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Overnight out-of-hours GP service 'manned by nurses', claims whistleblower

An out-of-hours GP service covering 250,000 patients is using senior nurses when doctors cannot be recruited to work the shifts, it has been reported.

The firm, Harmoni, regularly employs advanced nurses to work eight-hour overnight shifts covering districts of up to 150 square miles, a whistleblower claims.

In times of extreme staffing shortages, there has been just one advanced nurse practitioner working overnight in North Somerset, the Daily Mail reported.

The whistleblower told the newspaper that locum doctors have been flying in on EasyJet from Europe, or driving from elsewhere in Britain to perform back-to-back shifts round-the-clock; terminally-ill cancer patients have waited eight hours for a doctor to visit them at home and administer pain relief; and foreign doctors with a poor grasp of English have been used to plug gaps in the rota.

The whistleblower said that working for Harmoni was like “taking a loaded gun and sitting with it because at some point it’s going to become so unsafe it’s going to go off”.

“My personal feeling is that at times it has been unsafe,” the source said. “It’s a dereliction of duty. Everything is secondary to meeting budget.

“Patient care is compromised, employee care compromised,” the source added. “It’s an edict from on high. They have thinned rotas down to a bare minimum.”

A spokesman for Harmoni said: “The clinical staff employed by Harmoni are all self-employed GPs or advanced nurse practitioners who work on flexible contracts.

“Harmoni has comprehensive measures in place to ensure team members take sufficient breaks.

“Harmoni has in place some of the most robust interviewing procedures in this field to ensure the communications skills of GPs who work for us are of a high standard.

“On very rare occasions, and only after consultation and agreement with our commissioning colleagues in North Somerset that the service remained clinically safe, we have run an overnight shift with a very experienced advanced nurse practitioner providing the first point of contact with a GP available on-call to support with any advice needed and GPs available to support if a home visit was necessary.

“For Harmoni, and indeed virtually all out-of-hours providers, there are some occasions where filling all the planned GP rota slots is a challenge. Even when this is the case we ensure we are providing a service which is clinically safe and our service is constantly closely monitored by NHS commissioners to ensure this is the case.

“Our performance figures are accurately recorded in line with national guidelines and, again, carefully scrutinised by our commissioning colleagues.”

Harmoni has contracts across the country, and asked if this happens elsewhere, it answered: “Highly trained and experienced advanced nurse practitioners are a valued, important and often-used part of our workforce across the country.

“Harmoni imposes strict criteria on our recruitment of advanced nurse practitioners, selecting those with advanced qualifications and additional skills sets suitable for the urgent care environment.

“Advanced nurse practitioners do have certain limitations on the care they can provide such as with very young children and palliative care. Therefore, on the occasions when they are the first point of patient contact, we ensure there is always covering support available from a GP.”

A Department of Health spokesman said: “It is a legal requirement for the NHS to make sure the right, high quality out-of-hours services are in place for patients in their area.

“If this is not happening it is totally unacceptable and we expect the local NHS to take action immediately to improve their services.”

A new contract for providing out of hours GP services for Bristol, North Somerset and South Gloucestershire was awarded to a different service provider, BrisDoc, last month.

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Readers' comments (65)

  • welcome to your new tory privatised nhs

    profits befor patients...great eh!!

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  • Now that GPs are commissioning the service they will start looking at costs. Whilst they had PCTs over a barrell and could charge anything they liked for their services e.g. £250+ per hour at Christmas. I'm sure they are not going to pay this any longer and emergency care practitioners or advanced nursing practitioners will end up being more used in out of hours services.

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  • michael stone

    The one that most bothered me (because the fix seems obvious) when I read this in the Mail today, was:

    'Terminally-ill cancer patients made to wait eight hours for a doctor to visit them at home and adminsiter pain relief'

    I see acute pain during EoL, especially the 'near to death days', as 'an emergency': there isn't going to be any 'addiction problem' here, is there - so why on earth, cannot 999 paramedics be called and set up things like morphine drivers, in this situation, if the OOH service isn't doing its job properly ! This would also improve the understanding of 999 staff, of the complexity of 'dying at home' - a double plus !

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  • I work as an ANP in out of hours, I see and treat adults with any problem including palliative care. The gp out of hours rely on me and my colleagues to undertake over 90% of all home visits. After midnight there is 1 nurse to cover a patient population of over 120000, but there is an on call gp if its needed. The local gp commissioners found that a gp was not needed to be on shift as they are rarely needed, but they are there to give advice. It's more likely that the local medical director for palliative care is consulted rather than a gp. I think the key to this, is that you need very knowledgeable experienced nurses with safety netting provided by a medic, whether or not this is a gp or hospital registrar should be determined by the needs of the population rather than saving money.

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  • One could argue that end of life care should be the remit of day staff. If district nurses were allowed to do their job properly, breakthrough pain at night would be rare rather than the norm.

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  • You are right if there is a well staffed, experienced district nursing service over 24 hours the palliative care is their remit with anticipatory prescribing in place to ensure they can respond to emergencies, when this works it is far better than GP or ambulance however out of hours DN's are now falling under the remit of out of hours GP services with no direct line to the DN and GP's trying to pass any work they can to a nurse which can delay visits to palliatives. Also trusts prefer less experienced lower band nurses especially out of hours and can end up at times with only one HCA on duty to answer the phones. If we want cost effective care at home to keep people out of hospital and reduce 999 calls then its madness to do as my trust has and make senior DN's redundant.

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  • even those who pay their own private insurance are unable to access a doctor when they need to?

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  • Anonymous | 13-May-2013 7:47 pm

    Who cares?!

    Access to health care should not be based on ability to pay.

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  • tinkerbell

    why am i not surprised. Becoming so cynical is a real bummer.

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  • michael stone

    Tink, are you back from Greece yet ?

    If you are, and going back to 'you being a mental nurse': > Discuss and debate > View all Dignity Champion Discussion Forum threads > Can some Professionals please explain this one to me It confuses me enormously in legal terms

    I've used the long way round, because the links do not always seem to work - the link, which might work directly, is:

    I'm struggling to get my head around that one - your input as an expert, would be appreciated !

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  • tinkerbell

    DH Agent - as if ! | 16-May-2013 3:21 pm

    Yes Mike, I got back early hours sunday morning, will try to have a look at the website tomorrow, although far from 'expert' what part in particular are you trying to 'get your head round' and I will focus on that, as don't want to read through reams and reams and am 'inundated' at work at the moment playing 'catch up' following my holiday.

    Poor old community nurse that I am now. I have been taken on permanent after my trial secondment. (apparently they found the budget cos' someone else left for another job). Everybody's happy now.

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  • michael stone

    The post over at Dignity In care isn't very long, and is clearer.

    I suppose the sortest way to express my issue, is:

    Why do some professionals seem to believe that merely because mentally capable people have grown old and frail, those old and frail people are no longer the sole judges of the risks they are willing to personally accept in their own lives ?

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  • tinkerbell

    DH Agent - as if ! | 17-May-2013 1:30 pm

    Ageism in my opinion, also nobody wants to take the risk that something can go wrong and they will be hauled over the coals.

    Personally I think it is wrong, and there is far too much interference going on between social workers et al.
    Because someone is old does not mean that they cannot make an unwise decision if they have mental capacity.

    I personally would support someone with capacity to make an unwise issue especially if it is in relation to them maintaining their own independence, we cannot cover every eventuality or every risk, and like myself or yourself, should be allowed our freedom of choice and of course there is also a certain amount of lip service and double standards cos' i know of other old folk who are left in high risk danger without capacity whilst everyone wrangles over the cost of their care.

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  • michael stone

    tinkerbell | 17-May-2013 2:40 pm

    I can't work out where the legal basis comes from - without a court order, how can anybody legally stop, for example, an old person at risk of falling, from just going home after he/she has said 'It's my life, not yours'.

    I can see how HCPs might well think 'If we let him go home, he'll have fallen and he'll be back here next week' and that can't be right - but I can't see where 'so we have the power to stop him going home' comes from ! We don't stop people from smoking, or from climbing Everest (which kills a decent proportion) - so I also go with 'ageism', and I don't like ageism.

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  • Mike Stone
    If you are compos mentis then you can take your own discharge at your own risk.

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  • tinkerbell

    redpaddys12 | 17-May-2013 3:29 pm

    but Mike isn't:)

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  • michael stone

    tinkerbell | 17-May-2013 4:33 pm

    redpaddys12 | 17-May-2013 3:29 pm

    Yes, my understanding of the law is exactly what red states - but I keep coming across stuff written by various professionals, apparently departing from that simple concept: especially when people are old 'and at risk' (for example, of falling if discharged), somehow the fact that age does not stop a person from being the judge of their own 'life risks' seems to 'get very murky' !

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  • tinkerbell

    latest bad joke i heard this week.

    3 pieces of string go out to the pub.

    1st piece of string says '3 pints of your finest ale please my good man'

    Bartender says 'sorry we don't serve pieces of string'.

    2nd piece of string says 'let me have a try. 3 pints of your finest ale please landlord'.

    Bartender says 'sorry we don't serve pieces of string.

    third piece of string gets really annoyed, ruffles his fibres and ties himself into a knot approaches the barman and says

    '3 pints of your finest ale please'
    Barman says 'but aren't you are a piece of string too'.
    String replies
    'No a frayed not'.

    what a groaner. As told by our Admiral Nurse.

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  • michael stone

    By the way, I object to be called 'not compos mentis' - I believe that Compo's Menthos was a type of boiled mint sweet, mentioned in Last of the Summer Wine.

    And now that according to the BMJ I am a published author in the BMJ (if I had known exactly what the BMJ regards as a published article, then I would have proof read rather better !), I can't have these nasturtiums cast on my mental competence !

    I quite liked Tink's joke - perhaps I am losing it ?

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  • tinkerbell

    DH Agent - as if ! | 18-May-2013 1:38 pm

    Don't encourage me. Too Late.

    A prisoner is incarcerated in the dungeons for 25 years. They bring him food and water daily and ask if there's anything else he would like. He says 'some cigarettes'.

    After 25 years the guard opens his door and says 'how was it?'and the prisoner replies 'have you got a light?'.

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