Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Does it matter who owns general practice?

BMJ 2021; 373 doi: (Published 21 April 2021) Cite this as: BMJ 2021;373:n1026
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

Alarm has been voiced about Operose Health purchasing 37 general practices in London across 49 sites and whether this represents further “privatisation of the NHS by stealth.”12 Operose is the UK subsidiary of Centene, a multi-billion dollar US corporation whose main business is health insurance. However, some suggest that there’s no need for concern, as GP surgeries are already privately owned.

It’s true that general practices are run as businesses. This is because, at the founding of the NHS, most GPs worked as individuals from their own homes, and it would have been very difficult to nationalise them. We still run as small businesses, but we have only one contract and that is with the NHS. Aside from the occasional medical examination so that taxi drivers can continue to be licensed, we work exclusively for the NHS.

If we’re already a business, does it matter if we’re swallowed up by a bigger one? Well, it matters if this makes a difference to the quality of care our patients receive—and there are reasons why this may occur in theory, as well as some evidence that it does so in practice.

As GP partners, we constantly balance the best care for our patients against our need to pay and retain staff within the budget allotted in the (massively complicated) funding formula of our NHS contract. Luckily, we don’t need to turn a profit for shareholders, as we don’t have any. There are no investors expecting a return on their capital—if we did have them, we’d be duty bound to consider them when deciding whether we could afford another nurse or whether to replace expensive doctor hours with cheaper, but less expert, hours from other healthcare professionals.

It appears that these concerns may have played out in practice: research published in 2017 showed that patients who were registered with general practices owned by limited companies reported worse experiences of care than other patients.34 There’s a legitimate concern that, if your eye is always on the bottom line, standards will shift towards the minimum you can get away with.

It’s not clear whether the patients of the London surgeries taken over in this particular deal will notice a difference. But, as UK general practice is underfunded for the work demanded of it—and the scope to make a profit is consequently limited—this recent acquisition could be viewed as a loss leader by a US insurance company setting its sights on further opportunities in the UK health sector. The appointment of the outgoing chief executive of Operose as an “expert adviser for NHS transformation” at 10 Downing Street should make us worry about the future of our service.5