Views And Reviews No Holds Barred

Margaret McCartney: General practice can’t just exclude sick people

BMJ 2017; 359 doi: (Published 09 November 2017) Cite this as: BMJ 2017;359:j5190

Re: Margaret McCartney: General practice can’t just exclude sick people

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

16 November 2017
Mobasher Butt
GP, Medical Director
West London