Social enterprises have emerged from the ashes of GP co-operatives after the 2004 contract and are providing out-of hours services. Photograph: Martin GodwinGP co-operatives used to be a success story of the co-operative movement. In the mid-1990s, changes in NHS funding for out-of-hours services saw GPs group together to share the load equally. By the early 2000s, such co-ops were booming. The National Association of GP Co-operatives represented some 300 organisations with a membership of approximately 30,000 doctors across the UK. However, when the new NHS GP contract effectively released them from the obligation of providing out-of-hours services in 2004, most co-operatives (and indeed the association) disbanded faster than you could say "opt out".
Social enterprises have emerged from the ashes of the co-operatives. Some of those working within them effectively left general practice behind in favour of forming new social enterprises to tender for out-of-hours contracts.
"GP co-operatives is an old fashioned term now; it practically doesn't exist," says John Horrocks, chief executive of Urgent Health UK, the industry body for social enterprise out-of-hours providers. A tiny proportion of GP co-operatives do remain, but only in urban areas with a high enough population density to make it financially viable (contracts are based on cost per head of population, ranging from £8-12).
Social enterprises now account for around 42% of the out-of-hours market, with 33% from commercial firms and the NHS providing the bulk of the rest. "It's not the same as it used to be, where everyone took their turn in a co-operative," says Horrocks. "It's more of a lifestyle choice. Now, you often find GPs who specialise in out-of-hours … typically, a shift rota is available on the internet and the GP is able to sign up to whatever shifts they want to work." Meanwhile, the social enterprises they work for retain the NHS and co-operative ethos, says Horrocks.
Such enterprises include Badger (Birmingham & District General Practitioner Emergency Rooms), Brisdoc in Bristol, and Devon Doctors. The latter was originally a GP co-operative before it became a social enterprise in 2004, still owned by Devon's GP practices.
"While the CCGs [clinical commissioning groups] commission care, it is the GPs who most understand the consequences of good or poor care in the out-of-hours period," argues Chris Wright, chief executive of Devon Doctors. "Furthermore, the knowledge that no player in the company – be they director, employee or member – can benefit financially beyond a reasonable wage is vital in keeping the values of the company focused on sustainable quality care."
He adds: "There is no profit to be made in out-of-hours care, the resource is very limited, so 'for patients not profit' is the best ethos."
Partly thanks to the negative press that has surrounded commercial out-of-hours provision, Horrocks believes social enterprises are looked on favourably by commissioners. "The win rate for social enterprise is very good. As long as we can manage to persuade commissioners that what they want is a good quality, value-for-money service, rather than what the commercial sector tends to provide, which is a lower cost service but we would say dodgier quality … very often the commissioners are persuaded to go for social enterprise these days."
However, it in such a tumultuous sector, change is the only constant. Ed Mayo, secretary general of Co-operatives UK, argues: "While the most successful co-ops remain, out-of-hours services have gone the way of the rest of the NHS, towards open privatisation and, in some cases, outright service failure as a result."
Wright also warns that the commercial bidding process – in the past, he says, largely led by Harmoni – has driven down prices too much, making it all but impossible to provide a high standard of care. The well-documented disaster of the NHS 111 non-emergency medical helpline launch also provides a further challenge for a sector attempting to compete with private suppliers, with NHS Direct seemingly wanting rid of its stake as fast as possible.
As with many social enterprises working within public services, diversifying remains the name of the game. "Some [social enterprises] are already delivering good NHS 111 services in parts of London, Essex, Hertfordshire, Great Yarmouth and Waveney," says Wright, "Some are also delivering walk-in centres, minor injury units, A&E support, appropriate admission schemes and providing offender health and small community nursing services."
Devon Doctors is exploring working with GP practices to bid for other primary care contracts, particularly services such as district nursing and walk-in centres released under the Transforming Community Services initiative. Wright says it is very early days, but "we believe that our social enterprise model would ensure that contracts are focused on quality care for patients rather than extracting a profit".
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Spin outs need investment to compete for contracts against organisations with more financial muscle. Photograph: Johannes Eisele/AFP/Getty Images