General Practice is in crisis. A record number of GP practices closed last year as a result of growing patient demand without the requisite funding and workforce to respond. So a new app-based service for Londoners, which offers information services and video based consultations must be a good thing – right? The launch of GP at hand, which promises that you can see a GP in minutes for free, has been widely covered in the press. Whilst it has its fair share of promoters, they are some notable detractors. The purpose of this post is to curate those concerns and to consider implications for the future of digital in the NHS.
What is GP at hand?
GP at hand is a new NHS service offered by a GP Practice in partnership with the commercial company Babylon. The practice offers registered patients the ability to book an appointment via the app, have a video consultation via the app 24/7 and within two hours, pick up a prescription from their chosen pharmacist, visit one of six clinics in London Monday to Saturday. The app, which is powered by Babylon, also offers a symptom checker, health monitoring, and the option to replay your appointment so you can remind yourself of what was discussed. The app offers convenience, quick access and the ability to speak to a GP anytime and anywhere.
A quick reminder about how General Practice works
General Practices offer primary care services to a local community. On their website, NHS England say they are ‘at the heart of our communities, the foundation of the NHS.’ Most GPs are independent contractors and not direct employees of the NHS. As Margaret McCartney sets out, GPs do run their own practices as businesses. However, they do not compete with each other in the received sense of a business and they do not cherry pick well patients over poor and sick patients. Rather, they operate as a general practice offering services to the local population.
GP practices receive around £150 per patient per year and the fee is not tied to how often they see each patient – care is therefore based on need rather than profit. As described in this Guardian article, the NHS is a social insurance system, where funding attached to the 80% of patients within a GP practice who are comparatively well pays for the 20% who are sick.
Who is in and who is out?
The GP at hand website sets out an extensive list of people who are not eligible to register with the practice, including older people with conditions linked to frailty, people with complex mental health problems and people with learning disabilities. These exclusions have raised the largest amount of concerns amongst detractors.
Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, argues that the GP at hand model is opening the door to patients being cherry picked and a twin-track NHS. The app is being marketed to younger and healthier patients with those requiring more complex care being excluded. Sarah Wollaston, GP and Tory MP has argued that GP at hand is a non-universal service which excludes people most likely to need a GP. She expressed her concern in a tweet to the practice: ‘Stop misleading people who may wrongly believe yours is a universal service’ (Twitter, 10/11/2017; 19.10).
Writing in the British Medical Journal, Margaret McCartney asks why GP at hand has been able to exclude certain patient groups when General Practice cannot:
“It’s very odd for the NHS to allow a contract that enacts exclusion of people with these conditions by design. In fact, the NHS’s general medical services contract specifies that refusing people registration on the basis of illness or pregnancy is not allowed.”
So is GP at hand in contravention of the general medical services contract? And if so, what does this mean for the service?
Destabilising general practice
In his blog post on GP at hand, Roy Lilley calls out the new practice as ‘another layer of bureaucracy, cost and risk’. As GPs get paid by the number of patients on their books (rather than a fee-for-service) the new practice requires that you de-register from your local practice. If mostly fit and healthy patients leave their practice to register with GP at Hand, leaving behind people who are most unwell, then this leaves the most complex and labour intensive work for existing GP practices. This runs the risk of increasing the workload for already stretched GP services whilst GP at hand is able to do the least complex and most straightforward work.
More red tape
In her statement, Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, raises concerns about the option for patients to switch back to their GP if patients are not happy with the service. In addition, presumably if an existing patient falls into the category of excluded eligibility, by for example becoming pregnant or developing a mental health problem, they will need to de-register and go back to their local practice.
She argues that this is likely to create additional red tape for existing practices. She also suggests that the service could take GPs away from traditional general practice at a time when there is a workforce crisis.
GP in hand has come about off the back of the Government’s Patient Choice scheme which enables GP practices to register patients who live outside the practice area. The British Medical Association strongly advises practices that they should not register patients under this regulation as there is no universal arrangement in place for urgent GP care where the patient lives.
Writing in The Guardian, Simon Wessley argues that the Patient Choice Scheme means that those patients eligible to register for service ‘are likely to bring in the best return for the least work; those who won’t “burst the budget”. In other words, healthy people.’ This is a policy for those who have money, information and are mobile – not for those who are disadvantaged. He makes an equally salient argument that the link between general practitioners and their communities is fundamental one, with community and mental health services linked to local surgeries, with GPs acting as ‘the eyes and ears of local communities.’ He argues that the fracturing of GP practice from place could mean that issues such as child protection fall between the cracks if people register at different practices a reasonable distance apart.
The Patient Choice scheme enables services such as GP at Hand to operate in the way that they do. By fracturing the link between GPs and local communities, is a more profound disconnect going to occur beyond the more immediate destabilising of GP practice budgets?
In this opinion piece for the British Medical Journal the authors raise the issue of in-app purchases of private services within the GP at hand app. They question the extent to which this might herald the way for paid for services to services to feature more prominently in NHS workflow and to patients. They also question the extent to which private companies are ‘gaining access to strategic assets within the NHS architecture’ and the extent to which we should be creating algorithms that are publically owned and for the commons rather than the proprietary intellectual property of private companies.
So what’s the answer?
If traditional GP practices are being disrupted by GP at hand then surely the answer is to innovate by matching the appeal of convenient access and app based consultations. There are indeed many teleconsultation products out there and I have met GPs who use Skype on a regular basis. However, writing in the Guardian, GP Naureen Bhatti argues that the evidence is mixed on the benefits of such an apparently common sense innovation. She describes a mixed experience of trialing eConsult in her GP practice, whereby:
“Younger, generally healthier people use the technology often to get a medical opinion on minor illnesses that will get better in a few days. This might be acceptable if it freed up the GP’s time for sicker patients, but the emails need to be answered, and paradoxically add to the workload, instead of reducing it … the creeping coercion to offer electronic consultations inevitably diverts resources away from the care of sicker patients.”
In our rush to innovate we must ensure that we do not compromise the fundamental NHS principle of equal access to care based on need. We must ensure we don’t inadvertently disadvantage certain groups. We must ensure we generate good quality evidence that is independent of commercial interests. And we must separate out the benefits of digital technologies from some of the business models that underpin them. It is only in this way that we can protect the future of the NHS for ourselves and future generations.
And lastly – a legal challenge?
The British Medical Association is looking a potential judicial review after a vote was passed by a committee. It will be interesting to see what happens next.
Nb. I am updating this post as new articles are published.
You can find a response to the Margaret McCartney BMJ article by a GP at the GP in hand practice here.