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