IN DEPTH: Manea patient's death leads to call for changes

Doctors from anywhere in Europe can practise in the UK without any checks on their medical skills, clinical knowledge - or even their ability to speak English. But it took the death of a patient to highlight stark failings in the NHS out of hours system.

Doctors from anywhere in Europe can practise in the UK without any checks on their medical skills, clinical knowledge - or even their ability to speak English. But it took the death of a patient to highlight stark failings in the NHS out of hours system.

Hours after he thanked the doctor for easing his pain, David Gray was dead. Instead of a routine morphine injection, the foreign locum who made an out-of-hours call at his home in Manea, near March, gave him 10 times the normal dose of a drug he had never been called upon to prescribe before.

Dr Daniel Ubani had hardly slept before his first-ever shift with the on-call service SuffDoc. His English was so poor he could barely even converse with those who placed their lives in his hands on a February night in 2008.

It later emerged he was a cosmetic surgeon, who appeared never to have practised as a GP. There were question marks over his qualifications, past claims of malpractice. So how was he ever allowed near a patient?

Until 2004, local surgeries provided out of hours care. But doctors' leaders feared being on call 24-hours a day was taking its toll on exhausted GPs, raising fears over patient safety.

So doctors were allowed to opt-out of providing 24-hour cover, in return for a �6,000 pay cut, while the responsibility was passed to primary care trusts, who buy cover from private firms, co-operatives of GPs and other organisations.

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A shortage of doctors willing to work out-of-hours means foreign doctors or locums are commonly used. But while these are most commonly from other EU countries, European directives covering the freedom of workers to move between countries prevent health authorities from checking they are competent to practise.

Last night the independent regulator for UK doctors, the General Medical Council (GMC), said the system was "profoundly unsatisfactory".

The GMC maintains a register of all doctors eligible to practise medicine in the UK. Doctors who qualified in the UK, regardless of their nationality, were entitled to be registered provided their fitness to practise is not impaired.

Those who qualified outside the EU can be asked to take an English test and to demonstrate their knowledge and skills to a board before they are eligible to be registered.

Doctors from a European state are eligible for the register, provided their fitness to practise is not impaired. But the GMC may not test the medical skills, knowledge and language proficiency at the point of registration.

"The current situation is profoundly unsatisfactory,' said Niall Dickson, chief executive of the GMC. "We are not able to give the level of assurance we want because of the present legal framework.

"Our position is clear. In order to ensure patient safety, when doctors first register with us, we need to be able to test their English language proficiency and we need to be able to test their clinical knowledge and skills.

"At present we can do that for doctors from outside Europe but we can't do it with doctors from within the European Economic Area.

"We will continue to work with the Department of Health and through the European Parliament to secure the changes we need. The main obstacle to progress is the complex legal framework.'

The GMC believes there are 218,692 doctors on the UK register who hold a right to practise. Just over half gained their qualification in the UK.

While it supports the free movement of doctors around the EU, the spokeswoman said it needed "the discretion to test the English language proficiency and clinical knowledge and skills of all potential registrants to safeguard patients".

Last night Liberal Democrat health spokesman and north Norfolk MP Norman Lamb said: "The tragic death of David Gray has raised grave concerns about the safety of out-of-hours care in this country.

"The safeguards to stop dangerous doctors from overseas from practising here are completely inadequate. Patients' lives are being put at risk because standards across Europe are not uniformly good and foreign doctors can practice in the NHS without a test of competence and language.

"Ministers have known for some time that the safeguards in place are not adequate but they have failed to act.

"I have put forward proposals - together with Stuart and Rory Gray, the two sons of David Gray - to ensure every doctor working in this country can speak English, is familiar with our health service and is well trained."

The Lib Dems' proposals include language and competence tests for every doctor wishing to work in the UK and creating a criminal offence for a PCT to allow a doctor to operate without ensuring compliance with regulations

A report into our of hours care was published by the Department of Health hours after yesterday's verdict.

It followed a review by Dr David Colin-Thome, national clinical director for primary care at the Department of Health and Professor Steve Field, chairman of council at the Royal College of General Practitioners.

The review's recommendations included:

PCTs should review the performance management arrangements in place for their out-of-hours services and ensure they are robust and fit for purpose;

The Department of Health should issue guidance to PCTs to assist them in making decisions about whether or not a doctor has the necessary knowledge of English;

Out of hours providers should consider the recruitment and selection processes in place for clinical staff to ensure they are robust and that they are following best practice;

Strategic Health Authorities should consider how they monitor action taken by PCTs in response to this report and in carrying out appropriate performance management of out-of-hours providers; and

Providers should co-operate with other local and regional providers (both in and out-of-hours) to share any concerns over staff working excessive hours for their respective services.

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

Prof Field said: "The report outlines a number of important recommendations which will remind PCTs of their legal obligation to provide safe, high quality out of hours care.

"I'm pleased that Health Minister Mike O'Brien has accepted the report's recommendations in full and that there are plans to go even further to ensure patients will receive consistently good care, regardless of where they live."

Dr Laurence Buckman, chairman of the British Medical Association's GPs committee, said: "The BMA agrees with this report when it says out-of-hours provision is unacceptably patchy.

"There are some out-of-hours organisations that provide a quality service and others, as has been highlighted by the tragic and avoidable death of David Gray, that fall shockingly short.

"We think the recommendations made in this report are sensible and are glad to see the government has accepted them in full. We welcome the proposal for greater involvement of local GPs in assessing the quality of services.

"We hope this, combined with proposals to improve monitoring of services and the selection of clinicians will raise the standard of out-of-hours across the board so that all patients, no matter where they live, receive high quality care.