NHS may fail to spot patient safety concerns unless it improves monitoring of out-of-hours GP services, says CQC

2 October 2009

Early observations from regulator's enquiry into out-of-hours provider, Take Care Now, may indicate a nationwide gap in monitoring.

The Care Quality Commission (CQC) today said it fears Primary Care Trusts (PCTs) may not be effectively monitoring performance of GP out-of-hours services, and risk failing to spot patient safety concerns as a result.

Updating on its review of out-of-hours care provided by Take Care Now, the regulator warned the NHS it must improve its monitoring.

Following visits to the five PCTs that commission out-of-hours services from Take Care Now, CQC found that although trusts monitor response times of the service, they do not consistently and routinely look in detail at the quality of care. This could mean opportunities to spot potential problems and indications of poor care are missed.

As CQC found that monitoring varied across all five trusts, it believes this might be a widespread problem. It is concerned PCTs across the country may not be monitoring GP out-of-hours services closely enough.

It says PCTs must look at details like the quality of clinical decisions, the efficiency of call handling, the adequacy of staffing and doctors' training in order to rigorously monitor performance.

The work was triggered by the tragic case of Mr David Gray, a patient treated by an out-of-hours locum doctor from Germany who died following the administration of 100mg of diamorphine.

The CQC announced the scope of its enquiries in June, outlining that it would look at Take Care Now's out-of-hours service. It is focusing on current systems, including contractual and monitoring arrangements between PCTs and Take Care Now, as well as changes made after recent incidents.

Cynthia Bower, CQC's chief executive, said, "GP out-of-hours services provide vital care to people outside of normal surgery hours. As commissioners of these services, PCTs need to ensure people receive safe, quality care around the clock.

"Our visits to the five trusts that commission Take Care Now's services showed they are only scratching the surface in terms of how they are routinely monitoring the quality of out-of-hours services. If their monitoring is not robust enough, they may not be in a position to spot early indications of potential problems or poor care.

"Although we are still in the early stages of our enquiries, we believe this may point towards a national problem. We are therefore encouraging PCTs across the country to scrutinize in more detail the out-of-hours services they commission.

"PCTs need to dig deeper and keep a closer eye on important areas such as: efficiency and quality of call handling and triage; the number of unfilled shifts; the proportion of shifts covered by non-local doctors; the induction and training those doctors receive; and the quality of the decisions made by clinical staff. It's not just about monitoring numbers of people treated, or how much this costs. It's about examining the finer detail of the actual care patients receive, to ensure the service is safe and meeting people's needs."

"We have shared our findings with the Department of Health, which is today writing to all PCTs across the country asking them to make it a priority to review their monitoring arrangements for out-of-hours services."

In relation to Take Care Now as a provider of out-of-hours services, CQC found it had significantly reduced the chance of the original mistake happening again, by withdrawing 100mg doses of diamorphine. It has also made sure that schedule 2 controlled drugs, such as opiate-based drugs used in acute and palliative care, are stored and dispensed securely.

But there are some areas requiring further improvement. The CQC observed that Take Care Now needs to address:

• Unfilled shifts. The provider sometimes has difficulty filling doctors' shifts, which puts pressure on other staff and could affect the quality of the service.
• The policy on what action to take for people with a suspected stroke, as it was not consistent across the areas in which Take Care Now provides out-of-hours services. CQC says it must ensure that all patients with symptoms of stroke are transferred without delay to the 999 service.
• Its policy for managing medicines, as it includes some information that is currently too generic or not appropriate for out-of-hours services. It should be tailored to the actual out-of-hours services that the organisation provides.

CQC has also conducted enquiries at Cornwall and the Isles of Scilly PCT. Dr Ubani was on this trust's performers list, enabling him to work shifts for Take Care Now.

It found the trust has now taken steps to ensure overseas doctors provide evidence of proficiency in English, and those who do not work locally are removed from the performers list.

However, CQC also identified that although there are national regulations in place in respect of performers lists, there has not been a consistent approach by PCTs to the inclusion of doctors on these lists. It says this issue is being addressed by the Department of Health.

In the second phase of its enquiries, CQC will carry out: visits to remaining Take Care Now facilities; an audit of call handling, triaging and face-to-face assessment to establish the quality of interactions and decision-making; a survey of staff to hear their views on issues such as training; closer examination of arrangements for managing medicines; ongoing examination of the original incident to establish whether all lessons have been learned; and further consideration of how doctors are admitted to performers' lists and arrangements to monitor and maintain these lists.

The CQC is expected to publish its final report early in 2010, however, it may provide further updates in the interim if there are important lessons to be learned for Take Care Now or PCTs.

Ends

Notes to editors

The five PCTs where Take Care Now provides GP out-of-hours services are:

• NHS Worcestershire
• NHS Cambridgeshire
• NHS Suffolk
• NHS Great Yarmouth and Waveney
• NHS South West Essex

The CQC will also look at the arrangements in Cornwall and Isles of Scilly PCT for their performers list and their responsibility as a holder of this list.