The launch of GP at Hand’s London-wide service provides NHS access to GP appointments at the push of a smartphone button, 24 hours a day. Offered as the answer to long waits for GP appointments and the inconvenience of trekking off to the GP surgery, the service seems like a consumer paradise. It will certainly provide a challenge to established GP services, but how well will it serve its users and what will its impact be on the wider NHS?
For some ‘easy’ areas of GP care, it may well be brilliant. Episodes of relatively minor illness such as acne, minor nosebleeds or one-off urine infections can easily be treated through telephone or Skype consultations, with GP at Hand offering appointments for a physical examination if needed. But there are a number of issues to keep an eye on as the service beds in.
Things to look out for
First, GP at Hand is clearly focusing on the easier end of general practice (so-called ‘cream skimming’), and has a long list of ineligible patients, including pregnant women and frail older people. This will leave other forms of general practice to soak up more patients with complex needs.
Second, those who use GP at Hand might also have complicated or undifferentiated symptoms (i.e. where the cause is not clear) such as abdominal pain or persistent cough. One study showed that only 16 per cent of patients with this kind of undifferentiated symptom ended up with a firm diagnosis. Another found that around 25 per cent of GP patients had ‘medically unexplained symptoms’ (where no clear diagnosis could be found).
For these patients, continuity of care is important. And this is not just about informational continuity through access to medical records (which GP at Hand will provide). It is the deep knowledge of an individual and their social and family context, gained through an ongoing relationship with a GP, which informs decisions about whether to refer for investigations or whether to hold back and de-medicalise the response to some symptoms.
Third, how easy will the GP at Hand doctors find it to decline antibiotics or suggest alternatives to strong painkillers (which are driving the US opiate death epidemic) if they don’t know the people they are consulting with?
The BMJ’s Too much medicine campaign highlights the harms of over-treatment and over-medicalisation. The value to the NHS of general practice – which international comparisons have shown to achieve better outcomes at lower overall costs – is partly obtained because many NHS GPs know their patients well enough to decide, after initial investigations, that they can keep an eye on them in the community without referring for more and more tests. These are the core skills of medical generalism that GP at Hand will need to demonstrate.
This leads to the fourth issue that needs to be monitored: the opportunity costs of extending rapid access services. Critics of current general practice models argue that continuity is almost impossible to achieve without waiting a month for an appointment. This is partly because so many GPs are now opting to work in the ‘easy’ general practice of access hubs and online providers that few can be recruited to practices that take on the hard yard of care coordination, advocacy and de-medicalisation.
The Nuffield Trust has been researching new models of general practice for several years. We have argued that larger-scale, peer-led change and improvement and greater use of technology all offer ways to sustain general practice and the value that it adds to the NHS as a whole. We are currently examining which patients are likely to benefit most from technology-enabled rapid access services, and which might get better outcomes from traditional general practice (look out for our report on this subject in the next few months).
Three vital asks
In the meantime, there should be three asks of Babylon as it launches its GP at Hand service for NHS patients.
First, it should offer both good access and good continuity. The population of young working adults who are perhaps most likely to use GP at Hand will include some with multiple health problems for which continuity of care matters. This must be available to them with all the associated follow up, paperwork, advocacy and coordination with other services that is needed to deliver good care.
Second, GP at Hand must be open with its data, allowing comparison between its new service and traditional general practice on various quality measures. Not just in patient satisfaction – which will almost certainly be higher in the self-selecting group that chooses to use it – but in diabetic control, prescription rates for antibiotics and opiate painkillers, and markers of continuity.
Third, GP at Hand must be honest about the money and other resources it invests in the service. At the fuzzy boundary between private and public sector services, there will be plenty of opportunities to divert resources from the private side of the business into the NHS service and to run the new service as a loss leader. GP at Hand would be doing a disservice to the public if it created demand for a universal, instant-access service and the NHS could not afford to pay for it.
Rosen, R. (2017) "There’s an app for that, but it must pass the NHS test" https://www.nuffieldtrust.org.uk/news-item/there-s-an-app-for-that-but-it-must-pass-the-nhs-test