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Posts Tagged ‘Out-of-hours’

Low staff levels not only reason for death rates

By Mike Broad - 11th January 2012 8:28 am

Low staffing levels are not the only reason why mortality rates increase in hospitals at weekends, two leading experts claim on bmj.com.

Andrew Goddard, director of the Medical Workforce Unit at the Royal College of Physicians, and Peter Lees, founding director of the Faculty of Medical Leadership and Management, suggest that a contributory factor is that patients admitted at the weekend are sicker than those admitted during the week.

A recent report by Dr Foster Intelligence grabbed the headlines by supporting the hypothesis that only early assessment and intervention by experienced clinicians will result in improved weekend mortality.

The report compared hospital standardised mortality ratios (HSMRs) for patients admitted to English hospital trusts on two weekends in April 2011 with those admitted in the week, and showed a clear association between reduced numbers of senior doctors in hospitals and increased mortality at the weekend.

However Goddard and Lees’ editorial, on bmj.com, says that hospital coding (on which HSMRs rely) is not sensitive enough to allow correction for the patients being sicker at weekends.

Although patients with certain conditions - such as trauma, alcohol associated conditions, and self harm - are more often admitted at the weekend, the main reason that sicker patients are admitted at the weekend is variation in referral practice, the editorial says. Out-of-hours primary healthcare services have changed dramatically over the past decade in the UK, with increasing reliance on “emergency medical services” rather than patients’ own GP.

Provision of hospital support services is also reduced at the weekend, it says, so fewer interventional procedures, such as percutaneous coronary intervention for acute coronary conditions and endoscopy for upper gastrointestinal bleeding, are performed.

The editorial does acknowledge that even when factors are considered, the observation of increased mortality and low staffing levels cannot be discounted and pose a serious problem for the NHS - with the process of increasing doctor numbers being slow and expensive.

Emerging data show that working patterns for consultants influence mortality, with hospitals in which the admitting consultants work blocks of more than one day have lower excess weekend mortality than those with a ‘physician of the day’ model. It also calls for research into which specialties could deliver the most benefit.

The number of medical registrars (who run most hospitals at night) could easily be the defining predictor of hospital mortality, it says, despite current plans to reduce their numbers.

“This may need to be re-thought but, given the potential profound impact on clinical outcomes, decisions must be based on sound evidence,” it says.

It also suggests the problem is more significant in hospitals in the north of England.

The editorial concludes that the Dr Foster report raises more questions than it answers and calls for greater insight into community out of hours services, hospital staffing, and workforce configuration. “All need to be reviewed against the knowledge of which conditions are associated with increased mortality at the weekend. This is an opportunity that, if tackled intelligently, will improve the care of some of our sickest patients for many years to come.”

Tags: Consultants, Mortality rates, Out-of-hours
Posted in Hospital Dr News | No Comments »

“More consultant cover needed out-of-hours”

By Mike Broad - 2nd December 2010 9:58 am

Senior doctors need to be more available to work in acute admissions units, a survey finds.

The research, by the Royal College of Physicians, on the way care for very ill patients is managed recommends that hospitals need to increase the out-of-hours availability of consultants for acute care.

Care for very ill patients has improved significantly over the past few years due both to the introduction of acute medical admissions units in most major hospitals, and a major increase in the number of consultant physicians specialising in acute medicine to assist other hospital specialists working in acute medical admission units.

Despite these changes, the RCP says, many patients are only seen once per day in a formal ward round instead of the recommended two daily ward rounds. In three quarters of the acute medical admissions units accepting patients directly from GPs, there are regular bed shortages, so the report recommends that there are sufficient beds in future to ensure that very ill patients gain appropriate access to acute admissions wards.

Sir Richard Thompson, the new president of the Royal College of Physicians, urged the government to address the standard of care in hospitals in the evenings and at weekends. He said new working patterns are needed.

Forty eight per cent of consultant physicians responsible for assessing and treating the acute take still have to do routine clinics or other parts of their job as well as at the same time seeing the urgent patients. These duties should be cancelled on those days to allow physicians to concentrate wholly on the very ill patients.

Only 3% of hospitals provided weekend cover from consultant physicians specialising in acute medicine for nine to 12 hours and none for over 12 hours. Nearly three-quarters of hospitals in the survey had no cover from consultant physicians specialising in acute medicine over the weekend.

An accompanying statement from the RCP council recommends that consultant physician cover is available in hospitals every day for 12 hours per day.

Dr Jonathan Potter, clinical director of the RCP’s clinical effectiveness and evaluation unit, said: “Despite improvements in facilities and staffing, hospitals still need to address working arrangements to ensure that senior doctors are readily available to provide a consultant led service in acute medical admissions units seven days a week.”

Previous studies show that a consultant-delivered service is best for patient treatment and recovery.

Representatives of 126 hospitals completed the survey - 114 from England, six from Northern Ireland and six from Wales.

Read the RCP president’s blog on the issue.

Tags: Acute medicine, Consultants, Out-of-hours
Posted in Hospital Dr News | 4 Comments »

Patients deserve better out-of-hours care

By Sir Richard Thompson, president of the Royal College of Physicians - 9:52 am

For many years now the Royal College of Physicians has been working to improve acute care in hospitals, from creating the specialty of acute medicine to producing two major reports.

As a result, there have been major improvements in the organisation of acute care, but there is mounting evidence of poor care being delivered at night and at weekends, particularly the recent NCEPOD reports.

It is clear we need to do something extra to increase the amount of care delivered by consultant physicians.

Last week the RCP council agreed to recommend for the first time that any hospital admitting acutely ill patients should have a consultant physician on-site for at least 12 hours per day, seven days a week, who should have no other duties scheduled during this time. All medical wards should have a daily visit from a consultant; in most hospitals this will involve more than one physician.

We know that doctors are already working long hours - our latest census results say an average of 50 hours a week, which is four and a half hours more than their contract. More than half of those surveyed were working longer than the 48-hour limit set by the European Working Time Directive.

We are not expecting anyone to work longer than that, nor to increase their hours overall, instead we need to change job plans to reflect the different working patterns, which must include arrangements to ensure adequate rest.

The Department of Health are also considering policy in this area, and I have asked health secretary Andrew Lansley for a meeting to discuss the issue.

Dr Ubani’s gagging order application rejected

Healthcare Republic - 28th August 2010 8:58 am

Dr Stuart Gray, the GP whose father was killed by German locum Dr Daniel Ubani, has welcomed a court decision to reject a gagging order against himself and his family.

The court in Kempton, Germany, rejected the application by Dr Ubani for an injunction, which aimed to impose a ban on Dr Gray and his brother Rory Gray from talking to the press across Europe, including the UK.

The court ruled that the brothers can continue to brand Dr Ubani a “charlatan” and a “killer” but said the sons are not permitted to use “animal”.

Dr Gray said this is a “major milestone” for his family and that he will now concentrate on getting Dr Ubani struck off the medical register across Europe.

Out-of-hours firm had systemic failings, CQC says

BBC Health - 15th July 2010 9:33 am

A company providing out-of-hours care in an area where a pensioner died after a painkiller overdose had “systematic” failings, the NHS regulator says.

David Gray, 70, from Manea, Cambridgeshire, was killed by Dr Daniel Ubani, a German medic working his first NHS shift for Take Care Now.

The now-defunct firm was criticised for failing to act on previous cases and warnings on standards.

The Care Quality Commission said the whole NHS should learn lessons too.

The CQC criticised Take Care Now (TCN) for failing to investigate and learn from two previous cases of diamorphine overdoses prior to Mr Gray’s death.

German GP who killed patient in UK struck off

BBC Health - 18th June 2010 9:59 pm

An out-of-hours doctor from Germany who killed a patient with an overdose of a painkiller has been struck off by the GMC.

Dr Daniel Ubani, 67, injected David Gray, of Manea, Cambridgeshire, with 10 times the recommended dosage in 2008.

A GMC panel has ruled that Dr Ubani should be banned from practising in the UK.

Health Secretary Andrew Lansley said he was working to ensure foreign staff have the right language skills.

Dr Ubani was given a suspended sentence in Germany for death by negligence but is still able to practise there. The GMC’s powers do not extend to other countries.

GPs to take back out-of-hours, says government

Healthcare Republic - 18th May 2010 9:08 am

The Conservatives have confirmed they will force GPs to take back responsibilities for out-of-hours by entering into new contract negotiations.

Speaking to the Daily Mail, new health secretary Andrew Lansley said: “GPs should be responsible. There will need to be a new contract to make this point.”

Under Conservative plans, responsibility will be handed back from PCTs to GPs working in local groups, who will commission services or provide them by working in rotas through co-operatives.

GPC chairman Dr Laurence Buckman said he would not oppose responsibility for commissioning out of hours services being included in the contract.

“GPs involvement in out-of-hours commissioning will be a positive thing for GPs and their patients,” said Dr Buckman.

GMC wants new powers to test European docs

By Mike Broad - 19th March 2010 4:49 pm

The GMC has once again called for an urgent change in the law to enable them to test the language skills and competency of European doctors before they start work in the UK.

In presenting evidence to the health select committee, GMC chief executive Niall Dickson said the regulator needed more powers to be able to properly check the competence of European doctors.

Dickson said: “What we can do is check who they are; we can get from the competent European authority a certificate saying they are somebody of good standing, and thirdly we get the qualifications they produce.

“What we cannot do is look behind those things. We cannot say well that qualification doesn’t mean very much. If it is approved, and it is on the European list, then we simply have to accept them and in the case of Dr Ubani that was of course what happened.”

German doctor Dr David Ubani negligently killed a patient during an out-of-ours visit in Cambridgeshire in 2008. David Gray died after being administered 10 times the normal dose of diamorphine. The coroner, and a subsequent inquiry, raised serious concerns about the management of out-of-hours care.

Health minister Mike O’Brien, who also appeared in front of the committee, questioned whether empowering the GMC was the best way to tackle the problem.

He suggested that greater adherence to existing responsibilities, and better management of the ‘performers list’, by trusts and employers could be the solution.

O’Brien said: “I am making absolutely clear that PCTs should have been by law, since 2004, looking at language skills. They had no discretion on this; it was a legal obligation. They should be doing it now.”

He added: “The most important check, and where we have to tighten up a lot, is on the employer because the employer, either a co-operative or a private company, needs to ensure that the competence in terms of the skill and also the language skills are adequate to do GP services.”

Dr Ubani was employed as a locum GP covering an out-of-hours shift by private sector provider Take Care Now, which recruited him at short notice from Germany.

O’Brien felt that that working with PCTs and employers would be more expedient than changing the law. “If we go into a long drawn-out discussion about changing EU Directives, what the GMC want and giving them new powers…I think it will just take longer, but I want to sort this out by the end of this year,” he said.

Tags: Out-of-hours, Overseas doctors
Posted in Hospital Dr News | 2 Comments »

Our GPs must prevent out-of-hours “killings”

By Mike Broad - 4th February 2010 6:20 pm

Apologies over the unnecessary death of David Gray have filled the front pages and airwaves this week.

He was given a fatal overdose by Dr Daniel Ubani, a German doctor flown in to provide out-of-hours GP cover in Cambridgeshire, and a coroner ruled this week that his death amounted to gross negligence and manslaughter.

The coroner William Morris issued 11 recommendations to the Department of Health to improve out-of-hours GP services.

The main one, and most people’s biggest bone of contention, is the need for a review of how EU agreements work in the UK. Morris said the government must issue guidance to all NHS trusts over checking doctors’ English, their experience of the NHS and how they acquired their GP status.

However, as the GMC is at pains to point out, they’re not allowed to test doctors from the EU. The combination of EU law and domestic legislation (the Medical Act 1983) excludes the testing of a European applicant’s language proficiency or their competence.

This is a bit of a problem when you consider that Ubani was flown in at the eleventh hour, started work immediately with no induction and was utterly incompetent. (Makes you also wonder why we booted out loads of good doctors with excellent English from the sub-continent a couple of years ago).

Without wanting to come over all UKIP, our health secretary needs to grow a spine and put our relationship with Europe on a proper footing on this issue.

Morris also demanded “robust” clinical and management measures, including training and induction for non-UK doctors, and said only the company actually running the out-of-hours GP services should recruit doctors in future. It follows the Care Quality Commission making similar demands of trusts last year.

And this is where we get to the crux of it. Of course all overseas doctors coming into the UK should be tested and we should have a clear idea of the equivalence of their training. But, the real problem is how we’ve organised our out-of-hours GP services. Crap European doctors shouldn’t be required.

This week’s apology by NHS Cambridgeshire, which employed Take Care Now to provide the services in question, is revealing.

Dr Paul Zollinger-Read, chief executive of NHS Cambridgeshire, said: “We as an organisation still have much to learn from this case. Our monitoring of contracts has already improved significantly, but we must not become complacent.

“Systems around the registering of GPs by the GMC and on Performers’ Lists need to reviewed, and the recruitment, checking and vetting of GPs by our providers is vital if we are all to prevent this happening again.”

He’s got responsibility but seemingly limited power to control events. It doesn’t take much to go wrong, in a safety critical environment, where organisations are contracting and sub-contracting to the private sector, to lose sight of the process.

The reasons why Ubani was used remain. He was cheap and available (he even paid for his own flight and accommodation). It had nothing to do with quality. More checks will help but, in our new age of austerity, PCTs are still going to be looking for cheap deals.

I think it speaks volumes that Take Care Now is still in business, regardless of whether it has improved. It lost its Cambridgeshire contract, but still provides services for two other trusts: NHS Worcestershire and NHS Great Yarmouth and Waveney.

The GP contract has been an unmitigated disaster for out-of-hours care in the community. It’s time to bring local GP practices back into the equation and if that means the GP contract has to be re-negotiated, then so be it.

Tags: Out-of-hours, Overseas doctors
Posted in Dr Blogs | 2 Comments »

Employer of overdose GP loses second NHS contract

The Guardian - 18th December 2009 1:14 pm

A private company running out of hours GP services for the NHS has lost a second contract in the aftermath of the case of a foreign doctor who accidentally killed a patient on his first UK shift as a locum.

Take Care Now was stripped of one contract amid safety concerns and another will not be renewed. It still provides emergency GP services for three other local NHS trusts.

The company is under investigation by NHS watchdog the Care Quality Commission over the death of 70-year-old David Gray. He was given a massive overdose of a painkiller by Daniel Ubani, a German doctor who admitted to being unfamiliar with the drug, tired and lacking concentration.

The commission’s interim report in October raised questions about the company’s ability to fill shifts, manage medicines and take appropriate action for stroke patients. The NHS in Cambridgeshire sacked the company from running weekend and evening GP services in Fenland and east Cambridgeshire this month - four months before its contract was due to end - because of continuing safety concerns.

Now health chiefs in Suffolk have decided to switch out of hours provision to Harmoni HS, a company with six other similar NHS contracts.