14 December 2017
An NHS GP at the tip of your young, healthy finger?
An East End GP explains the shortcomings
By Naureen Bhatti
Last month I wrote in the Guardian about the new ‘GP at Hand’ service that had been launched with very little warning, causing shockwaves across general practice. The private provider Babylon, already offering a fee-based on-line GP consultation service, has expanded its reach by teaming up with an NHS practice to create a new on-line service, GP at Hand. In a nutshell, Londoners can now leave their current NHS practice, and sign up for almost instant online virtual care. GP at Hand says their patients can ‘book an appointment within seconds’ via its smartphone app and have a video consultation with an NHS GP within two hours “anytime, anywhere”. Those who need a face to face appointment will be seen within 48 hours at one of six sites across London.
Whilst acknowledging that there is a very real need for the NHS to embrace new technology, innovation should not come at the cost of equality of care based on clinical need, a fundamental principle of the NHS. GP at Hand was launched with a well-organised advertising campaign that made full use of social media to target the young and healthy. Its website cautions that its service may not be appropriate for those with “complex mental health problems or complex physical, psychological or social needs” as well as numerous other health problems, including being pregnant. And, as my Guardian article discussed, cherry picking the worried well while leaving patients with significant health problems to be looked after by their local GP risks undermining the financial stability of many practices. A GP practice gets paid an average of £151.37 a year per registered patient regardless of how many times they are seen. 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. Each time a patient registers with GP at Hand they become de-registered from their current practice, and the funding goes with them. Although the Carr Hill formula was introduced to fund practices with weighting for age and sex, it is widely acknowledged to be inadequate and is under review. By delivering care disproportionately to the worried well, GP at Hand potentially undermines healthcare delivery to those who need it most.
The funding crisis in our health care system is now widely acknowledged. While the main focus has been on hospitals there has been increasing recognition that general practice, which underpins the NHS by dealing with 90% of all healthcare contacts, has been badly neglected with overall spending reduced from 11% of the total NHS budget 10 years ago to less than 8% now. Our GPs have aged and many have been driven to early retirement by the stress of running their financially squeezed small businesses, while our younger doctors are either choosing not to become GPs or are leaving for the better lifestyle and remuneration available in Australia and New Zealand. Over the same period demand has increased by 16%, driven up by our aging population, the rising costs of new technologies and drugs, and, undoubtedly, some changes in patient expectations.
The GP forward view was launched 18 months ago to support general practice and fund innovative ways of working that embrace IT. For example, does everyone in the waiting room really need to see the GP face to face when we have instant messaging and videoconferencing? Do working adults really need to register with a practice in person during a working day? And why can’t we all see our own medical records that sit stored on the computers in our local practices?
All important questions, but GPs, while accepting that electronic innovations have to happen want evidence that these are making better use of resources and improving health outcomes. More importantly, will any proposed changes meet the NHS’s underlying principle of equality of care, based on clinical need, regardless of age, sex or income? There is evidence that improvements in access, through both telephone triage and on-line consulting, are minor in comparison to increase in workload and failure to free up GP time, and can actually increase the number of contacts (so called supply-induced demand), including increasing multiple attendances for the same problem in those with health anxieties. A London commissioning group recently dropped plans to pilot a symptom checker app to allow online patient triaging when it found that, instead of reducing demand, patients in the small test group were actually gaming the system to speed up getting a GP appointment. This resonates with our East London experience where on-line access introduced inequality, disadvantaging those patients without access to a computer, often the elderly, or those with poor IT skills, learning difficulties or English as a second language. Winners, unsurprisingly were the more affluent and articulate.
And we know that continuity with a trusted GP increases self-management and reduces hospital admissions. How will ‘virtual’ GPs reach the deep contextual knowledge of patients and their families GPs have traditionally relied on to safely hold patients in the community without onward referral to other services? Without this the cost to the NHS could be greater, particularly with any potential risk to other forms of general practice.
So, what of solutions? Payment of GP practices is already under review. Some have suggested developing a new lower payment rate for working age adults while considering a short-term subsidy for practices that lose more than a certain number of patients. However, this misses the point. The majority of the population falls into the 15-64 age bands that attracts lower funding, yet this mostly healthy group will still contain many who move in and out of significant illnesses that cannot be dealt with on-line, pregnancy and depression being just two common examples. Further, it contains people with ongoing lifestyle challenges that affect health and cannot easily be managed with apps, not just those with alcohol and drug use, but also those living in greater deprivation. Policy makers need to ensure that on-going evaluations of new innovations take a broad approach to understand the impact on patients, general practice and the wider NHS.
IT innovations have extraordinary potential but are ultimately part of a toolbox of different ways to access appropriate healthcare advice, available to all, and chosen to fit particular circumstances or the nature of the complaint on that occasion. And when needed it will be a trusted regular GP, not a bot, that gives wisdom, kindness, touch and compassion. Julian Tudor-Hart’s inverse care law will continue to apply if, as he himself paraphrased: “to the extent that healthcare becomes a commodity it becomes distributed just like champagne. That is rich people get loads of it. Poor people don’t get any of it.” We need to make sure the NHS embraces IT innovation but safeguards must be put in place because it is not the fit, healthy and impatient that need the NHS the most.
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