Dozens like Kelsey have died through incompetent out-of-hours cover for their GPs. So how safe are YOU
01:04 GMT, 10 July 2012
When Kelsey Smart finally made it to hospital, it was too late to save her from meningococcal meningitis
At 2am on June 15 last year, Lee Kerrigan took his six-year-old son Ethan to hospital.
The little boy was suffering from stomach pains and vomiting, but there were no doctors on duty in St Austell, Cornwall, and Mr Kerrigan was told to call the out-of-hours medical service.
He rang from the hospital car park and spoke to a nurse, who said to give Ethan painkillers and to take him to see the GP the next day.
She’d failed to recognise the warning signs of a burst appendix.
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Failed by the system: Jeffery Wingrove (left) suffered a brain haemorrhage and died in hospital; and Gary Lovett (right) who was told to take over-the-counter flu treatment. He died on Boxing Day
Five years after his death, the GMC ruled the doctor had ‘failed to elicit an adequate history; to consider all the symptoms and other information reported to her and refused to arrange a home visit when the situation clearly warranted one’.
In February, an out-of-hours GP failed to spot that five-year-old Kelsey Smart was suffering from a potentially fatal, but treatable, bacterial disease and sent her home. When the little girl from Bristol finally made it to hospital, it was too late to save her from meningococcal meningitis.
When father-of-two Craig Davidson injured his neck playing football, an out-of-hours doctor diagnosed a panic attack and prescribed tranquillisers. A few hours after the doctor’s visit, Craig, from Dundee, was found dead on the kitchen floor by his mother and son. He’d died from a ruptured spleen.
Charity worker Gary Lovett, 20, from Southampton, suffered vomiting, fever and chest pains a few days before Christmas 2010. Despite repeated calls from his parents to NHS Direct and the out-of-hours service, he was told to take over-the-counter flu treatment and was prescribed antibiotics by the out-of-hours doctors and sent home. He died on Boxing Day.
The problem with out-of-hours care is not simply this ‘small number of disastrous incidents’, as the Primary Care Foundation put it recently.
For even when patients aren’t experiencing ‘disastrous incidents’, many are deeply unhappy with the GP cover they receive.
According to a recent survey for the Department of Health, 14 per cent of patients rated their out-of-hours care as poor, while 16 per cent thought it was ‘neither good nor poor’, and 31 per cent said they had waited too long for help.
Until recently, your own GP would be the one who would respond to a call for help in the middle of the night.
‘The service as it used to run was working well from the perspective of patients,’ says Michael Watson, of the Patients Association.
‘We’ve changed it because GPs said they didn’t want to run it that way, but what we have changed to clearly isn’t working from the perspective of the patients.’
He’s referring to the fact that in 2004, GPs negotiated a contract that allowed them to opt out of out-of-hours care.
Into the breach stepped GP co-operatives — in which doctors banded together to share the burden of care — and, increasingly, commercial companies.
In 2010, there were 23 commercial companies running 227 surgeries and health centres around the country.
What kind of care does a commercial company provide It is perhaps telling that when it comes to how patients rate the care they receive, only one commercial provider appears in the top 30 in a recent survey by the Primary Care Foundation (an independent body that assesses health care).
At the other end of the table, commercial providers occupy three of the five bottom slots.
One of the major commercial providers is Serco — an international company that also carries out school inspections for Ofsted, as well as operating four prisons, two immigration centres and Boris Johnson’s cycle hire scheme for Transport for London.
Serco ran the out-of-hours service involved in Ethan Kerrigan’s case.
It is also under investigation by the Care Quality Commission over whistle-blower allegations that its out-of-hours GP cover in Cornwall has unsafe staffing levels, and that it’s been massaging figures to ensure it met performance targets, including waiting times.
For even when patients aren't experiencing 'disastrous incidents', many are deeply unhappy with the GP cover they receive
The NHS is facing increasing demands to save money and the fear is that more out-of-hours services will be taken over by big companies who can under-cut GP co-operatives.
Staffing is a key area of concern, both for co-operatives and commercial companies.
Many out-of-hours services are struggling to find enough doctors to provide safe and consistent cover.
An investigation earlier this year by Pulse, the GP magazine, found that in some parts of the country, up to a quarter of GP out-of-hours posts were going unfilled.
Ironically, the most severe shortages were in the east of England where, in the wake of the Ubani case, only local doctors are allowed to work in the system.
The problem is only going to be exacerbated by the NHS reforms.
One of the most significant changes being introduced is giving GPs the responsibility for commissioning services.
This has meant many GPs have had to be taken out of frontline action to set up commissioning groups — as a result, their colleagues have been ‘heaving under the pressure’ to continue providing just day-to-day care, the head of the Royal College of General Practitioners said in March.
Another looming upheaval threatens to further disrupt out-of-hours services.
This is the introduction of a national NHS 111 number designed to be a single clearing house for all urgent calls, including those made out of hours.
Currently, you call your own surgery, which will connect you to the out-of-hours service, NHS Direct or, in certain areas, dedicated numbers operated by private companies or GP co-operatives.
But when NHS 111 is rolled out next year, all calls will be answered by non-medical staff — they will be trained to ask a series of questions triggered by a computer program, which will decide what kind of help the patient needs.
In May, the annual conference of GPs expressed ‘serious concerns’ about the proposed service.
Chief among them was that triage — the process where the urgency of the patient’s case is assessed — won’t be performed by doctors, but non-clinicians.
‘Patient safety will be compromised,’ the GPs said.
Such concerns will resonate with the family of 20-year-old Gary Lovett, from Southampton, who’d called NHS Direct (which the new NHS 111 will replace) several times in the days before he died.
There is also anger that in some areas of the country, the ‘one size fits all’ 111 service will scrap better systems that have been working well for years.
In Shropshire, GPs banded together in 1996 to form their own service, Shropdoc.
Covering 600,000 patients in Shropshire, Powys and Telford and Wrekin, it deals with more than 200,000 calls every year.
Shropdoc is a not-for-profit organisation and all of its 300 members are GPs working in local practice.
‘We do not use agency doctors,’ says the service’s website.
A vital part of Shropdoc is a dedicated hotline number with every call answered by a doctor.
‘We operate on the same basis as the Army, that the most experienced and most qualified people do the triage, which is not a concept that will apply in NHS 111, where it will be the least experienced people,’ says Dr Mary McCarthy, a GP and chair of the Local Medical Committee.
GPs are concerned that especially vulnerable patients — including children, those with palliative care needs and chronic and complex conditions — won’t fit into the triage set of rules that has been devised for the non-medical 111 operators.
‘One of the problems about following a computer program is that you don’t give people scope to talk about what’s wrong,’ says Dr McCarthy.
‘They have to answer “Yes” or “No” to questions, while a GP taking a phone call will let the patient talk and listen to what they say.’
She fears the introduction of NHS 111 may see yet more commercial operators taking over out-of-hours services. ‘That seems to be the way things are going. Commercial companies seem to be coming in and cherry-picking,’ she says.
And from the patient’s point of view, that’s bad news — when it comes to patient satisfaction, only three commercial operators feature in the top 20 services, according to the recent survey by the Primary Care Foundation.
It is a similar story for most measures, including the time patients spend waiting to be seen.
The Care Quality Commission, which registers all out-of-hours services, says there are 115 operated by 47 providers, but it was unable to say how many of those were commercial operations — a factor ‘not terribly important to the regulatory process’, as it told the Mail.
The hope is that some of the NHS reforms — such as inspections by the Care Quality Commission — mean that ‘poor out-of-hours GPs will perhaps get picked up in a way they haven’t before’, says Michael Watson.
Joyce Robins, co-director of Patient Concern, is more cynical about the changes. ‘I have yet to hear what the benefit is for patients and I’m not sure there is any,’ she says.
‘And we haven’t seen the back of it, by any means. I’m on the West Sussex coast, where there’s a very elderly population.
'If you phone the out-of-hours service you might get a nurse, you might get a paramedic — if you get anybody — or you might get a doctor who has come from abroad and whose language you do not speak.
‘I have a neighbour who was very ill recently. Someone arrived and she couldn’t understand a word he said . . . it’s very, very dangerous.’
Indeed, four years after Mr Gray’s death, the proposal to protect patients by placing responsibility for doctors’ language skills on named ‘responsible officers’ has yet to be implemented.
‘Out-of-hours care is so patchy,’ says Joyce Robins.
‘We do get reports from people who are having excellent service, but then we get reports from others who are really left without cover.
‘We call it a National Health Service, but it’s nothing of the sort.
'There seems to be no overall hand on it and that seems to be what is wrong with the whole service, whether you talk about provision of drugs, waiting times or out-of-hours service.
‘It just depends where you live — it’s pot luck.’