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Tragic error highlights need for out-of-hours review, says Alliance

The tragic death of a 70-year old man, caused by a 100 mg diamorphine overdose administered by an out-of-hours European GP, calls for a careful review of the delivery of out-of-hours services and the employment of temporary and foreign GPs, says the NHS Alliance.

Dr Daniel Ubani, a doctor from Germany, injected patient David Gray with 10 times the usual dose of diamorphine. Dr Ubani was given a nine-month suspended sentence in Germany for negligence in 2008, and a fine of 5,000 Euros.

The case has led to calls for an urgent review of out-of-hours provision. Among those calling for changes is David Gray's son Stuart, who is himself a GP.

An investigation by BBC's Newsnight established that best policy guidelines were not followed by the company that employed Dr Ubani. The Care Quality Commission is investigating the case.

In a letter of apology to David Gray's family, Dr Ubani wrote: "My nerves were overstretched, I was too tired and lacked concentration and these factors played a major role in the mistake that occurred."

The NHS Alliance says the case requires "the right lessons" to be learnt over the tragic error. It says the case highlights issues around the knowledge and expertise of some European doctors who, under EU rules, are entitled to practise 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 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.

The NHS Alliance Urgent Primary Care Network believes this case raises key issues about the potential impact on patient safety of these rules. It says that the Care Quality Commission review following this case needs to look closely at the implications of these issues.

According to the Alliance, unless out-of-hours providers feel they can be reliably assured over issues of training, language and hours worked, they should perhaps err on the side of patient safety and not use any temporary GPs – "from the EU or anywhere else."

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".

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."

NHS Alliance

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Your comments (terms and conditions apply):

"It would appear that there are no national standards. May I recommend the OOH service available in NI, provided by North Down Doctors on call, assisted by rapid response nurses as an example of optimum efficiency. The nurses deal with IVs, sub-cuts, blocked catheters, displaced PEG tubes, etc, which frees up the GPs to deal with diagnostic issues. This service prioritises the possible conditions of its patients, their medical history and location. As a senior staff nurse in a private rehabilitation clinic, I have nothing but praise for the support we have received from our OOH colleagues." - Elizabeth Kennedy, Groomsport

"This issue does not necessarily relate to OOH systems as much as EU doctors not being fully aware of current British processes and proceedures. This is the issue that primarily needs addressing across the board with all medical practitioners.
The OOH system varies drastically - I presently work in a co-operative with members who have a vested interest in their public to provide a good service, which in turn ensures the standard of service remains at a high level - this is surely the better way of providing safe and effective OOH care and not a private provider where "cheaper" may also reflect upon the quality of service provided." - Name and address supplied

"It was much safer when YOUR GP came out to see YOU. But those days are long gone." - Pamela Fry, Berkshire

"All foreign doctors, regardless of where they come from, whether they are in the EU or not, should undergo further assessment and training if they wish to work in the UK!" - Shiona Robertson, Essex

"I am surprised there are not more serious untoward incidents, especially in rural areas, where the doctors essentially conduct telephone triage and send nurses out to see all the patients." - Alison, North Devon

"Lorry drivers from the Continent can drive without tacagrphs and end up killing whole families, why should it surprise us that European doctors do the same thing. There is no common sense in such a blatant abuse of EU regulations." - Carl Curtis, Southwark

"I think this is a blatant excuse. The man is a mature doctor and volunteered to go do a locum he knew he would have to start out on short of sleep! To think that he can raise his hours as an excuse is appalling. He is entirely responsible for his actions. Now if you speak of our 'housemen' who have to do a two year of rotas in a hospital or work in busy clinics who historically have had to do wiithout sleep, there is a case to be raised." -  S Robertson, London

"Out of hours should be done by GPs themselves for their patients or by PBC groups and all doctors to take turns. General triaging can be done by Harmoni as usual. GPs do not need extra pay as they don't spend the full time hours at practice, this way they will spend more time in practice and educate or reduce out of hours need for patients." - Name and address supplied

"Definitely! From personal experience of trying to use the system and from feedback from our patients the service is sadly lacking particularly in rural locations. Some elderly patients say they would rather wait all weekend to see someone on Monday thean attempt to use OOH service" - Lesley Watson, North Norfolk

"The system certainly needs an overhaul. I work in an extremely busy out of hours service, and it is now resembling A&E 10 years ago before the advent of widespread minor injury units (MIU) and 4 hr waiting targets. We sometimes have doctors with dubious skills, who are unaware of local protocols or pathways and whom the patients have had a problem understanding. The work is so arduous and stressful, that there is a difficulty in getting GPs to cover. The GPs we already have are looking to leave, and support from management is negligable. The burden of dealing with the incessant stream of people walking through our doors is usually left to nurses. We work with only 2 nurses after 10pm, and sometimes after 6pm, and waiting times are frequently 3 hrs. The nurses all work autonomously as ENP's or currently training towards Masters, many are prescribers, yet we have no recognition of our skills and predominantly work as band 6 in staff nurse coloured uniform. There is an increasing demand for out of hours services which is unsustainable and the public should be advised that out of hours services are for urgent and emergent cases that cannot wait until they see their own surgery in the morning." - Name and address supplied