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Editorials

General practice by smartphone

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4713 (Published 24 July 2019) Cite this as: BMJ 2019;366:l4713
  1. Martin Roland, emeritus professor of health services research
  1. University of Cambridge, Cambridge, UK
  1. mr108{at}cam.ac.uk

GP at Hand risks destabilising care for patients with the greatest needs

Matt Hancock, the secretary of state for health, believes that embracing new technology is key to making the NHS the best healthcare system in the world.1 One company, Babylon, is testing this to the limits by establishing an NHS general practice in London, GP at Hand, where almost all initial contacts are through smartphone consultations: only if the problem cannot be sorted out on the phone do patients travel to one of five clinics in London for a face-to-face consultation.

For most patients, GP at Hand’s doctors are unable to visit at home or in nursing homes. Some fear that the new service will fatally undermine traditional general practice, leaving GPs with sick and complex patients to look after as fit young patients move to GP at Hand. Indeed, the new service has proved popular, with over 50 000 patients now enrolled.

Independent evaluation

Answers to some questions about GP at Hand come from a recent independent evaluation.2

The evaluation confirms that GP at Hand caters principally to a healthy, affluent, young, and working population: 98.5% of patients are aged 20-64,3 two thirds live in affluent areas, and only 0.1% are cared for by the service’s “chronic care team.”

Registered patients found GP at Hand convenient and used the service more often than they did their previous practice, also reducing their previous high use of other urgent NHS services. However, a quarter of GP at Hand’s newly registered patients move back to a conventional NHS practice, many within two weeks.

The most recent inspection by the Care Quality Commission rated GP at Hand as “good” in most areas but found it needed to improve its performance in cervical cytology (64% coverage) and childhood immunisation (73-84% coverage).4 The service clearly meets the needs of some patients who value a fast convenient service, but it falls short of providing comprehensive proactive primary care.

The use of smartphones to provide medical care is not new and has proved effective in countries with few doctors or very rural populations. For example, Babylon provides smartphone based healthcare to over two million patients in Rwanda, as does Halodoc for two million members in Indonesia. In high income countries, specialists have used smartphone consultations to follow up patients with a wide range of conditions, from postoperative care and diabetes to end-of-life care.567 Indeed, more than half of Kaiser Permanente’s physician contacts in the US are now done virtually.8

But could—and should—smartphone consultations replace traditional approaches to accessing primary care in developed countries, and will Babylon’s GP at Hand make the NHS’s current crisis in primary care better or worse? The crisis stems from a combination of the increasing difficulty that patients experience accessing their GP, decreasing numbers of GPs, and an increasing workload, especially of older patients and patients with complex medical problems.9

Questions over funding

Phone and video consultations have much to offer as an adjunct to conventional primary and secondary care, and Babylon’s entry into the NHS is already stimulating other practices to widen the range of services they offer. There are fears that Babylon will make the shortage of GPs worse, although the evaluation found that GP at Hand enabled some GPs to increase their NHS work, finding it convenient to work part time from home alongside their work in conventional NHS practices.

However, the current NHS funding formula does not adjust adequately for the costs of providing a comprehensive primary care service, and the NHS needs urgently to review its arrangements that have allowed a private company to cream off fit young patients from existing NHS practices. If the GP at Hand model became widespread, it would risk destabilising care for patients with the greatest needs and those who need regular proactive care.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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