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19 December 2013

New out-of-hours care reforms were a game of Russian roulette for GPs. We pulled the trigger

Come April 2014, our out-of-hours service will be run by strangers based many hundreds of miles away.

By Phil Whitaker

The GPs in my area are in shock. We’ve just had our first dose of “Lansley’s medicine”. Andrew Lansley was the architect of the coalition government’s new-look NHS; one of a succession of politicians to use the crowbar of competition to prise apart the nation’s favourite public service, coincidentally offering the pickings to the private sector. Lansley’s medicine doesn’t taste at all nice – there’s no spoonful of sugar to help it go down.

We’ve always looked after our patients round the clock. In days of yore, each individual practice made a doctor available at nights, weekends and public holidays. As demand for out- of-hours care burgeoned during the 1990s, the 27 practices in our patch banded together in a “co-op”, covering each other on a rota basis to ensure our working lives remained sustainable. Everyone knew everyone, if not personally then certainly by reputation. We trusted each other to do a good job for our respective patients, and we also knew that our standing among our peers depended on our doing so.

In 2004 the Blair government handed responsibility for out-of-hours to primary care trusts (PCTs). Our co-op became a not-for-profit community benefit society and the PCT commissioned us to carry on business as usual. Periodically the PCT made noises about putting the service out to tender but they never followed through. They appreciated our high standards; we regularly featured in the top flight of national audits.

And then there were the horror stories from other parts of the country, places where private providers who’d undercut local GPs went on to deliver services characterised by long waits and dangerously skeletal staffing levels. Not infrequently these relied on agency doctors, some from abroad, with occasionally fatal results.

In April this year, PCTs ceased to exist and GPs, as clinical commissioning groups (CCGs), took over responsibility for the majority of NHS services. In our patch, one of the most pressing tasks has been to tackle the unsustainable pressure on our local A&E. We decided to relocate the expensive walk-in centre (foisted on us by the last Labour government) to the front door of A&E and reinvent it as an urgent care centre, dealing with the significant numbers of patients presenting to casualty with problems that could be managed by GPs. Part of the vision was to integrate this urgent care centre with the out-of-hours service to provide a efficient response to all urgent and unscheduled care needs.

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So far so good. But under the competition regulations in Lansley’s Health and Social Care Act we couldn’t just instate this new service and were obliged to put it out to tender. We felt that our track record in the community would stand us in good stead. We joined forces with the hospital and the ambulance trust to put forward a bid that was the epitome of the joined-up working the modern NHS needs. Our proposal was strong; strong enough to get us into the final two contenders. But not quite strong enough to win.

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To be clear: the winner (I’ll call them the Big Beast from the North) triumphed fairly and they do run good-quality out-of-hours services elsewhere in the country. What causes so much upset is that it was agonisingly close. The bids were scored by impartial outsiders according to a fixed rating system, and there was less than 1 per cent difference between us. There was no significant variance in cost.

The Big Beast – an organisation some 20 times larger than ourselves – has a high-powered management team that has experience of competing for several previous tenders (the process is hugely complex, time-consuming and expensive). This was the first time we’d done anything like this. The few extra points they scored essentially came down to knowing how much of what sort of detail to present where.

Our situation exposes the idiocy of Lansley’s reforms. As GPs, we’ve been told we’re best-placed to design services according to our population’s needs and we have been given the power to commission them. But we are also potential providers – the system has an automatic conflict of interest at its heart. To guard against partial decisions, we GPs have to absent ourselves from the assessment of bids.

A rating system, however sophisticated, can only supply crude numerical comparisons and allows no place for mature professional judgement. It is sheer madness to overturn years of successful service delivery and established working relationships on a variance of less than 1 per cent between incumbent and pretender, yet that’s what we now have to do.

Come April 2014, our out-of-hours service will be run by strangers based many hundreds of miles away. As yet, we don’t know the doctors who’ll be looking after our patients. Many of us fear a lack of control over this vital part of primary care. There is a lot of anger and a deep sense of loss. As one of my colleagues put it: we are grieving. The worst thing is it feels like suicide by Russian roulette. Lansley’s legislation compelled us to load a single bullet in the revolver. Conflict-of-interest considerations made us hand the gun to outsiders. They spun the chamber. One more click would have seen us survive. As it is, we have shot ourselves in the head.