Q&A: Out of hours care

Branwen Jeffreys Health correspondent, BBC News

David Gray was given a huge overdose of the painkiller diamorphine

GP out-of-hours care is being criticised.

An inquest has said a patient died because of a "gross error" by a overseas doctor doing his first shift for the NHS.

But the verdict also raised serious questions about how the entire system is operating.

How has out of hours care changed?

In 2004, the overwhelming majority of GPs across the UK gave up responsibility for organising out of hours care when a new contract allowed them to opt out in return for losing £6,000 pounds a year from their income.

Many practices actually had stopped seeing their own patients in the mid 1990s, when they were allowed to buy in an agency to cover for them or work as larger co operatives.

The NHS took on the job of organising private companies or GP co-operatives to provide care for patients at night and weekends, and soon found it was more complicated and expensive than expected.

Figures from the National Audit Office showed that in England the £392 million cost in 2005-6 of out of hours care was 22% more than the money allocated by the government.

Have concerns been raised before?

Out-of-hours care has been a politically sensitive issue in recent years.

Because contracts are negotiated locally, there have been concerns that there is too much variation in the quality of care being offered.

A report just published by the Primary Care Foundation found in some areas of England 78% of patients rated care as good or very good, while in the poorest performers only 46% felt well looked after.

And there is a surprising variation in how much the NHS in England will pay for out of hours care per head of population around £4 per year to £16.

While services in rural areas with bigger distances to cover tend to cost more, that doesn't completely explain the variation.

A report by the Care Quality Commission has also raised further concerns about out-of-hours care.

In response to the case of Dr Ubani, the regulator looked at five trusts which used the company, Take Care Now, that employed Dr Ubani and warned they were failing to properly monitor services.

It said the variations in performance suggested it could be a nationwide problem.

What did the inquest find?

An inquest into the deaths of two patients treated by German doctor Dr Daniel Ubani has criticised the entire system.

David Gray, 70, from Cambridgeshire, died in 2008 from an overdose of the painkiller diamorphine after being seen by German medic Dr Daniel Ubani.

The coroner ruled his death was "unlawful killing". While the second patient who died, Iris Edwards, 86, was judged to have passed away because of natural causes, the coroner accepted she could have received better treatment.

He identified failings in Take Care Now, the private firm running out-of-hours care in the county, the NHS trust responsible for services, the doctors' regulator, the General Medical Council and the government.

In all, he made 11 recommendations to improve the system. These mainly focused on better communication between different parts of the NHS, a more robust system of checks and tougher scrutiny.

The government carried out its own review, aware of the failings of the case before the verdict.

The review promised improvements will be made, but only time will tell if they meet the requirements of the coroner and, for that matter, family of Mr Gray.

What checks are there on foreign doctors coming into the UK ?

It depends on where they are coming from.

Doctors from outside Europe face rigorous tests from the medical regulator, the General Medical Council (GMC).

They sit a written exam, and undergo practical tests of their clinical and communication skills which can involve actors playing the role of patients.

Only then are they put on the medical register which allows them to work as a doctor in the UK. The total cost to the doctor of sitting these exams is £575.

Why is it different for European doctors?

Under European law their professional qualifications have to be accepted by the GMC.

So a doctor who has trained and qualified in a country anywhere in the European Economic Area, or had their qualifications accepted by that country is entitled to practice as long as they can present proof of those qualifications.

The GMC is not allowed to systematically check their language or clinical skills.

The GMC has said it has serious concerns about the effect of these limitations on its ability to safeguard patients.

Who checks these European doctors?

Once they have been put on the register by the GMC they can apply to the NHS in different areas to go on what is called a "performers list".

In Wales that list is held nationally.

In England each area has its own list, with different criteria for inclusion.

Some require a higher standard of proof that a doctor can speak good english for example.

Doctors are also typically required to provide proof that they are insured, an application for a Criminal Records Bureau check and evidence of any qualifications.

In practice once a doctor is accepted onto a performers list in one part of England they are likely to be able to work in another area too.

How many doctors are flying in from Europe to do these shifts?

There are no centrally kept figures, and no way of telling apart doctors coming in to do an out-of-hours shift or those coming to work more permanently in the UK.

The two countries which have provided the largest number of GPs working in the UK are India and Germany.

In 2008, the total number of Indian trained GPs working was 4,942 and German trained was 1,122 doctors.

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