APMS contracts
The 2004, GP contract reforms also brought in a new form of contract called Alternative Provider of Medical Services (APMS). This moved even further away from the traditional model and allowed the whole contract to be owned by a private company, none of whom had to be GPs or provide care directly themselves. This boosted opportunities for commercialisation and profit-making. The APMS contract is for a fixed price but large amounts of money can be made by amalgamating many APMS contracts under a single owner, and practising methods to reduce costs, such as downsizing and downskilling the workforce. Many APMS contracts are owned by companies with shareholders who share in the dividends. There are now over 200 APMS contracts in England.
After the Achilles Heel, the Trojan Horse!
When APMS contracts were originally proposed it was claimed they were a way to innovate and bring new and better GP services into under-doctored areas. Whether that really was the aim, or just a plausible but misleading pretext, the actual effect has been to enable GP services to be taken over by large private companies. APMS contracts, like other GP contracts held by companies, can be bought and sold through the sleight of hand of buying and selling the company that holds the APMS contract - or even the holding company that owns the company that holds the APMS contract! - thus getting around the ban on the sale of practices. That’s how AT Medics Ltd managed to sell their 37 practices in London to Operose Health, a subsidiary of the mega US health insurance corporation Centene.
Their motivation may not just be to make money from providing General Practice. There are other opportunities for making money such as being paid for setting up 'new models of care', data harvesting, development of technological health care delivery, and much more. Companies like Operose have been contracted by the NHS both to advise on the purchasing of services and to provide services. This is a very cosy relationship, ripe for abuse, corruption and cronyism.
Let’s look more closely at Operose and Centene
Operose already have contracts for twenty-one GP practices and several health services across England. Operose is a heavily loss-making subsidiary of the US-based health insurer, Centene Corporation which is registered in Delaware. Operose has paid no UK tax.Centene could pull the plug on Operose at any time forcing the shut-down of a large number of GP practices.In the USA Centene has been found guilty of fraud many times and is currently being sued by Ohio for fraudulent overcharging. Operose Health’s publicity states openly that its market strategy is to exit NHS contracts that do not make a profit.In one instance an Operose associate company pulled out of running Camden Road Surgery giving patients only 4 weeks to register elsewhere.
What’s wrong with commercial General Practice?
These companies have the creation of profit rather than the provision of care as their driving motivation. They don’t see the value in the provision of personal continuing healthcare from a family GP committed to their community. It’s cheaper to provide fragmented care from a downsized and down-skilled workforce. That is why personal continuing care is the aspect of General Practice that has most withered in those organisations providing commercial GP services, including some of the ones run by GP 'doctorpreneurs'.
The advent of 'digital-first' services - whereby patients can access an unknown GP, based anywhere in the country and with no knowledge of the patient or connection with the community within which the patient lives, and with no ongoing responsibility for their care - is seen as the new model of 21st century GP care. If that can be combined with reducing demand from the patients that need the most care - mainly elderly people and those with long term conditions - by making access more difficult for them, limiting the range of treatments they can expect, and replacing their care with technological gizmos, then so much the better for profits.
The fact that there is no evidence that this model of care is efficient, effective, inclusive or even caring does not seem to matter. Nor does it seem to matter that the patients who most use and need health services were never asked if they wanted this model and that most doctors find it meaningless and soul-destroying, no doubt contributing to the collapse in popularity of General Practice as a profession for young doctors.
Back to the future?
This is why the claim made that GPs have always been private since the inception of the NHS does not explain the profound changes that have happened in General Practice over the years, and the risks facing it now - changing from a personal continuing community service, to a remote, impersonal, episodic one based on and driven by commercial values. These profound changes have been enabled and supported by contractual changes. If we want to reclaim and regenerate General Practice as a service based on public service, rather than commercial values, the first step is to abolish APMS practices and end the ability of practices to be owned, bought and sold by private companies.
We can debate the pros and cons of ending independent contractor status. A salaried GP option, employed directly by the NHS may be a good solution, but seems a long way off. In the meantime, reversing the changes brought about by the 2004 contract and in particular, abolishing the APMS contract would go a long way to remedying what has gone wrong. This is not about going back in time to some misremembered golden age – it is about having the model with the best evidence for effective, efficient and positively-experienced health care.
There is an abundance of evidence that personal continuing health care works really well in terms of health outcomes, as well as patient satisfaction and GP job satisfaction, recruitment and retention. We need to bring it back.
Dr Louise Irvine
(Louise has been a GP in South London for 25 years and is a member of Keep Our NHS Public)
[1: GMS - general medical services contract; PMS - personal medical services contract; APMS - alternative provider of medical services contract]
