themselves over their employees' fitness to practice out-of-hours as they would do for any local GP doing the same job.

"Our organisation finds this burden of proof difficult to make and so has as a policy not to use temporary GPs at all, EU or otherwise".

Dr Ray Montague, of out-of-hours providers BrisDoc and member of the NHS Alliance Urgent Primary Care Network, said, "This shocking and tragic case should sharpen all our thinking about the delivery of out-of-hours care. We cannot risk another case like this.

"The Government and professional bodies must help providers to put in place necessary measures to ensure that all doctors who practise in Britain are trained to British standards, and that all patients are protected."

Comparative performance data

The out-of-hours sector takes the improvement of quality of patient care very seriously, and has been developing a national benchmark of out-of-hours services (run by the Primary Care Foundation and supported by NHS Alliance). The benchmark looks at comparative performance and clinical variation; in particular, the performance of outliers (unusually low performers) is a vital indicator of potential problems.

Though this benchmark (issued in March 2009, comparing 63 providers nationally) is in its early days, it is a key part of the move to drive up the quality of primary care. A benchmark can never prevent tragic errors, but should lead to a systematic review of patient outcomes and clinical performance.

Notes

1. Dr Ubani's guilt has been established in court in his native Germany, leading to sanctions of a 5,000 Euro fine and a nine-month suspended sentence. The legal principle of 'double-jeopardy' means that no further prosecution in the UK is likely. In a letter of apology to David Gray's family, Dr Ubani wrote (original spelling uncorrected), "My nerves were over strectched, I was too tired and lacked concentration and these factors played a major roole in the mistake that occurred. I have my own Practise in Germany as a GP and a Surgeon sinc almost 22 years. In this time I have not had such fatal cases". Dr Ubani's letter also suggests that his error was to mistake diamorphine for the very different drug pethidine, which can safely be administered in 100 mg quantities. Dr Ubani's briefcase contained detailed instructions about both drugs.

2. The NHS Alliance Urgent Primary Care Network supports providers of primary and community health services for NHS patients. It includes those providing urgent care (including out-of-hours services)

Source
NHS Alliance

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