URSULA WHITE

February 2021

Dear Secretary of State,

I am writing to express my concern on discovering that, as of February 2021, Operose Health has acquired AT Medics, a company that currently has contracts to operate 49 GP London surgeries (Lacobucci 2021). Operose Health was created in January 2020 as a subsidiary of Centene, a large US-based corporation providing managed care services (Centene 2021). Centene also have investment in Circle Health Group, a private health provider, which won contracts to manage Hinchingbrooke Hospital in 2012. Circle were forced to hand back their contracts to the NHS after reports of significant failures of care and financial mismanagement (The Kings Fund 2021).

I am a GP working in an urban London practice and this came to my attention as a neighbouring practice had been taken over by AT Medics. I am deeply concerned that despite your assurances that the NHS is “not for sale’’ (Hancock 2019); the largest provider of NHS GP surgeries in England is now part of a global corporation. This is concerning because the fundamental aim of any corporation is to maximise the value of the enterprise for its shareholders. This leads us to question whether Operose Health has the best interests of its NHS patients or whether it merely seeks to fulfil its contractual obligations and maximise profits. As a practicing GP, I feel strongly that patients benefit from care that is both delivered and organised by those who understand the local community. I am immensely proud to work within the NHS and to offer a service that remains free at the point of delivery. Whilst the NHS is not yet a true commodity, I am concerned by the fact that the commodification of health underlies much of its recent policy reform (Moody 2011).

Your attempts to marketize the NHS are not new. Kenneth Clarke introduced the 1990 NHS and Community Care Act to create an internal market whereby part of the system was designated with a purchasing function and providers were competing for contracts (Heaton Mason and Morgan 2002). New Labour extended this by creating Primary Care Trusts (PCTs) where services could be commissioned outside of the NHS (The Kings Fund 2021). Under the 2012 Health and Social Care Act, PCTs became Clinical Commissioning Groups (CCGs) which were able to purchase services from any provider. This resulted in a large number of contracts being awarded to private providers with the hope that introducing competition would lead to better care at reduced cost (The Kings Fund 2021). However, the reality has been declining quality, longer waiting times, further cancellations and lower staffing levels (Murray et al 2016).

The marketisation of health care is based on the principle that introducing competition to the provision of services will drive improved quality, better management and innovation. However, care provision is a unique labour force that does not necessarily abide by market forces (Duffy 2013). Economic distortions are common as relationships form the basis of good care and this cannot be easily measured or quantified. The marketisation of healthcare prioritises what can be measured (quantity) over quality. During a busy overbooked clinic, my ‘productivity’ may appear high, but this cannot be achieved without sacrifice. One consequence of squeezed appointment times is the rule ‘’one appointment, one problem’’ created by practices in attempts to manage ever expanding workloads. As doctors and patients both recognise, this model of care fails to consider the complexity of illness (McCartney 2014). Furthermore, illness should be best understood from a biosocial framework whereby diseases and negative social or environmental factors, such as poverty, can co-exist and exacerbate one another (Singer et al 2017). In this way, certain populations already affected by social inequality, can disproportionately suffer from disease clusters. Attempts to understand illness as singular entities are reductive and unhelpful. My reflections appear to be experienced by the wider GP community who recognise that increasing workloads undermine patient safety (Patel 2019) and may contribute to a general practice workforce crisis (Wilkinson 2021). This is just one example of how market-based

approaches to healthcare reform may undermine their very goal of high quality of care through heavy reliance on quantitative analysis and objectives.

One way of assessing these effects is to look elsewhere where these changes have occurred more rapidly and to a greater extent. The UK’s strategy reflects that promoted on a global stage. The World Bank 1993 Development Project underscored a cost-effective strategy that promoted a market-based approach to healthcare provision and financing (World Bank 1993). However, anthropological analysis which looks at the local effects of macro policies is revealing and could be helpful in thinking about how global and national policy shapes people’s lives.

In the United States, a restructuring programme for Medicaid managed mental health services in New Mexico transformed the way healthcare providers understood their role and responsibility (Willging 2005). The healthcare reforms were based on an ideology which emphasised corporate management techniques to promote the healthcare workers’ discipline and accountability. However, in reality, this undermined the relationships between healthcare providers and their patients as they felt conflicted by rival demands from the patient, government and the provider. The new neoliberal ideology encouraged profit over service which dominated decisions around patient care. Furthermore, this framework shifted accountability from the state to the front-line workers themselves and reinforced blame cultures against the poor by emphasising that patients were self-empowered consumers and therefore responsible for their own health. Overall, the research problematised the public-private model of health care and illustrated some of the unexpected consequences of outsourcing care contracts and promoting a neoliberal agenda.

Further research in the United States has echoed this sentiment where healthcare reform designed to increase care workers financial accountability caused moral conflict as they were faced with the realisation that profit presided over ‘calling’ and the vulnerable poor were reimagined as revenue (Robins 2001). The healthcare workers understood their work in moral terms and were explicit in interviews that they were not motivated by financial gains. Following the reforms, some simply left their jobs. Those that remained developed a new frustration with their low wages and long hours as they reconceptualised their work in monetary terms. These ethnographic examples demonstrate that even simple structural changes can cause fundamental shifts in care workers’ moral orientations and the dynamics between healthcare professional and patient.

Radical transformations of models of healthcare have occurred over the last three decades in post-Soviet states. Mongolia is an interesting case study as until the 1990s, when it elected for market-based healthcare reforms, it had little influence from capitalism and had a well organised and equitable socialist model of health care (WHO 2001). Health reform in post-Soviet Mongolia, driven by the influx of foreign aid, consisted of creating a public-private hybrid with the hope that the vulnerable would still have some access to health care whilst services would benefit from a marketized model. However, research has demonstrated that privatisation of certain sectors of health care fragmented the service in such a way that it created barriers for individuals to navigate the system (Janes et al 2006). Primary care, which dominated the public side of the health care system, remained rudimentary and underfunded. Barriers to healthcare were experienced most by the more vulnerable sectors of society. Focus on increasing maternal mortality has demonstrated that Mongolian women have, in particular, have been the victims of broader neoliberal economic reform (Janes and Chuluundorj 2004). Reduced access to healthcare has resulted in maternal death due to delayed hospital presentation, poor health infrastructure and medical staff who feel unequipped to deal with obstetric emergencies. Unsurprisingly, women who were poor, young and had lower levels of education suffered the most.

The running of multiple GP practices by an American corporation is a significant step in neoliberal reform and the future of the NHS is under threat. Outsourcing to the private sector fragments healthcare services and creates a chaotic system that most disadvantages vulnerable members of society. The ideology that is inevitable if healthcare is to be run by corporations – that is, profit over patients- permeates the system and causes radical shifts in the moral economy of care. Primary care services should be run locally by those who understand the complexity of illness and the local realities of those who experience ill health. Health reform should be directed towards providing a more holistic service that considers the social determinants of health. If this is ignored, health inequality will only deepen. Government reforms such as this will be felt by all members of society and should cause pause for thought as to how we want our health service to look like in the future.

Yours Sincerely,

A GP

References:

1. Centene Corporation. “Form 10-K Annual Report 2020” 2021. https://investors.centene.com/static-files/f41e7424-3656-4057-aff6-237f11e4db94

2. Duffy, M. Albelda, R. Hammonds, C. 2013. “Counting care work: The empirical and policy applications of care theory” Social Problems 60 (2): 145-167

3. Hancock, M. 2019. Twitter. Post November 19 2019 20.05 https://twitter.com/MattHancock/status/1196884713224507394

4. Heaton, N. Mason, B. Morgan, J. 2002. “Partnership and multi-unionism in the Health Service” Industrial Relations Journal 33(2): 112-126

5. Janes, C, R. Chuluundorj, O. Hilliard, C, E. Rak, K. Janchiv, K. 2006. “Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context” Global Public Health 1:1, 5-30

6. Janes, C, R. Chuluundorj, O. 2004. “Free markets and dead mothers: the social ecology of maternal mortality in post socialist Mongolia” Medical Anthropology Quarterly 18(2): 230-257

7. Lacobucci, G. 2021. ‘’Subsidiary of US healthcare firm will run more than 50 GP practices after takeover deal’’ The British Medical Journal 371:519

8. McCartney, M. 2014. “One problem” The British Medical Journal 2014;348 doi: https://doi.org/10.1136/bmj.g3584

9. Moody, K. 2011. “Capitalist care: will the coalition government’s ‘reforms’ move the NHS toward a US style healthcare market” Capital and Class 35(3):415-434

10. Murray, R, J. Jabbal, J. Thompson, B. Baird, Maaguire, D. Northern, E. 2016. “Quarterly Monitoring Report 21”. The King’s Fund. qmr.kingsfund.org.uk/2016/21

11. Patel, A. 2019. “How GP workload is jeopardising patient safety”. Pulse. https://www.pulsetoday.co.uk/analysis/workload/how-gp-workload-is-jeopardising-patient-safety/?p=5184

12. Robins, C. 2001. “Generating revenues: fiscal changes in public mental health care and the emergence of moral conflicts among care givers” Culture, Medicine and Psychiatry 25:457-466

13. Singer, M. Bulled, N. Ostracht, B. Mendenhall, E. “Syndemics and the biosocial conception of health” The Lancet 389: 941–50

14. The Kings Fund. 2021. “Is the NHS being privatised?” https://www.kingsfund.org.uk/publications/articles/big-election-questions-nhs-privatised

15. Wilkinson, E. 2021. “GP workforce not keeping pace with current demand, figures show” Pulse http://www.pulsetoday.co.uk/news/workforce/gp-workforce-not-keeping-pace-with-current-demand-figures-show/

16. Willging, C, E. 2005. “Power, blame, and accountability; medicaid managed care for mental health services in New Mexico” Medical Anthropology Quarterly 19: 84–102.

17. World Bank. 1993. Investing in Health: World Development Report 1993 (New York: Oxford University Press)

18. World Health Organization [WHO] .2001. Health sector review: Mongolia (Ulaanbaatar, Mongolia: World Health Organization)