The advent of GP at Hand – the first example of remote technology being used to create an entirely new primary care delivery model within the NHS – has been met with a mixture of excitement and hostility since its launch last November.
It offers patients around-the-clock access to GP services at short notice via a mobile app – including video consultations with a health care professional, access to a symptom checker and health monitoring software. Face-to-face appointments are available during office hours at one of six sites across London, after an initial video consultation.
GP at Hand has been registering new patients at a rate of 4,000 per month – perhaps indicating patients’ desire for quick and easy access to a GP at a time that suits them, via the technology they use most often: their smartphone. Patients across London are eligible to register with the service, but to do so must deregister from their traditional GP practice.
And this aspect of the model is arguably the most disruptive. It has far-reaching implications for the funding that general practice receives and how it is calculated, as well as referrals to other parts of the system and patient experience.
So what are the issues?
Concerns about GP at Hand’s impact on the way general practice funding is calculated and allocated are well rehearsed. The Carr-Hill formula – which calculates how much funding GP practices receive – takes age and deprivation into account, and practices also receive more money for patients within the first year of registration, to cover additional administrative costs, health checks and new referrals.
But given that GP at Hand patients have opted into the model and are overwhelmingly under 40, many think they are unlikely to be high users of health services. There are concerns that GP at Hand may be able to profit from patients with minor needs – which in any other practice would go into subsidising care for complex patients. And that may have knock-on effects for other practices, who are likely to be left with more expensive patients and less money to manage them.
In theory, the Carr-Hill formula should be able to address this, but it is unclear if the formula is sensitive enough to deal with large numbers of younger (potentially healthier) people joining a practice en masse.
There are also concerns about the impact such a model has on activity outside of the practice. As anyone in London is eligible to register with GP at Hand, it means patients are often referred to services outside of the clinical commissioning group (CCG) contract portfolio – in this case the contracts held by Hammersmith and Fulham CCG. As a result, the provider has to invoice that CCG.
Consequently, the CCG has put significant admin resource into reimbursing providers across London. The unprecedented fast pace at which patients are registering has resulted in Hammersmith and Fulham requesting an additional £18 million to cover the influx of patients for the rest of the year.
Finally, the GP at Hand model may also prioritise access to primary care services over other aspects of quality of care. Patients are allocated a face-to-face appointment at one of the participating GP practices, without choosing a practice based on geographical convenience, quality ratings, or relationship with a particular health care professional.
They therefore forfeit their ability to choose their face-to-face interactions. Research shows that continuity is associated with improved patient outcomes and increased patient satisfaction, and that reduced continuity is associated with increased (potentially preventable) hospitalisations. We need a better understanding of what is lost when access is prioritised over other aspects of quality.
What does this mean for the future of general practice?
The rate at which new patients are registering with GP at Hand, as well as the sheer number of private providers offering on-demand video consultations, suggests there is considerable demand for this kind of service.
Historically though, uptake of video consultations in traditional general practice has been low. Perhaps the time has come for traditional general practice to draw on models in the private sector and experiment with how it can offer on-demand services. Of course, there is always the risk of supply-induced demand, and of changing the prevailing narrative from one of supporting patient engagement, empowerment and self-care to one of relying on professionals. Any change would need to be carefully evaluated in real time.
It is too soon to tell whether those registered with GP at Hand will be content with a remote service in the long term, particularly if they develop ongoing health needs. We are already hearing about patients leaving GP at Hand and returning to their original GP. We need to understand why that is, and gaining a picture of the case mix of people deregistering will be an important part of that.
If, on the other hand, its popularity continues to rise – and the model is replicated across the country – there could be repercussions for smaller practices losing large numbers of patients. In this scenario, it could be challenging for those unable or unwilling to use a digital-first service to get a face-to-face appointment – although uptake large enough to cause destabilisation at this scale seems fairly unlikely at present.
The GP at Hand model is, without doubt, disruptive. Used at scale, it necessitates changes to funding and contractual arrangements as well as service planning. Not only this, it transforms the nature of interactions between patients and professionals.
But it isn’t clear – at least yet – that it’s destabilising general practice. We don’t know how the service and uptake will evolve. Rather than view it as a threat to traditional general practice, perhaps it should be viewed as an opportunity (or a challenge from the market) to offer a new service that – for many – is preferable to how it’s always been.
Castle-Clarke S and Scobie S (2018) "GP at Hand: destabilising or modernising general practice?”, Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/gp-at-hand-destabilising-or-modernising-general-practice