Intended for healthcare professionals

Views And Reviews

Are disruptive innovators in GP provision strengthening or weakening the NHS?

BMJ 2017; 359 doi: (Published 29 November 2017) Cite this as: BMJ 2017;359:j5470
  1. Rebecca Rosen, GP1
  1. 1Greenwich, London, UK
  2. 2Nuffield Trust, UK
  1. rebecca.rosen{at}

GP at Hand speaks to enthusiasts for “segmenting” general practice

The launch of GP at Hand has triggered a mass of Twitter activity, much of which has focused on the cost of this tech driven new service. GP at Hand suggest, at the NHS’s request, that the service maybe not be appropriate for patients with complex needs.

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 will tackle GP at Hand’s challenge to traditional GP practices if some of their (probably younger) patients move to the app.

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 say 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—particularly drug and alcohol use—who cannot easily be managed with apps, as well as those with undifferentiated symptoms and health anxieties who may be frequent users of services and drive higher overall costs.

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 average use. Those of the “mainly healthy adult” population with certain conditions and characteristics that GP at Hand say may be less appropriate for their service are 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 to Carr-Hill adjustments miss the fundamental point—skimming selected patients from within population segments will leave other practices to care for those from the same segment for whom there is evidence of higher cost.

This argument also works the other way around, however. The queueless system will create demand induced by supply (estimated in previous studies to be around 16%) and may act as a magnet for people with health anxieties (estimated to be around 9% of patients presenting with new symptoms) who book multiple appointments for the same problem. These patients could add to the cost of delivering GP at Hand—though not necessarily in a way that the NHS wants to encourage or pay for.

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. Questions about pricing, continuity, and potential to undermine other forms of general practice highlight the risks of 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 destabilisation of the traditional model of general practice. Frustrated by the inflexibility of the GMS contract, they could see this as an opportunity to force a new model for GP services.

But traditional general practices have proved remarkably cost effective in the past few years. Studies reported in the Lancet concluded that GP workload has increased by 16% over a period when funding decreased from 11% to 8% of the total NHS budget. It seems unlikely that any alternative organisational form that offers care to all comers could achieve the same.

We need to collect data to track the impact of GP at Hand on patient outcomes and the wider NHS. Once we have this information, we’ll be in a better position to judge whether Carr-Hill needs an overhaul and whether disruptive innovators in GP provision are strengthening or weakening the NHS as a whole.


  • Competing interests: None declared.

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