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At the heart of general practice since 1960

Running an out-of-hours company

Dr David Lloyd describes what it’s like to work at Harmoni, a large out-of-hours company that began life as a GP co-op

Dr David Lloyd describes what it's like to work at Harmoni, a large out-of-hours company that began life as a GP co-op

Harmoni started as a simple organisation.

Now it consists of a whole floor of open-plan offices. Today, the organisation's departments include: organisational governance, human resources, finance, rotas, the medical directorship and IT.

We used to be a GP co-operative. Our customers were our workers and their patients were our patients. Now our customers are PCTs, and most of the GPs we cover for out-of-hours we never see or hear from. But we still cover the patients, and they will always be our priority.

New obligations

With new relationships come new obligations. We are slaves to NRQs –the national quality requirements.

We have A&E targets, too, and Harmoni buzzes with jargon words just like hospitals do. The definitive clinical assessment (DCA) starts the process and has to be done within an hour or PCTs get upset, patients worry and we lose money.

So imagine large meetings with lots of people poring over spreadsheets, analysing the delays in the system and finely balancing capacity to demand.

A&E departments and hospitals start to panic when their workload goes up or down a few percentage points; demand for out-of-hours may vary twofold or threefold depending on the weather, what's on television or what the latest virus to hit town does to the population.

On an average weekday, 70 doctors and nurses will be at work around the various Harmoni sites. Add into that the receptionists, the call handlers, drivers and co-ordinators and a small army mobilises when most GPs are back at home.

By the law of averages something will go wrong and will need last-minute adjustments.

We will need to make phone calls to shift resources and bring in staff at short notice. Bright, dedicated, managers are the heroes in this battle, remaining calm and professional while juggling the day's unplanned changes.

I used to think medicine had its tense moments, and it still does occasionally, but keeping an out-of-hours company together minute by minute beats it hands down.

I have nothing but admiration for our managers.

Unsocial hours, irritated patients and stroppy doctors are constants in their jobs and yet they sail serenely through it every day, logging every incident for the daily report.

And these incidents can vary from the mundane – for example, a driver putting petrol into a diesel visiting car – to the scary and bizarre, such as ‘doctor fallen in river' or ‘we've just been shot at by an angry patient'.

I suppose we do it because we like the unexpected. You never know what's going to come in next, or what combination of problems and circumstances the patients will bring.

Analysts love to talk about appropriate or inappropriate uses of resources. But to us nobody is inappropriate – they are patients with problems.

We operate in some posh areas where phoning for advice is second nature. But we also work at the front end of A&E departments where the English language is the second or third most popular way of communicating.

How can we expect those patients to work their way through NHS Direct? And how can we expect the practice receptionist to fully gauge their needs?

We have a night and weekend job to provide primary care to people who believe they have a health problem. We now have a day job too, manning urgent care centres and trying to do our duty to Lord Darzi.

I think he is right that nobody should walk straight into A&E without at least a primary care assessment first. Perhaps we should look at what happens in Italy where you are sent a bill if you are considered to be a primary care case and you get it free if you have a serious problem.

So we are morphing into the provision of urgent care rather than primary care. With the ever-increasing emphasis on long-term conditions in general practice, the skills Harmoni needs are diverging from those required by the traditional GP.

Medical education

An extra area of expertise, medical education, is now required. We have to train up our own cadre of urgent care professionals and make sure GP registrars have enough exposure to Harmoni to make the agonising decision to choose

out-of-hours work as a career. It's a choice I never had to make when I started 30 years ago.

And there is yet another area of expertise: we have a bid team, a group of people that the average GP probably never meets, made up of professional sales and marketing types whose job is to research new markets and bid for new contracts.

Harmoni is now bidding for daytime health centres as well as out-of-hours contracts, and the resources involved in putting together bids are enormous.

All of our contracts are APMS and by definition have a finite length, so the team has to put together bids for new and established contracts alike.

We obviously have to take note of our shareholders: 50% of Harmoni is owned by the company West London GPs, which has decided to not opt out of out-of-hours care.

We need to answer to them, and to the IT consultancy that owns the other half of Harmoni, about where the money goes and what profits we make.

So the circle is almost complete. Harmoni began as part of general practice and diverged away, but now the 8am to 8pm health centres and urgent care centres are bringing back the idea of 24/7 general practice.

Plus ça change, plus c'est la même chose.

Dr David Lloyd is a GP in Harrow, north London, and joint medical director of Harmoni

How Harmoni developed

1996

Co-op of 75 GPs founded in Harrow PCT
Pioneer in using nurse triage
Enlarged to take on out-of-hours care in Ealing, Hillingdon and Brent

1999

Commissioned to run NHS Direct call centre in west London

2004

Pitched and won out-of-hours care contract in Buckinghamshire and west Hertfordshire for opted-out GPs

2005

Harmoni became a joint venture by joining forces with WCI – an IT consultancy company

2006

Launched out-of-hours businesses in north Somerset and north-east Essex

2006-8

Several joint ventures with GP provider companies

Launched urgent care centre and referral management system in Hillingdon

2008

New out-of-hours business in West Sussex

Set up joint venture with Badger

Launched out-of-hours business in south Staffordshire

Started to bid for GP-led health centres around the country

Harmoni company profile

• Covers five million patients out of hours
• Employs 1,000 doctors on a sessional or salaried basis
• Employs 100 nurses
• Turnover expected to be £42m this year
• Company returns a profit

Dr David Lloyd, who helped set up the GP out of hours service Harmoni

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