For some years GPs in City and Hackney have been concerned about the quality of out-of-hours care (OOH) care and have discussed how we could improve it. We realised that we needed to take back the responsibility ourselves as the care we could give people when we were a co-operative, prior to opting out of OOH, had been excellent. We could see that being able to work closely with our local hospital and with other local services would improve the pathway for patients and thus the care they received.
Two years ago we started planning to opt back in to providing OOH care. We discussed this in detail with the Primary Care Trust (PCT). We produced a business plan which was discussed with the PCT on numerous occasions and in June 2012 this was sent to the PCT cluster board of inner north east London. There was some urgency about this. Harmoni had been given the contract for OOH in City and Hackney on a temporary basis in 2010 and was then formally awarded it following a ‘mini-procurement’. Their contract has already been extended and is due to run out on 31st March 2013. The plan was that the GPs would opt back in and then provide the OOH care via a social enterprise. The social enterprise would take over on 1st April.
The PCT board met and decided to ask their procurement panel for an opinion as to whether allowing GPs to opt back in was risky or not. The procurement panel decided that this was the least risky option and advised the board that we should be able to opt back in.
However, on 30th January this year the PCT cluster board met and decided that it was too risky to allow the GPs to opt back in. Furthermore they announced that they would extend Harmoni’s contract again by another nine months.
At the Hackney Health Overview and Scrutiny committee on February 6th, two of the board members attended to explain why they had made this decision. They said that GPs opting back in to providing OOH care is ‘illegal’. I pointed out that GPs in Leicestershire had been allowed to opt back in to out-of-hours care two years ago. A contract variation is perfectly allowable. The PCT should withhold its consent only if there are reasonable grounds to do so. Who is being reasonable here? The two representatives continued to insist that they had no choice, but they did have a choice. They chose Harmoni.
So let’s look at the concept of ‘risk’. Risk to whom: to PCT managers or to patients? All are agreed that the proposed GP organisation would be very likely to offer an excellent service to our population. There have been several articles in the Guardian newspapers querying the conduct of Harmoni. One article cites local GPs with a number of concerns over the firms operations, suggesting “decisions about treatment appeared to them to be made on the grounds of cost and payment rather than clinical need”, while another describes senior doctors warning that “its service in London is so short-staffed it is regularly unsafe”. A recent survey of patients attending A&E at Homerton Hospital had 25% patients reporting they were dissatisfied with the GP out-of-hours. Also, a full 62% of patients didn’t know how to contact their out-of-hours provider which makes me wonder what efforts Harmoni have made in Hackney to inform patients of their presence. Interestingly, Harmoni in Hackney receives nearly 50% less calls than the OOH organisation in neighbouring Tower Hamlets despite having a very similar demographic. In summary, the risk the managers talk about is presumably to themselves rather than any risk to patients.
Let’s look at how this fits with the Health and Social Care Act 2012. The government sold this act by repeatedly stating that it was all about giving power to GPs (who know best what is good for their patients) and patients (who know best what is best for themselves). As readers may be aware, Andrew Lansley stated in early 2012 that ‘It is a fundamental principle of the Bill that you as commissioners, not the Secretary of State and not regulators, should decide when and how competition should be used to serve your patients’ interests. The healthcare regulator, Monitor, would not have the power to force you to put services out to competition’.
The GPs in City and Hackney have acted altruistically. We don’t want to work out of hours. We would far rather be doing other things with our evenings and weekends. However we are proposing to do this because we truly believe we have to improve the care our patients receive out of hours. We have set up a social enterprise so we would not be ‘lining our pockets’ as some wish to imply. We wish to work closely with the Homerton Hospital to provide an ‘integrated’ service (another buzz word in the Department of Health who are all for integration, we hear). We want to be able to offer a top quality educational opportunity to young GPs who are training. We want to be able to work together in the organisation so that younger GPs can learn about Hackney and how it works from more experienced GPs, while the more experienced GPs can learn some cutting edge medicine from the younger ones. Most of all we want to provide a service that gives appropriate and high quality primary care to the citizens of City and Hackney.
However this is not to be, according to the PCT cluster board. They would rather extend the contract of a commercial organisation about which a number of concerns have been raised relating to their performance and safety. They say there will be a proper procurement process which will have to be run by the Clinical Commissioning Group (CCG) and that we ‘need not worry as it is a level playing field’. Of course it is as level a field as the corner shop bidding against Tescos but that doesn’t seem to worry the cluster board. They have taken no account of patient safety or what the patients in City and Hackney want in spite of being written to by Hackney LINKS (the local patient organisation) prior to the board decision. They continue to insist they have patient safety as their first concern but I fail to understand how they can possibly argue this. At the very least they could have asked the GP organisation to take on OOH on 1st April as a temporary solution. They didn’t. I do not understand why.
The Daily Mail recently suggested that GPs should opt back in and take responsibility for their patients. We have offered to do just that. But the response has been that the market must be involved. Is a huge company like Harmoni (now part of Care UK) bidding against a handful of GPs running a social enterprise a level playing field? We have learnt the answer the hard way in City & Hackney, and it is patients who may suffer.
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