On 13 June, Panorama was devoted to an investigation of the US company Centene, now the largest provider of General Practitioner services in the UK (next to the NHS) through its subsidiary Operose, with around 600,000 patients.
This undercover exposé showed that we in KONP were right to campaign along with others against Operose and other private companies holding APMS contracts for general practice, and we must continue to monitor and oppose these contracts whenever they come up for renewal.
The introduction of the Alternative Provider of Medical Services (APMS) contract by the Labour government in 2004 permitted private companies to set up in general practice. Operose Health was formed in early 2020 when the Centene Corporation brought together its UK companies – The Practice Group and Simplify Health. In February 2021, Operose Health acquired AT Medics with a large number of GP surgery contracts in London. Its former chief executive was Samantha Jones, recently appointed as Downing Street’s first chief operating officer. Ms Jones is an ex- NHS children’s nurse who moved into management, becoming chief executive of two hospital trusts before moving on to work at NHS England as director of care strategies.
The half hour programme was based around evidence collected by an undercover reporter (Jacqui Wakefield) working as a medical receptionist in an unidentified London practice owned and run by Centene/Operose, with a list size of 20,000 patients. Commentary and insight were provided by NHS GPs Sam Everington and Helen Salisbury, with whom the undercover footage including observations from Operose staff were shared.
Jacqui Wakefield quickly established a level of chaos in the practice, with many patients finding it impossible to get appointments, some in tears on the phone. On one day, not a single doctor was available (Operose claim there were five working) and no appointments could be made. The next day there was huge demand. Some further context was given by an elderly couple in Basingstoke talking about when their local GP surgery catering for 42,000 patients was taken over by Operose. Full time GPs dropped from 25 to 11, and continuity of care was clearly eroded.
Through answers to questions innocently put to practice staff and testimony from patients and families who have used the GP services, a worrying picture emerged. One of the salaried GP employees commented on very high work load with attendant risk of mistakes. Recent NHS data for 6,500 GP practices indicated that on average there are 1.2 full time GPs for 2000 patients, while for Operose the figure was only 0.6. Managers referred to a GP ‘duty director’ always being available, while they had not in fact been in the practice for six weeks. It was made clear to the receptionist that she should never under any circumstances refer to the director as being absent. An experienced nurse talked of skilled nursing tasks being delegated to staff without sufficient training or knowledge. Parents spoke of the impossibility of getting a face-to-face consultation for their toddler who, after they went to A&E in desperation, was found to have leukaemia.
Two physician associates (PAs) with little training or experience of work were in effect being used as GPs on the grounds (according to a manager) that they were much cheaper – half the salary in fact. PAs generally have a science degree then get two years of practical training, and are important members of hospital and primary care teams. They have very useful skills such as history taking to arrive at a possible diagnosis, but cannot replace GPs and don’t have the training to do all things that a GP does. According to the NHS Employers website, their ability to practise independently and make independent decisions is enabled by collaboration and supportive working relationships with their clinical supervisors, with whom they can discuss cases, seek advice and review patients. In the Operose practice, it seemed clear there was little supervision or opportunity for either discussion or continuing education (‘sometimes I hardly see a GP; I don’t debrief everyday’).
While Operose claimed its use of PAs was in line with the NHS long term plan, it employs 6 times as many PAs in relation to patient numbers as GP NHS practices.
The undercover receptionist also found that there was a team located in the surgery sorting letters and reports from around 30 practices. Its job was to decide which documents needed to be seen by a clinician; without medical knowledge they struggled with this task so that correspondence might never get the attention of a doctor.
Operose – cause for huge concern
The GP commentators questioned whether this Operose business model was not posing real safety risks for patients, with PAs being used wrongly as cheap substitutes for trained GPs, recommendations in correspondence and investigation results not being accessed in a timely manner, a deficiency of support and supervision of PAs, an absence of senior hands-on medical staff to maintain overall standards of care, and a deficiency of doctors for numbers of patients. They concluded that generating profit rather than providing excellent care was the overriding concern, with money being put before patient safety. This should perhaps not be a surprise given Centene’s commitment to maximising profit per share or the fact that Centene has faced repeated legal problems in the US (where its services cover 1 in 15 people). According to the Panorama team, Centene has paid out $264 million in no fault settlements and set aside £1bn for other claims. In the light of the evidence from London, it concluded that patients here were getting a raw deal.
In order to protect patients, the CQC and commissioning bodies now need to look closely at the quality of service being provided in all Operose practices. Campaigners should also scan websites of Operose practices for evidence of meetings and minutes from Patient Participation Groups, collating relevant feedback about services when available.
John Puntis, Co-chair Keep Our NHS Public, retired consultant paediatrician