Exclusive GPs were left ‘outraged’ and ‘demoralised’ when a private company providing out-of-hours and 111 services ‘threatened to terminate’ those who did not meet a performance goal of three to four cases per hour.
GPs working for the company commented to Pulse that they thought this was a ‘blunt tool’ for performance management which they feared could have negative impacts on patient safety.
Totally PLC, the parent company for Vocare, manages a team of 75 GPs who work remotely as either salaried staff or contractors. It has since apologised to GP staff for its communication regarding performance, but Pulse understands that at least one GP has left after receiving a warning email earlier this year.
Pulse understands that in May a number of GPs were approached by managers with details of their ‘average cases’ over a year-long period, and those who fell below the target of three cases per hour were given a two-week ‘review/notice period’ to improve.
An email seen by Pulse said: ‘If there is no improvement, then we will no longer require your services with us and will contact you to collect your IT equipment.’
GPs working for Totally, who wished to remain anonymous, said these emails ‘caused absolute outrage’ among the team, with younger GPs ‘scared witless’ as they relied on the income from Totally.
They told Pulse that at least one GP was asked to leave and return IT equipment as a result of this email, but the company has declined to comment on individual cases.
One GP, who is based in the south of England and has worked for Totally for several years, said the warning email felt ‘as if out of nowhere there was a bucket of cold water poured over [her] head’.
‘You sort of feel as if you failed as a doctor and you just feel you were the only one, and you’re ashamed, you’re embarrassed and all these mixed feelings that go with it,’ she told Pulse.
But after receiving the email in mid-May, this GP quickly realised that many others were in the same position, saying she was aware of around 20 GPs in the remote team who received a very similar warning.
The GP told Pulse that this kind of target is ‘bound to be affecting patient care’ since GPs ‘end up being tempted to cherry pick’ those cases which are ‘easier’ rather than more complex cases such as ‘an 89-year-old lady with dizziness’.
In an update sent to GPs in June, Totally management said that consulting 25 patients over an eight-hour period – which equates to just over three cases per hour – is ‘achievable’ and ‘in line with BMA and NHS England guidelines’.
However, the same GP said telephone triage is ‘a different scenario altogether’ compared to consultations in GP practices, and pointed out that most GPs ‘do not have a KPI’ and ‘do not have to achieve’ certain targets.
She said: ‘Three [cases per hour] can be achievable, but I don’t think four is achievable – this is me with years of experience – not safely, I don’t think four is achievable.
‘Three is, if it’s a good day, but you could very easily not have a good day. You could get stuck on a call for at least an hour, because at the same time, we’ve got constant messages coming our way saying “don’t put anyone down for a home visit”.
‘And so we’re left with an elderly patient who needs a visit. […] and you then get stuck because you have to sort this patient out safely. And it can be a nightmare. It really can be a nightmare.’
The same GP also said Totally has cut out-of-hours IT support, which ‘is the time you need it more than ever’.
‘There are lots of IT problems, technical problems, on each shift – and as doctors, we’re supposed to sort these out’.
On the personal impact of Totally’s management decisions, the GP said: ‘I don’t think I’ve ever come across anything as demoralising as this, to be perfectly honest, and I’ve worked for lots of trusts.
‘The whole thing is demoralising, I’m actually sitting here half contemplating resigning, handing in the computer, and calling it a day.
‘But I feel that’s easy enough for me to do, but I just think this is unfair on people who are actually relying on this as their only source of income.’
Another GP, also based in the south of England, raised concerns particularly about the impact on younger GPs or those struggling for work, saying the current job climate is ‘the perfect storm’ for ‘bad practice’.
She told Pulse: ‘Because the job climate is poor at the moment for GPs, people are even more frightened and being pushed to work in a way that isn’t necessarily right for them or isn’t necessarily right for the patients.
‘But people are even less inclined to whistleblow or stand their ground because there’s no other jobs out there.’
This GP, who has worked at the company for several years, also received a performance warning email from the company, and said she ended up ‘supporting’ other GPs due to concern for their mental health.
‘Luckily for me, I’m long enough in the tooth and I had other different forms of work, but some of my younger colleagues were absolutely scared witless because they were relying on this work, whether it was salaried or contracted, as a substantive role, working around maybe caring responsibilities and working around young children, being able to work from home, and hours to suit them.’
She said the emails Totally sent out to the GP team were ‘completely bad management’ and ‘completely driven by target’.
‘They don’t understand when people’s professionalism is called into question, the mental health impact that has,’ the GP told Pulse.
On the management team itself, this GP claimed that the company had ‘radically slashed’ the clinical leadership when Vocare became part of Totally PLC, and that ‘two nurse managers’ are now responsible for the remote GP team.
An update sent to GPs in June by Totally chief operating officer Mr Prasad Godbole apologised ‘unreservedly’ for the warning emails sent in the previous month, and suggested they start ‘performance/productivity monitoring with a clean slate with immediate effect’.
He said: ‘I have discussed this with the team and all are in agreement that the communication in terms of productivity/performance could have been improved.’
However, he indicated that the process described in the warning emails was only ‘on hold’, and in the meantime GPs will still receive ‘quarterly’ case volume reports and audits on performance, with ‘random checks’ on five individuals each month.
The update also explained that the company is ‘considering the feasibility of providing out-of-hours IT support’ but that it is a ‘work in progress’.
A Totally spokesperson told Pulse that as a healthcare provider the company has a ‘responsibility’ to ensure high quality services, and they therefore ‘audit performance to ensure that all patients receive the care that they require’.
The spokesperson continued: ‘Non-clinical line managers and clinical leads, to whom our GPs are accountable, support our workforce to help maintain those high standards – this includes, for example, regular meetings with our medical director which our entire team of GPs is invited to attend.’
On its performance targets, Totally told Pulse: ‘The benchmark which we use for number of GP consultations is 3-4 per hour, as per the BMAs guidance of 25 per day, although as an experienced provider we are aware that not every patient is the same and some consultations may take much longer.
‘We monitor the number of patients seen as a way to monitor quality but we take more complex calls, and other issues which may impact the number of patients any GP can see, into consideration.’
The company did not deny the claims made by GP staff regarding the warning emails and termination, but said it is unable to comment on individual cases.
Staffordshire and Stoke-on-Trent ICB, which commissions Totally to provide a GP OOH service, told Pulse that it ‘monitors the performance of all providers’ but there is no specific target for cases per hour.
A spokesperson said: ‘For the GP out of hours service, this includes a metric in relation to the percentage of call backs within the disposition timeframe set by NHS111, of which our target is 95%.
‘The ICB does not set KPIs for the number of cases a GP triages via telephone within this contract.’
Vocare, which is now part of Totally PLC, was established around 30 years ago to provide urgent care services in the north of England.
It now provides NHS 111 and clinical assessment services across a number of areas including the North East, Yorkshire and Staffordshire, and is NHS England’s ‘provider of resilience support’.
Earlier this year, Pulse reported on an OOH provider ‘diversifying’ its workforce away from GPs due to financial constraints, leaving doctors struggling to find shifts
while the consultants are getting £200 per hour for locum shifts in hospital, OOH GPs are getting warning letter for measly £70-80 per hour. Medical school are full of even more prospective GPs, future would be very grim.
3-4 patient contacts per hour! Remotely! Sorry for sounding like an old fart but in my day in OOHs we would triage 10-12 per hour.We had the odd colleague who did 2-3 per hour they were known as skivers. Is it any wonder……..
How many £millions was the private company Totally plc’s contract, all the while its GPs were presumably doing less than 3-4 cases per hour? Cushy little number if you can get it…
Another dud deal transferring public money to private pockets..ICB must be sleeping or captured.
JB what has changed is that 80% of phone calls “ triaged” are dealt with entirely by phone and few are brought down compared to 5 years ago and even fewer have home Visits. In the past a phone call leading to a
Patient coming down can be done in 20 seconds as there was no point in taking longer if they are coming down. But now the emphasis is doing the full job over the phone for the majority.
Silly me MH that explains it all???
Less than 3 per hour averaged over the whole year, i would be interested to know how many per hour the average GP at the company was doing, it does sound like very slow consulting, maybe an email wasn’t the best way to communicate but how else can they performance manage and stop people taking the mickey?
NHSE beware, the future GP salaried service in action. Quadruple your costs and productivity drops by 50%.
Why would anyone want to continue working for a company that treats highly skilled professionals in this way? Out-of-hours work is high-risk and triage needs to be thorough and robust and, with increasing pressures to refer patients to services other than EDs, which usually involve considerable time spent trying to contact these admission avoidance services, and with increasingly complex and elderly patients being managed by OOH services, it is understandable why ‘so-called’ targets cannot be met. Check your contract to see if these KPIs are mentioned there. If not, then this stinks of bullying. Medicine is not a conveyer belt. Go work for a provider who respects both your expertise and your focus on patient safety.
3 patient’s an hour for telephone triage?
“Are you having a larf?”
I wouldn’t be employing someone that slow to work for me.
I have gone through the 5 stages of grief regarding the death of General Practice (denial, anger, bargaining, depression and I’m now at acceptance). I’m now looking forward to being an employee and seeing a set number of patients each day with none of the extra stuff.
I think I will be able to struggle through 4-5 telephone triages in about 15 minutes.
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What they really need to be looking at is Outcome of cases closed , which these 111 providers don’t seem to care about. Most patients are needlessly sent on to another service when a GP with even mediocre skills should be able to manage on the phone. Of course a percentage do need to be seen on the day. They have a KPI for end to end case closure. Otherwise what is the point of the 111 GP service . It’s not just the quantity it’s also the quality. It is possible to achieve a high audit score as its a tick box exercise and still send a patient needlessly to another service. One has to question the need for 111.
@James Bisset:
You said it: “In my day…”. Not your day any more though. Safe doctoring today, preempting patient and staff complaints, misconduct charges, navigating NHS culture, not to mention joining the queue for handovers, taking patients there yourself, tyding up the list …enough said.