GP concern at private out-of-hours provider enforcing ‘morally wrong’ targets

Exclusive GPs working for a private out-of-hours (OOH) provider in the South West have raised serious concerns about new performance targets which they say are ‘morally completely wrong’. 

HealthHero, a large digital health company which bought the OOH provider Medvivo in 2020, told its GP workforce in April that ‘allocation of shifts will go to those who are most able to meet’ the required targets. 

These requirements include triaging four cases per hour, ensuring 80% of telephone consultations are closed ‘with no onward referral’ to a treatment centre or home visit, and ensuring that less than 5% of cases are sent on to secondary care or the emergency department (see box).

GPs told Pulse that this new performance management system raises serious patient safety concerns, while also ‘worsening anxiety at a time when job security feels very precarious anyway’.

They are also worried about the company’s ‘significant’ shift over recent years towards a non-GP workforce, with an ‘almost exclusively GP workforce’ having been ‘gradually replaced’ with other allied health professionals.

In response, HealthHero stressed that their performance requirements are ‘primarily about patient safety’, arguing that ‘it is not appropriate that some clinicians give unnecessary time to patients whose needs do not require it’. 

The company also said that using a ‘mix of clinicians’ including advanced clinical practitioners is a ‘national imperative and widely encouraged across the NHS’.

Medvivo, which now functions under the wider company name HealthHero, is contracted to provide out-of-hours services for Bath and North East Somerset, Swindon and Wiltshire (BSW) ICB, and it works with hundreds of GPs on a sessional basis.

Pulse has recently reported on the same company as its selection by Shropshire, Telford and Wrekin ICB to provide OOH services – in place of a longstanding GP cooperative – sparked concern from patients about potential ‘cost cutting’.

In an email sent to GPs working in BSW on 11 April, seen by Pulse, HealthHero set out its performance requirements, citing the ‘context of increasing financial efficiency pressures across the NHS’. 

It referenced the new ‘ledger/case allocation system’ as ‘one of the methods introduced to optimise case management’. The ledger means that triaging GPs can no longer see the full list of patients but are instead assigned patients one by one. 

Managers told GPs that these measures have ‘considerably reduced’ the ‘shift inactive time’, noting that their aim is to promote ‘equity’ among clinicians.

The email continued ‘Sadly, despite numerous previous communications, it is apparent that there is still significant disparity between the consultation rate and outcomes for some clinicians. This is not only unfair to colleagues, but lengthy delays potentially put patients at risk of deterioration.’

‘Therefore, we now need to clearly define our expectations and, moving forwards, allocation of shifts will go to those who are most able to meet service requirements,’ it added.

The private provider noted that there will be ‘occasions when there is a complex case requiring a longer consultation’ but emphasised that ‘cases need to be managed efficiently’.

‘Complex cases should be in the minority and should not impact significantly on overall cases per hour.’

The email also told GPs that these targets ‘will now also form part’ of their sessional contract with the company. 

It added: ‘I appreciate that this communication may be unsettling for some of you but I make no apologies for the content and the standards we are setting. 

‘For the reasons stated above, this is the right thing to do for our patients and our colleagues, and essential for us to be able to fulfil our NHS contract with the ICB.’

One GP who has worked in the local OOH service for 16 years told Pulse he will not work for HealthHero anymore due to the ‘emerging governance of the organisation’.

On the cases per hour target, he said he ‘quite like[s] the idea that they’re trying to increase productivity’, but said there is ‘no leeway around it’ and ‘no room for going through cases more slowly, if the clinical circumstances require that’. 

But the GP, who preferred to remain anonymous, said the target he finds ‘hardest to accept’ is the need to close 80% of cases without an onward referral.

He said: ‘I don’t really care about that, because as far as I’m concerned, if the patient requires a home visit, then they should have one. I’m not going to make a decision based on the imperative of the company. I’m going to act on the basis of what I feel is right.’

The GP claimed the company has implemented ‘arbitrary targets’, noting that there does not seem to be ‘any evidence that it improves outcomes’. 

He continued: ‘’To me, that is just totally anathema to how you practise medicine. You do it on the basis of need, clinical need […] it’s against the grain of the way I’ve been trained, and I think morally, it’s just completely wrong.’

He also said that the role of clinical navigator – the clinician who ‘oversees the whole patch’ during a shift – is ‘increasingly’ being filled by nurse practitioners and emergency practitioners. 

‘One of my concerns is the increased emphasis on care by non-medical clinicians, I find it difficult to deal with, and it’s not just because they swallow up a lot of the shifts and it’s harder to find work in the service – it’s because I just find it an unsafe set of circumstances,’ he told Pulse. 

Another experienced GP who works for HealthHero, and preferred to remain anonymous, said she is ‘seeking alternative work’ as she believes the service to be ‘unsafe for patients’. 

But she said the current unemployment crisis is ‘forcing large numbers of sessional GPs to take whatever shifts they can get in the absence of alternative sources of work’. 

‘Every sessional GP I know working for HealthHero is actively seeking work with other OOH providers and elsewhere because of concerns for patient safety, an increasingly demoralising work environment and poor pay,’ she told Pulse. 

On the performance targets specifically, the same GP said ‘speed of consulting’ data is being used to ‘preferentially offer shifts to the faster consulters’.

She continued: ‘Indeed, the latest round of shift allocations has seen several very experienced and highly regarded local GPs with a long history with the company not offered any shifts whilst the company actively recruits fresh GPs with no OOH experience to work remotely.’

The ‘culture’ of linking consulting speed to the ‘chance of securing shifts’ will ‘promote unsafe patient care both directly through pressure to consult quickly and through the service being overwhelmed by unnecessary face to face contacts’, she argued. 

Another GP, who is also ‘desperately’ trying to find other work to replace her HealthHero hours, said the recent implementation of performance monitoring is ‘bonkers at the minute because there’s not enough cases’. 

‘So all of us have failed all of our targets across the board, because there’s not enough patients going through the system to keep everybody busy all the time,’ she told Pulse. 

She said the targets are ‘not appropriate’ since there is ‘so much complexity in managing out-of-hours care’, and it creates ‘anxiety’ for GPs if they are concerned that sending too many people for a home visit will put their job ‘at risk’.

The GP added: ‘People feel like they are facing that horrible position between, am I a good doctor? Do I put my patients first? Do I protect my registration? Or do I do what the company tells me, and do I just try and stick to these targets? And it feels like there’s a conflict between those two things, which creates a lot of anxiety and worry for people.’

On the shift towards a non-GP workforce, the same GP said ‘there used to be a lot more GPs’ when she started a few years ago.

‘I’ve noticed a significant change in that time. I did mostly base stuff then, but I always had another GP on with me, and then suddenly, you’re on with a paramedic and you’re on with a nurse. And even in that two years, there’s been a dramatic change in workforce planning. It’s been huge, really, really huge.’

Pulse has approached BSW ICB for comment.

In November last year, Pulse reported on a different private OOH provider threatening to terminate GPs who did not meet their new performance targets, leaving the workforce ‘outraged’ and ‘demoralised’.