qualified medical staff who are left without adequate supervision. tonight, we ask is patient safety being compromised? they're putting profits, money, ahead of quality of care. - that is a massive risk to patients. my name's jacqui wakefield and i'm undercover at this london practice. it's run by a private company called operose health. operose has an estimated annual turnover of £88 million and is owned by a big american corporation. we're not naming this practice, or anyone who works here. it looks after around 20,000 patients. when phone lines open at 8am, dozens of patients wait in a queue to speak to me. 0perose health has grown rapidly in recent years. since 2016, it's spent millions buying gp practices across england. it now runs 70 surgeries with nearly 600,000 patients, making it the biggest gp provider to the nhs. panorama has spoken to a dozen former employees from across the 0perose group. one is a nurse who says she was sidelined in favour of lower paid, less qualified staff. she's asked us to protect her identity because she still works in the nhs. a lot of my roles got taken away from me and given to healthcare assistants who had been trained up, not even healthcare assistants with a huge amount of clinical experience. i think the major risk by giving these tasks to people with less training and less knowledge is that they don't know what they don't know and that's when things get missed. this doctor says she left 0perose because of the pressure. we were being asked to do increasingly more work so that was one thing. so we just had more and more patients to a level that i have never seen before in general practice you are rushing things and it doesn't always feel safe. people aren't receiving the care they need and mistakes do happen. sun's out, nice cup of tea in the garden. in basingstoke, 76—year—old john and his wife diane both have ongoing health issues and rely heavily on their local surgery. we had a very good gp. we could get appointments to see him quite readily, not necessarily the same day obviously, but certainly within a couple of days or a week. during the pandemic, it became harder for all of us to get face—to—face appointments with a gp. but when 0perose took over john's practice in 2020, he says things soon became worse. you won't get to talk to a doctor. you won't get an appointment with a doctor. there aren't the resources there to handle the face—to—face appointments that people really feel that they used to enjoy and now can't. nhs data shows that before 0perose took overjohn�*s practice, there was the equivalent of 25 full—time doctors for around 42,000 patients. now, there's 11. when i think about what's next, i feel very concerned that we won't get the care that we need when we need it. 0perose says 97% of its practices are rated �*good' or �*0utstanding' by the care quality commission, and it works "in the best interests of patients, providing access to the highest quality of care." back at the london practice where i'm working, i arrive one morning to find that neither i nor any of the other receptionists here can book a single appointment with a gp for that day. i'm told there's just one doctor on site and they're dealing with patients from another practice. it has a knock—on effect. the next day we're inundated with calls. even if we had, like, one more doctor full—time this week, it would have been a lot more bearable. even if we had, like, one more doctor full—time this week, it would have been a lot more bearable. i've neverfelt so guilty in a job, like, having to turn all these people away who were really worried and stressed. and i'm sitting there being, like, i literally cannot do anything. i showed my undercover footage to professor sir sam everington, a senior practicing gp. i showed my undercover footage to professor sir sam everington, a senior practicing gp. i'm quite horrified. you've got 20,000 patients, and not a single doctor seeing patients. that's unbelievable and completely unsafe. what about in the context of there is a shortage of gps generally? is that an excuse? the general shortage of gps in the country — absolutely no excuse. so, all of us in general practise have stressful days when we've got doctors down or ill or off on holiday or whatever. we're used to that. 0perose says five doctors were working that day, but when we asked if the doctors were available for appointments, 0perose didn't respond. across the uk, there's a severe shortage of gps, but more are now being trained. panorama has analysed the most recent nhs data for 6,500 practices across england. we found for every 2,000 registered patients, there is, on average, the equivalent of 1.2 full—time gps. but at 0perose practices, the average is half that, at a little over 0.6 full—time equivalent gps. i see firsthand what that can mean for patients. this patient says that following his discharge from hospital, he needs to see his gp regularly. this patient says that following his discharge from hospital, he needs to see his gp regularly. i think the most frustrating thing is seeing people, especially older people or vulnerable patients, they are the ones who miss out on the appointments and don't get the care that they need. 0perose says it's increased the gp headcount at this practice to its highest level ever. across all its practices, it says it's recruited 38 gps in the last 12 months and is in the process of recruiting 14 more. helen salisbury runs a gp practice in oxford. 0k, and how are we doing? oh, wow, actually it's looking not too bad at all today, is it? we've still got a few slots. it's quite hard working in general practise at the moment gps are finding that they're working very, very long hours. if there aren't enough gps, that means patients are not getting the appointments that they need. the worst—case scenario is they have a symptom, maybe a cough that hasn't gone away, maybe some bleeding from their bottom that needs investigation, and they don't see a gp and they don't get it investigated and the time that they're diagnosed is when they turn up to a&e with a cancer. this is antony barson, his partner rose and their two and 2.5—year—old daughter isla. she never used to cry. she was a really good baby. up until about a year old, 18 months, she wasjust a perfectly normal little girl. then in april last year, antony — a paramedic ? realised something realised something was wrong with his daughter. she would go blue for periods of time. we're talking aboutjust having a bath and noticing that her lips and extremities were turning blue. she was in pain, but she couldn't... she was too young to tell you. during the pandemic, nhs england advised that children under five with persistent symptoms should get face—to—face appointments. isla was a patient at an 0perose—run surgery in nottinghamshire. antony says he had two phone appointments before he was able to get a face—to—face for his daughter. they weren't really keen on having isla into surgery and they tried to really say that they were all normal things that, you know, oh, she's probably got a bit of a blockage so you can have some something to move constipation. that's probably why she's got the stomach ache. they didn't really explain why she was going blue. antony says no tests were done and he was told to give his daughter calpol. when isla's symptoms got worse, he says he couldn't get another face—to—face appointment. every time we phoned the gp, it was a different doctor that we spoke to. we weren't absolutely sure whether it was the pandemic that had caused it, but we noticed that people that had been there before had left or gone. and that's when we start to realise that things have changed. it was still difficult to get a doctor appointment at our surgery. so we took her to a&e instead. more than a month after her symptoms began, blood tests in hospital revealed isla had an acute form of leukaemia. i feel the not being able to get an appointment with any gp, let alone the same gp, has been detrimental to isla's health. if we'd seen the same doctor, i think it could have been spotted a lot quicker and we wouldn't have had such a poorly child. isla's now receiving treatment at a specialist cancer unit. it's really tough. it's very tough. it's a very lonely place. 0perose says it's "unable to discuss individual cases," but "all patient complaints are logged, fully investigated and, depending on the seriousness, shared with local commissioners, the wider nhs and the coc?. since the start of the nhs, gp surgeries have been run as small businesses, owned and managed by doctors known as partners. in 2007, the then labour government wanted to drive competition and innovation. so it changed the rules to allow bigger businesses like 0perose to buy into general practice. over the last 15 years or so there's been a change away from groups of doctors holding those contracts, to a situation when actually private companies can own those contracts. so, the people providing the medical services have two conflicting pressures. one is to make money so that the shareholders get a return on their investment, and the other is to provide the best possible service to the patient. at the 0perose practice where i'm working, it's overseen by a gp director. during nearly six weeks here, i've not seen him once. when i tell a patient the gp director isn't here, i get told off by one of the other receptionists. i wonder what technically here means. so i ask the practice manager. i don't understand it. i'm a partner in a general practice. i'm seeing patients every week and it's the only way i can make sure the practice runs really efficiently and well, if i'm actually doing the job myself. and what's your reaction to the fact that he says he's always available to call? is that good enough? absolutely not. what does that mean? no. you absolutely have to be on site as a gp to supervise, train, support all your team. you cannot do it remotely. as i get to know how the practice works, i notice that lots of patients are booked in with clinical staff called physician associates — or pas. physicians associates have been around in the usa for quite a long time, but they're quite new in this country. physician associates are being increasingly employed in general practice to help relieve the pressure. but they're not as highly trained or qualified as a gp. they are people who've had a science degree of some sort, and then they have two years practical training to come and work in a health care setting. and they have some really useful skills. they can take a medical history, so find out what's wrong. but physicians associates cannot replace gps. they don't have the training to do all the things a gp does. where i'm working, the distinction between gps and pas appears blurred. there are two pas here, both pretty new to the role. the other pa hasn't been here that long either. nhs data shows 0perose practices employ six times as many physician associates as the nhs average. the practice manager at my surgery explains why they hire them. 0perose pays their salaries, but like other practices can claim money back from the nhs as part of a scheme to expand the number of people working in general practice. i having lots of different people | within your team is really good. when i hear words like cheap, i'm not quite sure that they're utterly focused on giving the best possible care in the _ circumstances to patients. the pa should never be treated - as a cheap replacement for a doctor or nurse or anyone else. and if you hear that attitude, that is really worrying. - 0perose says it's not over reliant on physician associates at the practice where i was working, and its use of pas is in line with the nhs long—term plan. while pas can see patients on their own, they're supposed to be closely supervised by a gp. a doctor should check in with them every day. |a physician's associate should be| able to get support after they see every patient at the end of the surgery. - they also would get protected . learning time half a day a month where they're all learning together as a team in the practice. - wars— the sort of level of support and supervision that a physicians associate needs to have. - at this practice, ten minutes a day is set aside to answer the pas�* questions, but they tell me they the thing i worry about here is the physicians associates i are saying they're not getting enough supervision so they. know they need more. they're clearly articulating it, but they're not getting it. - and that's a problem. and that must be massively stressful for them. - but, inevitably, that - cannot be a safe system. 0perose says at the practice where i was working there is a clinical lead available to help answer pas�* questions. it says it has a clear process of supervision and invests heavily in pa training. we now serve one in 15 americans across all 50 states... 0perose is a uk—based company but its wholly owned by us health giant centene corporation. centene's local approach and unwavering commitment to helping at—risk populations has never been stronger. centene provides health care for some of the poorest people in america. data analyst antonio ciacca discovered evidence that centene was profiteering on contracts it had with pharmacists in ohio. i received a growing number of complaints from pharmacy owners, claiming that they were getting underpaid on prescription drugs that they were dispensing within our state medicaid programme. antonio's discovery prompted a series of lawsuits across america. so far, centene has paid out $264 million in no—fault settlements, including $88 million in ohio. there is no admission of wrongdoing on the part of centene. that's kind of standard in these sort of settlement agreements. so i will accept an apology note that has a dollar sign and many zeros after it. centene has set aside more than a billion dollars to settle other claims. these companies are entrusted to take care of our state's poor. and what we found was that they were taking those precious dollars and instead lining their own pockets. centene denies it made excessive profits and says it's changed its pricing model for medicines to improve transparency. i'm nearing the end of my time undercover. i've gathered evidence of short staffing and a lack of proper oversight. then i'm told about another part of the 0perose 0peration. in an office upstairs i find a team trying to sort thousands of digital medical reports, test results and hospital letters for about 30 0perose practices across england. the team has daily targets. lots and lots of letters arrive at a gp practice every day, those might contain things like this patient needs this change lots and lots of letters arrive at a gp practice every day, those might contain things like this patient needs this change in medication or these blood tests, or this is a new diagnosis. most of them, the doctors do need to see. it's not uncommon in the nhs for admin staff to have no medical training. here, they tell me they decide which documents find their way to a gp, a pharmacist or get sent forfiling. but one member of the team tells me they're so worried about making mistakes they sometimes use google to help work out what to do. but that wasn't all. 0ver lunch, they tell me they see documents piling up in the inboxes of doctors and pharmacists at other 0perose practices. if what i'm being told is right, it could have serious consequences for patients. if a letter destined for the gp is not being acted on for six months, that is a massive risk to patients, both in terms of the development of a more serious disease and them dying earlier. the government need to send in cqc and do an in—depth investigation on this practice. they're putting profits, money, ahead of quality of care. and that will have an impact. 0perose says its document workflow helps to ensure that clinicians receive accurate and well coded documentation in a timely manner and that the process is audited monthly for quality and safety. 0perose denies profit is being prioritised ahead of patient care. the department of health says all nhs gp services are subject to the same regulation and standards, and patients should always receive high—quality care. the care quality commission, which regulates general practice, says it takes all concerns raised with the cqc seriously, and will be following up as appropriate. general practice is under pressure like never before. i've seen staff doing their best in difficult circumstances. but, after six weeks undercover at one 0perose surgery, what i've seen and heard suggests patients are getting a raw deal. this is bbc news. our top stories: russia's foreign minister, sergei lavrov, again insists there is no war in ukraine. in an exclusive interview with the bbc, he repeats the kremlin line that it was not an invasion. translation: we didn't invade 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