You may have seen advertisements on public transport about how to get a GP appointment ‘instantly’, or within a matter of hours. Consultations can be either over the phone or by video, using an app. These new healthcare services have emerged following controversial changes back in 2013 that allowed individuals to register with GP practices outside the area where they lived (such as where they work).
Private GP services
Some of these app-based services, run by private companies, charge fees rather than providing NHS care. For example, Push Doctor offers a 10-minute video consultation with a GP for a fee of £20 (an additional 10 minutes costs a further £20). There is also an admin charge of £8 if you need a prescription – and as this is a private prescription, all patients will pay full charges when picking their prescription up at the pharmacist. In addition, any referral or sick note will cost a further £15.
Slightly differently, Babylon is a subscription health service that uses an artificial intelligence triage system to check symptoms before offering a GP consultation by video.
Babylon claims that 75% of problems can be dealt with virtually. If a physical consultation is necessary, patients can get instant referrals to either specialists within the Babylon system or to BUPA consultants. Investigations like blood tests are booked at a nearby ‘partner’ facility or in some cases patients might be sent a home diagnostic kit. Any prescriptions required are sent by first class post to the patient’s preferred pharmacist.
The off-shore company behind Babylon (Babylon Healthcare Services), is headed by Ali Parsa (ex Goldman Sachs banker and formerly CEO of Circle – a company with a very poor history of handling patients’ records). Parsa believes that eventually the Babylon app will be able to diagnose patients without the involvement of a doctor. It’s recently been targeting big companies such as banks, energy companies and media companies, offering group subscriptions to employees as a ‘perk’, and on the basis that ‘having a GP in their pocket’ will cut down the amount of time staff will take off work.
For those who can afford the fees, are basically healthy and can use the technology, these app-based systems that ‘put a GP in your pocket’ may seem very attractive. However, they also raise serious concerns.
The Care Quality Commission, for example, inspected Babylon in July 2017 and found that
- Prescribing decisions were not always made appropriately, or based on a thorough medical history and were not always made in line with national guidance and best practice.
- Information was not always shared with a patient’s usual GP to ensure prescribing was safe or appropriate.
- There was no system in place to give assurance that patients’ conditions were being appropriately monitored.
As Margaret McCartney points out in ‘The State of Medicine’, research shows that patients with an on-going condition, or multiple or complex needs will be better off with continuity of care and more holistic care. Push Doctor seems to agree – one of the co-founders of specialist investment company Oxford Capital (it raised £8.2 million to fund Push Doctor) is quoted as saying that the NHS should be left to the elderly and infirm, while time-poor 18-40 year olds use the new app-based services.
But as McCartney argues, given the shortage of GPs, these tech companies use market forces rather than patients’ need to determine access to GPs. These new systems offer GPs better pay and less stressful conditions, so are likely to drain doctors from an NHS that is already critically short of staff. This means other patients – those remaining solely with the NHS – may find they have a longer wait to see their GP in future.
GP at Hand
In addition to these companies offering private services to patients still registered with a more traditional GP practice, Babylon Healthcare Ltd is also involved in GP at Hand. This is an on-line GP service providing same-day NHS care for patients living or working across London as a replacement for their usual GP practice.
Patients register with the Lillie Road Medical Centre – a GP practice in west London – and book an appointment via a smart phone and (after going through the AI symptom check) are usually offered a video consultation within two hours, although those who need a face-to-face consultation have to visit one of six sites across London. There are no home visits.
Significantly, the service is not available to anyone – it’s not open to those with long-term or complex physical conditions, complex mental health problems, complex social needs, learning difficulties or safeguarding issues, or to pregnant women or people who are just old and frail: you could say that GP at Hand cherry picks healthy patients who are not going to need much in the way of care and so are less of a drain on profits.
And GP at Hand is not just failing to offer equal access to care. There are concerns that GP at Hand also undermines the very basis on which GP practices across the NHS stay financially stable. As one GP puts it:
“We get paid an average of £151.37 a year for each registered patient, regardless of age or health and no matter how many times they are seen. We cannot refuse to register patients or advise them to register elsewhere based on age, gender or disability. If my surgery put a list on its website telling the most ill people in our catchment area we weren’t suitable for them, NHS England would serve us a breach of contract notice and could close us down.”
The Lillie Road Medical Centre has seen its list of registered patients increase from 2,500 in April 2017 to 24,652 in March 2018, with 75% of patients coming from outside north-west London. Board papers for the Hammersmith and Fulham Clinical Commissioning Group (the CCG that funds the Lillie Road practice) raise concern that this rapid growth could drive up the CCG’s costs by at least £10 million, something not anticipated in their spending plans for 2018/19 that could result in the CCG failing to meet its statutory requirement to deliver financial balance.
When patients register with GP at Hand, they (often unknowingly) de-register from their current GP practice. The NHS is a social insurance system: in primary care, around 80% of patients registered with a GP practice will be reasonably well, and their funding helps to subsidise the care of the 20% of patients who are sick. But when patients register with GP at Hand, their funding follows them. And because GP at Hand cherry picks patients who are mostly well, it destabilises other GP practices, leaving them with less funding to cope with a greater proportion of sick patients. Put another way, GP at Hand diverts resources from those with the greatest health care need.