Some out-of-hours services are so underfunded that many doctors refuse to work for them for fear of putting their registration at risk, a GPC negotiator has warned.

Dr Peter Holden told GP that many providers relied on overseas doctors because they paid so badly that many UK doctors would not work for them.

'Those who do fear for their own registration because the service is under par,' he added.

Dr Holden's comments came in response to a Care Quality Commission (CQC) report warning PCTs to increase monitoring of the quality of out-of-hours GP services.

The report followed an incident last year in which a patient died after being given 10 times the recommended dose of diamorphine by German locum Dr Daniel Ubani, who was working for out-of-hours provider Take Care Now (TCN).

The CQC noted TCN's efforts to improve the security of its drug stores. It also noted that NHS Cornwall and Isles of Scilly, which put Dr Ubani on its performers list, had taken steps to ensure that overseas doctors provide evidence of proficiency in English before joining.

But the regulator warned PCTs to scrutinise out-of-hours services more closely, looking in detail at their call handling and triage, clinical decision-making, and numbers of unfilled shifts and overseas doctors.

The CQC added that the second phase of its inquiry would include an audit of call-handling and triaging and unannounced visits to TCN facilities.

Health minister Mike O'Brien warned PCTs that they had 'a clear legal responsibility' to monitor the quality of their out-of-hours care. He said DoH national clinical director for primary care Dr David Colin-Thome would write to PCTs to reinforce the CQC advice.

Dr Colin-Thome and RCGP chairman Professor Steve Field will work to identify ways to strengthen monitoring and commissioning of out-of-hours services, he said.

Dr Holden predicted that the CQC's final report would require PCTs to involve GPs in out-of-hours commissioning.