Allegations in Cornwall are still being investigated as health services go out to tender in line with new policies
When the co-operative of doctors from surgeries across Cornwall that ran the out-of-hours GP service lost its contract with the local primary care trust in 2006, they were not sure why, but suspected money played a large part.
The winning bidder was Serco, the private contractor that is a leading provider of services to government and local authorities in many sectors – from defence to prisons and education – but a relative newcomer to health. The terms of the contract are deemed commercially confidential, as is the competitive bidding process, so they are not open to public scrutiny.
The former chair of the GP co-operative company, KernowDoc, Dr Gareth Emrys-Jones, said that the service was being run for £7.5m a year until that point. Any private sector bidder would be likely to factor in profits, but the co-operative ran the service as a not-for-profit operation. The PCT was unable to confirm the cost of the previous service when asked by the Guardian, but did say that the first Serco contract was worth £6.1m a year over five years. It was renewed last October for a further five years at a price of £6.4m a year.
According to its critics, that dramatic cut and a profit-making ethos have left the service beset by serious problems and have made it unsafe. A series of claims about its shortcomings are now being investigated by the health regulator, the Care Quality Commission. Staff say they have been pressurised to downgrade their assessment of the urgency of calls.
The allegations were vigorously denied by the PCT and by Serco, whose managing director of acute and community services, Paul Forden, said that it was the victim of a political battle. “A lot of people are objecting to change,” he said. “There’s a lot of politics going on there. We’ve investigated and there’s nothing unsafe.” Serco denies pressurising staff to downgrade calls and says that they are trained to prioritise each case on its merits, exercising their clinical judgment, with computer software supporting them.
The PCT says it has also conducted an independent audit and found no evidence to support an allegation of altering data, and it believes the service meets required national standards.
Private contracts will soon become the norm in the health service, as large parts of NHS services are put out to competitive tender following the passing of the government’s controversial health and social care bill. Over the next few months, under the coalition policy of opening the NHS up to “any qualified provider”, all 52 of England’s newly formed PCT clusters are required to identify at least three community services that will be the subject of bids. Serco, which had revenue of £4.6bn in 2011, is likely to win further NHS contracts.
Whatever the outcome of the investigation, the experience in Cornwall raises vital questions about how privatised contracts will be scrutinised and how far complex medical priorities can be reduced to a series of legal clauses; whether public sector bodies have the negotiating and auditing expertise to oversee them; how companies with an obligation to shareholders to make a profit can run them more cheaply than their public equivalents; and what whistleblowing policies are needed.
Serco’s Cornwall out-of-hours service has a controversial history. The company first won the contract under Labour reforms to introduce more of a market to health services. But complaints about the standard of service and levels of provision quickly emerged. They were raised in a parliamentary debate in 2007 and the company was given an improvement notice by the PCT that year following a number of incidents. In 2010, a Cornish boy, Ethan Kerrigan, six, died as a result of a burst appendix when the Serco out-of-hours service advised putting him to bed rather than sending a GP to examine him. Costcutting had left the service with insufficient transport and staff, according to local GPs at the time.
Forden said that Ethan’s death had been a terrible tragedy, and while appendicitis was very hard to diagnose in young children, the service had learned lessons from it and changed guidelines and practice since.
Serco says it has also invested heavily to deal with earlier problems. But concerns came to a head again last year, according to sources within the company. On at least one occasion in May 2011, they alleged, a GP believed he was the only doctor on duty through the night covering home visits for the whole county. Serco denies this has ever been the case. Another Serco GP was sufficiently concerned about safety by the summer, after holiday weekends during which large numbers of shifts were unfilled even though Cornwall’s population swells with tourists during these periods, to raise the alarm with the PCT.
Sources claim that his name was passed back to Serco and he was told he should not have spoken out. The PCT said it could not comment because of data protection rules. Serco categorically denies that any action has been taken against him or any other whistleblower in relation to the contract, and says it has robust policies on whistleblowing. The GP involved still works shifts for Serco and has now also been given a role monitoring the Serco contract for the PCT.
By October last year, just as the contract was up for renewal, senior clinicians were worried enough to write formally and jointly to Serco’s operations director for Cornwall, Karl Cole, saying: “We feel compelled to voice our concerns about patient safety due to the current shortage of medical manpower. The number of unfilled shifts is unacceptably high, putting patient safety at risk. We are surprised and relieved that there has not been a critical event or patient death resulting from the extremely low levels of cover we have experienced in the recent months. Chronic understaffing of clinical shifts has become the norm for Serco Health in Cornwall.”
Discussions took place later that month about recruiting more staff and making shifts more attractive to locum GPs and nurses. Serco was awarded the contract for another five years later in October. It said that it “already had plans in place [for] a more robust model of using employed GPs rather than locums, once the contract has been signed. Since [then] the number of employed GPs has increased, with the total number of GPs remaining constant. GP engagement is high and this has been praised at a recent performance board meeting by GP commissioners, some of whom were the individuals that raised the issue in 2011.”
The PCT made it a condition of the new contract that the company introduce a more automated system – known as Pathways – to assess the urgency of patients’ calls. This reduces the need for expert clinicians to triage calls, and instead leads call handlers who no longer have to be higher-grade clinicians through a series of computer generated questions and checks to assess what response patients need.
This new system will mean a round of redundancies among experienced nurses who have worked triaging calls in the call centre and new, flatter pay scales being introduced to reflect the lower level of skill needed to answer calls. A Serco presentation to nursing staff recorded that the company was looking for a reduction in nursing hours in the triage centre of 48%, with some redeployment to other parts of Serco. Forden said many of the current difficulties related to staff being unwilling to adapt to new working methods.
Sue Matthews, the regional officer for the Royal College of Nursing in Cornwall, said that her members had much broader concerns in addition to fears about how the more automated system of call-handling would work. “Our members have reported waiting hours being extended by several hours, and that the current reporting system is being manipulated so that it does not reflect accurate activity or the time of visits or callback times,” she said.
In parallel with the CQC investigation, the Royal Cornwall Hospital trust is reviewing why there was a surge in attendance at the hospital’s A&E in February and March this year and whether it was related to shortcomings in community and out-of-hours services. Serco says it works closely with the trust to keep admissions down and that the issue has not been raised with it.
Serco pointed out that a national benchmarking exercise looking at data from 104 PCTs found Serco’s out-of-hours service to be one of the best performing in the country. (The exercise was conducted by the Primary Care Foundation, a business consultancy that counts Serco and the Department of Health among its clients and was based on data for the financial year 2010-2011 supplied by the services themselves.)
It added that patient satisfaction surveys consistently rated the service either “excellent” or “good”. “We are fully committed to providing the best possible care for patients,” it said.
The PCT remains confident that the service is adequately resourced and meeting national standards. Bridget Sampson, director of primary care for Cornwall, said: “We are disappointed that rumours still persist around the quality of service provided by Serco. Patient surveys show a high level of satisfaction with the service and an independent audit did not find any evidence of data being changed. The contract provides a value for money, high quality service for patients with equitable access to GP appointments out of hours.”
Meanwhile, should any GP be tempted to whistleblow and approach their union, the British Medical Association’s confidential helpline, they might be startled to find, is manned under contract to the BMA – by Serco.
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