Serco took over the out-of-hours GP service in Cornwall in April 2006, replacing the incumbent co-operative of local doctors in a competitive tender. But senior managers admit it has taken more than a year to get the service right.
One key lesson has been a recognition that telephone triage - clinically assessing the urgency of callers' cases - is a specialist skill in its own right that needs to be taught to all clinicians, no matter how experienced they may be in other areas.
'Telephone triage takes away a clinician's most important tools - their hands and their eyes,' says Serco's lead nurse Jude Marson.
'All the information they would get from touching a patient and looking at them is gone, instead they have to listen very carefully to what they are saying and what they are not saying. It may sound obvious but it is a whole new skill-set.'
Ms Marson has set up a specialised training programme for nurses doing triage - giving them simulated cases and then gradually bringing them on to handle real calls under close supervision before allowing them to go solo and decide whether a call needs a home visit or a referral to a clinic, or can be dealt with by telephone advice.
The service's doctors are offered learning days on telephone triage and also get monthly feedback on their performance from local medical director Dr Richard Clapp. He compares their call-handling rates to colleagues', in particular looking at the proportion they think need a home visit or clinic appointment.
'You would expect all clinicians to have roughly similar rates for deciding on face-to-face contact rather than telephone advice,' says Dr Clapp. 'If an individual is markedly different, I sit down with them and talk through why that might be. Often it is a misunderstanding about procedures.'
Managing calls appropriately is the bedrock of a successful out-of-hours service: demand models include assumptions about what proportion will need a home visit and a small number of clinicians operating at different rates can mean a service that should be adequately resourced to meet expected demand quickly struggles to cope.
Serco’s team admit that poor preparation and training caused serious problems during the first year of their contract with Cornwall and Scilly Isles primary care trust.
'Our proposal was based on moving from GP-led triage to nurse-led triage,' says contract manager Sara Bailey.
'That change has to be carefully managed and all staff need to be closely supported during it, but we did it too quickly.
'We were expecting nurses to handle too many calls too quickly, without the proper support. They tended to be slower than the GPs who had been providing the service, so response times fell.
'At the same time, many GPs felt they were being frozen out. Then they would see mounting delays in responding to calls, and sometimes clinical decisions they disagreed with. As a result some left the service - meaning we had to rely even more on doctors from outside Cornwall and even abroad. That, in turn, led to problems with geography and sometimes language, which further damaged the reputation of the service.'
Relations with non-clinical staff had also deteriorated. Short-sighted cost-cutting such as cancelling free tea and coffee hit morale. Human resources issues such as putting all staff on proper contracts - promised in the bid - had not materialised.
By early 2007, service levels were far too low and local MPs were up in arms. The commissioning PCT imposed a 20-day improvement plan. Serco, keen to develop a major health business, acted. A new management team including Ms Bailey, Dr Clapp and Ms Marson was brought in and supported by a turnaround team from across Serco. That brought extra investment in IT, HR and management – and most importantly money for more clinicians, cars and clinics to get service levels back up.
Now, 18 months on, Ms Bailey says the contract is stable and delivering high service levels, even though some of the extra resources put in have been scaled back.
Staff are more engaged and communicate far more through one-to-one meetings, team briefings and weekly newsletters. The free tea and coffee are back, plus a summer party at the Eden Project. Almost all staff are on proper contracts. The nursing team is growing, with some part-time staff ditching their day jobs to work full-time at Serco, and local GPs are also returning to work at the service.
'I think they can see it is a safe and well-run service and an environment where we work with them as individuals to help them develop their skills, so they can deliver a better service to patients,' says Dr Clapp.