Daniel Ubani may be some way short of the notoriety of Harold Shipman, but he has left in his wake similarly profound changes to the way general practice is regulated.
Ubani’s incompetence, in killing 70-year-old patient David Gray, has alerted the GMC to the dangers of employing untested doctors from across the EU, and set in motion significant reforms to out-of-hours care, including moves by PCTs to ensure services are run entirely by local GPs.
Ubani’s fatal actions took place in Cambridgeshire, and it’s there NHS managers have pioneered a local-only policy for out-of-hours care. A third of trusts in England are now following them down that path, with some introducing particularly tough restrictions, such as barring use of locum agencies.
NHS managers have recognised that a key problem with Ubani was not only that his language skills were inadequate and he was clinically inexperienced in general practice, but that he had no knowledge of the local healthcare system – of how its services were run and the drugs and doses that were made available.
All the same, PCTs’ change in policy is dramatic. We have gone from out-of-hours providers being allowed to employ fly-by-night overseas doctors with barely any induction at all into the NHS, to a strict policy of local GPs for local people.
A number of trusts adopting the policy are in London, where there is an excess of doctors and plenty of younger GPs willing to work out of hours.
A local-doctor policy feels like it ought to be workable in the capital. But it is much less clear that this is true in rural areas, ironically such as Cambridgeshire, where there may often be a shortage of doctors generally and specifically of GPs willing to work for the rates available on out-of-hours shifts.
There are likely to be two main consequences. Firstly, out-of-hours costs will inevitably rise, because what will buy you a German locum with next to no experience of general practice will not buy you an established local GP. And secondly, there is bound to be increased pressure for GPs working in practices up and down the country to make themselves available for out-of-hours shifts once again. GPs are already used to getting begging emails from PCTs, desperate to fill vacant out-of-hours slots. Expect the pressure to rise, perhaps particularly when it is GP consortia holding the whip.
In an ideal world, all out-of-hours shifts would be run be local GPs – and where it’s workable PCTs are right to opt for that policy. But there are questions over whether the NHS can afford that in many areas, and concerns that pressing GPs to do it for less than it’s worth could further damage the profession’s fragile morale.
It might often be more pragmatic instead to ratchet up testing procedures for EU doctors, and to mandate a full and thorough induction period for everyone cleared to work out of hours.
It is essential the NHS learns the lessons of the Ubani case. But they must be the right lessons, and appropriate to the local area.
Local GPs are the best people to cover out-of-hours shifts – but if the NHS is going to insist on the best, it must be prepared to pay for it.