Only local doctors should provide out of hours primary care, say experts

June 22, 2010

Only doctors familiar with local health services should provide out of hours primary care, argue two experts, following the death of a patient given an overdose of diamorphine by an out of hours doctor.

This is just one of several wide ranging changes needed to ensure the quality and safety of out of hours care, say Dr Paul Cosford and Dr Justyn Thomas from NHS East of England in a paper published in the today.

David Gray died after he was wrongly injected with 100 mg diamorphine by Daniel Ubani, a doctor based in Germany and providing out of hours in Cambridgeshire. Dr Ubani had never worked in the United Kingdom, did not practise primary care in Germany, and was not familiar with local health care or with diamorphine. Yet he could fly in on Friday evening and work unsupervised on Saturday without routine access to patient notes.

Dr Ubani made a critical and fatal error, say the authors, but they believe that solely to blame him is to miss several key facts and that a wider examination of the system that allowed him to practise in these circumstances is needed.

They point out that many areas do have high quality out of hours care, but point to other contributing factors in this case and recommend areas for change.

These include a review of laws governing registration of doctors from the European Economic Area. "This is not to prevent the free movement of well qualified doctors," they explain, "but to recognise that healthcare systems differ across the EU, and that doctors' competence is at least partly specific to the system in which they work."

Secondly, they strongly advocate changes to the PCT performers list system. Currently a doctor on one list can practice anywhere in England, but this system should require GPs to be on the list of the PCT where they work, with the extra provision that GPs should be able to enter more than one list if they have good reason.

They also argue that arrangements for out of hours primary care should be reviewed locally to ensure that operate within structured teams providing high quality, safe care.

"As a profession, we should not accept a system that allows incidents such as this in any part of the NHS," they conclude. "Clinical leaders throughout the NHS must advocate and lead the necessary changes."

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