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Take back out-of-hours? We would if we could

GPs in City and Hackney have been blocked from taking back responsibility for out-of-hours care under competition rules that are stacked against smaller providers, says Dr Deborah Colvin

Politicians have made it clear that they want GPs to take back out-of-hours care. Many GPs do not wish to do so, but some are interested in working closely with secondary care and local clinicians to improve the service.

In City and Hackney, after two years of encouragement from the then-PCT to opt back in to out-of-hours, and after four in five GPs signed up to do this, the PCT cluster board decided they could not allow this.

During a meeting last January, City and Hackney OOH commissioning advisory panel discussed the option of local GPs’ proposal to run OOH service via social enterprise model (known as HUHSE) but found that, ‘in the absence of a fair and equitable competitive element’, it could not allow it.

Instead, they extended the existing provider Harmoni’s contract for the third time.1 The decision has left our fledging organisation struggling to exist while we wait for the tender to happen.

The leader of City and Hackney CCG, Dr Clare Highton, asked health secretary Jeremy Hunt at a meeting what advice he had for us. His answer was ‘be brave’. But is not bravery that wins you contracts in the NHS. It is power and money.

The old GP co-ops were very successful and, in a few cases, have continued to run since the change in the GP contract. Some of these are ‘for-profit’ and some ‘not-for-profit’. But the NHS playing field is not level for smaller providers, and stacked against small GP-run co-ops who are the ones the RCGP and the GPC have suggested should take back responsibility for out-of-hours.

CSUs are able to decide to include draconian financial requirements that make it impossible for new organisations to bid. More importantly, large for-profit organisations already have tendering teams that have prepared for tenders repeatedly and have all their documentation ready. They have the infrastructure and the financial strength to be able to afford to tender.

How can new organisations raise the £50,000-100,000 it costs to run a tender? How do they have contracts up and running and people ready to start work when they have no money prior to the contract starting to buy software and cars, to name just two expenses? How do they have the expertise to know what tendering documents should look like?

One of the shocking things about tenders is that the past performance of the tendering organisations must not be taken in to account – apparently that produces bias. Organisations who are known to have a poor track record can win tenders when the commissioners don’t want them simply because their tender document is so glossy, so full of management speak, so full of promises of marvellous services that they score most highly on every point.

Examples of big organisations winning tenders, running them poorly, and asking for extra funding because they can’t manage on the estimate in their tender are rife around the country. It seems as if a group of GPs that decides to set up a not-for-profit out-of-hours organisation is up against an almost-impossible world; most will give up.

In a free market - which Government seems to believe improves services - not-for-profit organisations like this have little chance of succeeding. Yet politicians continue to insist that GPs are the best people to do out-of-hours and that is what they want to happen, without rewriting the rules.

We lack a truly level playing field where what counts is the service being offered, not the empty promises made by organisations that care more for return on investment than they do for patients.

Dr Deborah Colvin is a GP in Hackney and chair of City and Hackney LMC


1 CQC. Harmoni North Central London profile

Readers' comments (8)

  • I read this and felt it necessary to provide some clarity to the debate which I hope will help.

    The regulations are clear, It is up to the CCG to decide whether it wishes to tender services or not, based on what believes is best for it's population / patients

    CSU's don't make the rules, they guide the CCG through a maze of regulations to ensure that whatever decision the CCG makes is lawful and can withstand challenges from the "market".

    CCGs do not have to tender every service but they must:
    Follow due process
    Act Fairly
    Be Transparent
    Do everything in the patients interest

    The key to this is patient and clinical engagement to ensure buy in for any commissioning decisions.

    I declare an interest as I do work in a CSU but hope this comment helps

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  • this unfortunately was the same issue when GP surgeries were coming up for tender. salaried GP's were trying to put in bids for them so that they could develop their own partnership status. unfortunately the tenders were so complex that they were outbid by private companies. There was no outcry and noone helped us then within the establishment. The Virgin's and Practice PLC's of this world then took over these contracts. The really tough times will come for practices when LES and DES's go out to any willing provider. GP's have no infrastructure and they are so disunited that I don't see one developing. There is a partner / salaried split. male /female split etc.

    Dr Colvin, we feel very sorry for what you are going through at present. We had seen the tender come up for City and Hackney on NHS supply 2 Health and it upset us considering how hard you were trying to deliver great services for your population.

    We work for the private companies as we have no where else to go. The only way I see out is to starve them of a supply of doctors, so that they cannot deliver the service. Cancel all the salaried contracts in City and Hackney, make everyone a partner in the practices and then see what support you get then in your endeavors.

    united you stand, divided you fall.

    - anonymous salaried!

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  • Interesting comments.According to its website Dr.Colvin's practice has 5 partners,5 salaried GPs and 4 GP registrars.

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  • Thanks for your comments. In answer to the CSU member, David Nicholson's response to my letter to him about this was very clear, the CCG has to tender. The mantra that CCGs can decide whether to tender or not is unacceptable as it is being made clear on the ground repeatedly that NHS England is insisting CCGs do tender. Thanks to the salaried GP comment - I entirely agree that we would be more united as partners one and all. However many salaried GPs don't want to be partners. I have talked to a number of salaried doctors about becoming partners recently and they are not interested. Being salaried suits a number of doctors.

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  • Dr Colvin

    impose it. Be brave, turn round and say this is how we are going to do things in city and hackney. Make the salaried's the exception. There are surgeries where the are 1-2 partners and then multiple salaried doctors on a low pay. the patients there have no continuity of care, they have multiple resignations with little long term relationships, ironically they probably have a higher incidence of out of hours usage. These few practices are now Causing problems for the rest of the practices, this needs to stop. the only way you are going to stop this is Is with contractual lever usage. the abuse of the salaried GP's by day leads to these same people signing up with Harmoni. Harmoni is not a clinician led organisation, it is manager led. the person in charge of the shifts and the bases is often non clinical. Make the salaried doctors partners and they will give up Harmoni tomorrow. Harmoni will not be able to function without local doctors. Once harmoni are out of the picture then you can have a real conversation with the practices to work out what you guys are going to do about urgent care and out of hours. That discussion will be clinician led and the implementation will be by the same people making the decisions. It is very easy to say out of hours care is poor, and that there are too many people on shift when you are working 9-5 looking at pretty graphs and dashboards and if you are not a GP. It is not the best use of our managers. Decision should be taken to as close to the front line as reasonably possible.

    Most salaried GP's I am coming across want to be partners. Pulse could you run a survey on this for us. I would like to create an evidence base on this topic as we currently have hearsay.

    GP's of all persuasions want a successful NHS. They are willing to work and sacrifice for it, but we are not willing to be second class citizens in our own service.

    Unfortunately I guess harmoni will win the bid again. I don't see you winning against them. If not harmoni, it may be Malling Health, Concordia, Hurley Group etc. I just hope that the CCG gives you the contract and I wish you luck. You guys did deserve it.

    - anonymous salaried!

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  • I thought the NHS was about patient care but it does appear that money is all that matters!

    Allow GP's to decide if they want to provide the service themselves of have it covered by another service … not forgetting that GP's took a £6000 salary cut because the government felt it could provide the service cheaper!

    It seems tat the government thinks it knows best but when they mess up, they expect GP's to back them!

    GP's are the NHS!

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  • @12:16 above Good points made. Also to Dr.Colvin's comment about salaried doctors not wanting partnership, that has been the excuse of partners since 2005. Unfortunately this has generated two big divides in general practice:partners and salaried/locum. There is a small group of newly quallified doctors who might prefer salaried posts at first. This dis-unity in general practice and the ongoing problem of 'conflict of interests' for CCGs means upcoming battles are unlikely to be won.

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  • The CCGs should have the right to employ services they think best for the area without putting up for tender. Unfortunately as I said above the GP divide has generated a workforce for private companies. hence the current situation. If all GPs were allowed partnerships the private companies would not have the strength they do now. Also some law perhaps created specifically for this situation so that services are not competed for unless the Gps locally are unable to provide it. (scrap the conflict of interest!)

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