Time to face up to the locums scandal

“On rare occasions single catastrophic errors rightly lead to a complete review of a healthcare service,” write Paul Cosford and Justyn Thomas this week (doi:10.1136/bmj.c3194). They have in mind the death of David Gray from an overdose of diamorphine given by German based locum Daniel Ubani. Without absolving Ubani of responsibility, they are damning of the system that allowed a doctor who had previously failed an English language test, had never worked in the UK, and did not practise primary care in Germany, to fly in one evening and work unsupervised the following day.

They call for changes, including letting the General Medical Council assess competence and language skills for doctors coming from the EU—something the GMC is pushing for (doi:10.1136/bmj.c3385). But their well moderated anger also falls on doctors as a whole. “We should not accept a system that allows incidents such as this in any part of the NHS,” they say.

Anger is equally justified from Chris Isles and for similar reasons, though (so far) without the tragic outcome (doi:10.1136/bmj.c1412). His efforts to fill his hospital’s rota were met with a series of inadequate or unreliable locum applicants. He reserves his main ire for the locum agencies, which he says should long ago have been regulated. You can vote on this question in our poll on bmj.com.

A month ago a BMJ investigation questioned WHO’s decision not to disclose financial conflicts of interest among its industry sponsored advisors (BMJ 2010;340:c2912). This week we publish some responses, including one from WHO’s director general Margaret Chan (doi:10.1136/bmj.c3463). Hindsight is a wonderful thing, and no one will underestimate the challenge WHO faced when the first reports of deaths from A/H1N1 influenza were reported in Mexico. But basic mistakes were made from the start, as Asa Christina Laurell from Mexico City reminds us (doi:10.1136/bmj.c3465). “Attack rates and case fatality rates were not calculated but would have shown that the new virus was mild,” she writes.

And as Ron Law points out (doi:10.1136/bmj.c3460), when WHO redefined “pandemic” a month before the pandemic was declared, it not only dropped the words “with enormous numbers of deaths and illness,” but also the requirement for a new subtype. Only with these changes could H1N1 fit the bill. Law writes, “It was not a new subtype, it was not causing enormous numbers of deaths and illness, and a significant number of people had already been exposed to an immunologically similar virus.”

Chan says changes to the definition were discussed as early as 2007, long before H1N1 came on the scene. But by dramatically weakening its definition WHO opened up the pandemic field to almost all viruses. And in failing to follow even its own rules on financial conflicts of interest, it has opened itself up to serious and justified criticism. Chan says, “At no time, not for one second, did commercial interests enter my decision making.” But as Tom Jefferson and Peter Doshi, point out in their letter, “this self evaluation is irrelevant and misses the point: that transparent declarations of interest are crucial to allow others to decide for themselves” (doi:10.1136/bmj.c3461).