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Dis-Harmoni in Hackney

April 21, 2013

Competing for out-of-hours care

Critics of the health reforms who accuse the private sector of cherry picking sometimes have a point, but not for primary care out-of-hours calls.

Time was when no-one wanted to do them.  Old style general practitioners had to, it was in the contract, but they were a pain, so they set up rotas, and especially in big cities switched over to a ragbag of commercial Doctors Deputising Services (DDS) to fill the gaps. These outfits were often staffed by doctors who couldn’t get jobs elsewhere, or who were moonlighting and tired – the Dangerous Doctors Service – so it was frowned on to use them too much, and they had to be paid out of practice funds, so complicated and inefficient systems grew up with practices switching over at different times. Patients sometimes got through directly to a doctor, sometimes a dispatcher, but they rarely got to see their own GP.

Then in 2004 GPs negotiated a new contract with the Department of Health allowing them to opt out of 24-hour care altogether. Nearly all, 90%, did so, and the Primary Care Trusts, who ran things back then, had to find someone else to do the work. In Hackney the PCT chose Harmoni, one of the best of the old deputising services.  Harmoni had started out in 1996, as a GP cooperative in nearby Harrow, and the new GP contract allowed it to expand. In 2005 venture capital was bought in and a whole network of phone banks, 24-hour surgeries, and doctors and drivers set up. It is now the county’s largest provider of out-of-hours care. All calls are triaged by a nurse, and their contract insists that they keep data on response times, visit and referral rates, and clinical incidents. By all accounts they make a decent profit.

Although patients still rarely if ever see their own GP, it’s probably an improvement. Harmoni faces losing the contract if it performs badly, the opposite of the old system where the GPs didn’t want to do it, but couldn’t avoid it!   But it’s tricky to prove, because the old system didn’t keep the same records, times have changed, and patients behaviour and expectations are different.

Then a funny thing happened. The Hackney GPs saw how profitable out of hours care could be, and set up a new co-operative, City and Hackney Urgent Healthcare Social Enterprise (CHUHSE) to win the contract back!  You might think they wouldn’t stand a chance, but they have some good cards to play. Where night call problems used to be smoothed over as quickly as possible, now they’re ammunition for the cause. Patient groups pop up, and articles alleging poor standards by Harmoni appear in The Guardian (click here and here).

CHUHSE‘s first bid last summer failed, allegedly because the PCT was nervous about allocating the contract to a new provider without proper tendering, just before handing over to the new Clinical Commissioning Groups. That’s one of the points of the new system – to make it more difficult for local GPs to allocate contracts to their mates. CHUHSE is grumbling, and alleging that they were knocked back for political reasons.

But patients should be delighted. Two organisations are competing hard to provide an unpopular service, and the people who know best, the local GP-led Clinical Commissioning Groups will decide after a proper procurement process.

Jim Thornton

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