Rebecca Rosen: GP at Hand and disruptive innovation in general practice provision

The launch of GP at Hand has triggered a mass of Twitter activity, much of which has focused on how much to pay for this tech-driven new service, given that GP at Hand suggest, at the NHS’s request, that a variety of patient groups with complex needs may be less appropriate for this service. 

There has been a fair bit of maths in the tweets, including whether being paid six times more to treat older people than working-age adults addresses the challenge to traditional GP practices if some of their (probably younger) patients move to GP at Hand.  

This misses the point. The majority of the population falls into the 15-64 age bands that attract lower funding. While this group is formed of mostly healthy adults (hence the lower payment), it contains many who move in and out of the kinds of illness and states of health that GP at Hand suggest are less appropriate for their service. Those who are pregnant or with a bout of depression are two of these groups.

It also contains people with ongoing lifestyle challenges that jeopardise health and which cannot be easily managed with apps—particularly drug and alcohol use. And those with undifferentiated symptoms and health anxieties who may be high users of services and drive higher overall costs (see below).

The Carr-Hill formula (which is used to calculate payment rates for GP services by adjusting registered patient numbers for characteristics such as age, sex, and deprivation) has never been ideal, but spread over a large population it can accommodate the concept of average use. GP at Hand suggests various members of the “mainly healthy adult” population segment with certain conditions and characteristics may be less appropriate for their service. This is the subgroup who use more services and therefore cost more. One Dutch study, for example, reported that depressed patients cost twice as much to care for in primary care as those who were not depressed.

So Twitter challenges about Carr-Hill adjustments miss the fundamental point that “cream-skimming” selected patients from within population segments leaves other practices to care for those from the same segment, for which there is evidence of higher cost.

This argument also works the other way around. The easy access and potential fragmentation of seeing the first available clinician in a queue-less system will create supply-induced demand (estimated in previous studies to be around 16 per cent) and may act as a magnet for people with health anxieties (estimated in one study at around 9 per cent of patients presenting with new symptoms) who book multiple appointments for the same problem. These patients might add to the cost of delivering GP at Hand—though not necessarily in a way that the NHS as a whole wants to encourage or pay for.  

And what of patients with undifferentiated symptoms who may well benefit from a period of continuity of care and the skills of medical generalism (called for in my previous blog)? Will GP at Hand GPs be able to develop the trust and deep contextual knowledge of patients and their families needed to reach a diagnosis where one can be found, or safely conclude that it is ok to hold a patient in the community without onward referral to other services? If not, the service may create additional cost to the NHS as a whole.

The introduction of GP at Hand speaks to enthusiasts for ‘segmenting’ general practice—breaking off chunks of care to be delivered to different population sub-groups in different ways. The questions outlined here about pricing, continuity and potential to undermine other forms of general practice highlight the risks associated with disrupting a healthcare ecosystem that is recognised to add value to the NHS as a whole.

Some people may be rubbing their hands with delight at the prospect of the sudden destabilisation of a traditional model of general practice. Frustrated for years by the inflexibility of the GMS contract, they could see this as an opportunity to force a new organisational model for GP services.

But these small businesses have proved remarkably cost effective in the last few years. Studies reported in The Lancet concluded that GP workload has increased 16 per cent over a period when funding decreased from 11 per cent to 8 per cent of the total NHS budget. It seems unlikely that any alternative organisational form that offers care to all comers could achieve the same, without so-called cream-skimming.

So, how should we cope with the pricing challenge in the short term, while we collect data to track the impact of GP at Hand on patient outcomes and the wider NHS?

Firstly, if it is suggested that complex and more costly patients are “less appropriate” for registering with GP at Hand, we should develop a new, lower payment rate for the remaining people who register with the service and are more likely to have self-limiting conditions requiring less follow up and GP time.

Secondly, policymakers could consider creating a short-term subsidy for practices that lose more than a certain number of patients to GP at Hand for the period while its impact is evaluated. While it would be undesirable to subsidise poor practices that patients happily deregister from when provided with an alternative, there is a real risk that many other practices would close with knock-on effects on safety and list closures in neighbouring clinics. Without some intervention to stabilise existing services, patient groups who it is suggested don’t register with GP at Hand may have nowhere else to register.

Thirdly, ensure that ongoing evaluation of GP at Hand and similar models takes a broad approach—looking at consultation rates, case mix, and onward referral to other services so that we can understand the impact of this new model on patients, providers of GP services, and on the wider NHS.

Fourthly, ensure that a full-cost evaluation of GP at Hand is undertaken so that any cross subsidies from the wider business that support the new service are transparent from the start, and onward referral rates to other services and the associated costs to the NHS can be understood.

Finally, we need to be clear about which aspects of quality are most important to us in general practice. There may be a long-term loss to patients if efforts to improve continuity and promote coordination between primary, community, and secondary care are weakened by pursuit of short-term gains in convenience.

Once we have this information, we’ll be in a better position to judge whether Carr-Hill needs a fundamental overhaul and whether disruptive innovators in GP provision are strengthening or weakening the NHS as a whole. 

Rebecca Rosen is a senior fellow in Health Policy at the Nuffield Trust and a General Practitioner in Greenwich. She is also an accredited public health specialist. Her current policy interests include integrated care, primary care, new organisational models for general practice and NHS commissioning. 

Competing interests: None declared.

A Nuffield Trust report on segmentation and value in general practice will be published in the new year.

Note: This piece originally referred to “the inflexibility of the GMC contract.” This was corrected on 1 December to the “GMS contract.”