Margaret McCartney: General practice can’t just exclude sick peopleBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5190 (Published 09 November 2017) Cite this as: BMJ 2017;359:j5190
All rapid responses
The issue remains that GP at Hand is using Babylon technology, Dr Butt is the medical director of Babylon Health, and the results of the pilot of the app which Gp at Hand is using, and which is ‘powered by Babylon’ has not been published or independently verified.
Dr Butt asks if I would care for a patient with a severe learning disability by phone. Of course, when appropriate. The use of phone appointments is often useful for patients and families and carers of people with a severe learning disability, but critically it is not our only method of consultation. I would also hope that over a period of time family members and carers will become known to us. GP at Hand do say that they can see patients in one of their affiliated surgeries if patients need to be seen face to face. So why is GP at Hand having to advise that patients with certain conditions should 'seek advice' before registering? A GP service, to be commissioned by the NHS, should surely be what is needed by all - including and especially the most vulnerable patients.
I was taught over two decades ago about the 80/20 rule - 20% of our patients need 80% of the work. There is indeed some weighting within the Carr Hill formula, which calculates workload according to proxy measures, such as file opening and closing and coding. (1) This does not take into account prescription signing, letter reading, filing and actions, concurrent consultations (eg doctor being asked to see a patient already in with another professional), is likely to underestimate the impact of house calls on many practices, does not account for palliative care or child protection, discussion and advice with our other team members, or the correspondence involved with dealing sorting out, for example, the poor quality of Atos medical assessments. It has long been known that the formula has not taken account of deprivation and that consultation rates rise with deprivation but funding does not (2,3) The fact that GP surgeries are closing citing inadequate funding would suggest that funding is not meeting needs to maintain, never mind expand services (4). Most practices supply services based on funding received for a mix of patients. Get rid of the mix, and the usual basis for funding collapses.
Proven technology should be used in the NHS. I welcome evidence based, safe tech which reduces health inequalities, increases access based on need and resists over medicalisation. I don't think this is it.
Competing interests: I wrote the article
Babylon continue to deny that their GP at hand technology will not destabilise other general practices by “cherry picking” younger, fitter patients. They rightly point out that the payment under the Carhill formula is weighted for age, however, it is still a fact that GPs, despite that the per capita payment for younger patients is lower, rely on these patients to cross subsidise more complex patients. The GP at hand app will undermine this cross subsidy, which is fundamental to the whole NHS.
They say that the list of conditions is not a list of exclusions, merely good practice to inform these patients that they may be better registered elsewhere. It is not difficult to see how patients will interpret this. Time will tell whether the sick and complex feel that they will get a better service from the GP at Hand technology if they register and stay registered with the service. Whatever Babylon’s protestations to the contrary it seems likely that this is a service that will benefit younger patients with simple conditions and that “cherry picking” is inevitable.
Competing interests: No competing interests
1. The babylon app has not been piloted in North London. babylon technology powers an NHS 111 app that is being piloted in North London. The decision to publish the evaluation results for all NHS 111 online pilots lies with NHS England. This pilot is completely independent of the GP at Hand service and has no relevance to this article.
2. GP at Hand is a service for everyone living within our initial London eligibility area. NHS England policy requires all practices registering out-of-area patients under the “Choice of GP practice” policy to assess whether it is clinically appropriate to register the patient (1). We do this by offering advice to patients interested in joining the digital GP at Hand service. NHS England have provided us with some examples of conditions where, to be prudent, they feel it would be sensible for a patient to seek advice before registering. This is categorically not a list of exclusions.
In the rare cases where an individual’s health needs mean they are not suitable for a digital-first service, they have the full choice to register at any traditional practice with an open list. This is simply responsible practice that makes sure the specific needs of patients are being put first at all times and they get the best and most appropriate care for their needs.
I notice your own practice in Scotland offers telephone consultations for “when you don't need to be examined, especially for longer term follow up of conditions, or where you know what the problem is likely to be, e.g. a urine infection” (2) . If a patient in your practice with severe learning difficulties asked if this was an appropriate method of care for them, as a responsible practitioner, what would you advise?
3. You suggest our service will destabilise general practice by diverting resources away from other practices. Our service is run under a GMS contract. The GMS contract sum is largely determined by the Carr-Hill formula (3) , which generates a weighted patient list according to a set of calculations about the expected workload generated by a patient, including factors of age, sex and additional needs of patients. This translates to more funding for registered patients who are older and less funding for younger (and hence on average healthier) patients. As NHS Digital sets out:
“Global sum makes up the bulk of payments to practices, and allocates funding in accordance with the Carr-Hill formula. This formula takes into consideration, along with other practice characteristics, individual patients' age, gender and health conditions and calculates a "weighted" count of patients according to need. This means that two practices with the same number of patients may have very different weighted patient numbers due to widely varying patient characteristics and health conditions, and as a result, these practices which may seem to be similar in terms of list size, could receive very different levels of funding.” (4)
So to suggest we are diverting funding away by only taking on younger patients is again incorrect. I would urge you to gain a better understanding of the formula and how GPs are paid to avoid misleading BMJ readers, and to correct your article once you have done this.
As an NHS GP partner, I know the increasing pressures GPs and the NHS is under. The plain fact is, if we are going to continue meeting the ever-increasing demands on our NHS whilst continuing to deliver first class care, we have to leverage technology and innovation, like almost every other industry has. I am proud that it’s our own NHS that is leading the way in harnessing new technology to make healthcare more easily accessible to patients. I would hope that fellow GPs could commend those trying to advance new technologies to the benefit of patients and the health service alike rather than pitching ideological battles against them.
Dr Mobasher Butt
Competing interests: Partner at GP at Hand