Intended for healthcare professionals

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
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}

GP at Hand, an NHS general practice in west London, is offering to register patients for virtual consultations. It may also permanently destabilise English general practice.

One partner of GP at Hand is Mobasher Butt, medical director of the health IT company Babylon, and the practice uses the Babylon symptom checker app. This app, the practice says, gives patients “useful medical information and accurate triage advice.”1

Interesting, because it also says that “The GP at Hand practice shall not be responsible for the artificial intelligence symptom checker which is a separate service provided by Babylon via the App.”2 The results of a pilot study of this app in north London do not yet seem to be published. Babylon has claimed to have independent evidence of safety, but I’ve yet to see it.3 Babylon says that the app “enables your purchase of healthcare and other products sold by our third party product partners.”2

GP at Hand provides video call consultations for patients. If necessary, patients can arrange to be seen in person at one of several participating general practices. Its website says that the doctor may ask the patient to “perform simple checks, like feeling the glands on your neck.”1

Who is it for? GP at Hand says, “We deliver all the core NHS primary care services”4—but it then qualifies this by saying that “the NHS has suggested that the service may however be less appropriate” for people with learning difficulties, dementia, “complex physical, psychological, and social needs,” “complex mental health conditions,” drug dependence, or terminal illness, as well as for pregnant women and frail older people.5

It’s very odd for the NHS to allow a contract that enacts exclusion of people with these conditions by design. In fact, the NHS’s general medical services contract specifies that refusing people registration on the basis of illness or pregnancy is not allowed.6 So why this exception?

GPs are paid in a stupid way, such that we receive a flat rate of around £150 per patient per year. No matter how many home visits you have, no matter how many drugs are prescribed to you, the rate is about the same. The Quality and Outcomes Framework (now gone in Scotland) attempted to pay for specific disease management, and other fees and services are tangled in there, but that’s the essence.

Life could be made much easier for general practice by declining more complicated patients. But it would not be general practice

The people who barely need to see a doctor balance out those who need multiple visits. General practice needs a mix of patients—some with complex problems, some without—to ensure that it’s funded properly. Life could be made much easier for general practice by declining to take on our more complicated, and sicker, patients. But it would not be general practice.

What, then, would it be? Small groups of GPs running and working in their practices for their whole career are not businesses in the true sense. I don’t advertise or actively compete with my neighbouring practices to take their patients. If I were a business I’d concentrate on well people, offer them things they didn’t need—but were pleased and grateful to be offered—and avoid sick and poor people, for they create a lot of work. But the NHS distributes care on the basis of need: it cannot aspire to business principles.

This destabilisation has come from the top. The Patient Choice Scheme, piloted in 2012-13,7 allows patients to register with a GP while living outside their catchment area. However, the BMA has “strongly advised” practices not to register patients under this regulation, as there’s no universal arrangement for urgent GP care where the patient lives (NHS England “does not currently consider it appropriate to register out of area patients under the new regulation as, until services for patients that register out of area are confirmed to be in place nationally, the criteria to set aside home visits cannot be met.”7)

Until now, the need for urgent GP care for patients who are out of their GP’s area has been met by temporarily registering them and visiting as needed. GP at Hand has got around this, and the corporatisation of general practice—where chains of practices sign up to a private/NHS hybrid—is rapidly descending on us. Sadly, young GPs will not know any other way.

When the NHS was born, general practice was left outside the NHS to contract to it while hospital consultants were brought inside. This has left unjustifiable loopholes and plenty of scope for general practice to be tied in knots—or, as here, wilfully strangled.