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GPs go forth

GP at Hand set to apply to be single network in 'destabilising' move

Exclusive Babylon GP at Hand is in the process of registering as its own primary care network, Pulse has learned. 

Babylon said it is 'well placed' to become a network and may include other 'like-minded' practices.

GP leaders have expressed concern over this move, which they say will ‘disrupt the system to the point of destruction’.

They are concerned that the digital-first service will breach the rule that networks must exist within local boundaries.

Currently, groups of practices are advised to cover 30,000-50,000 patients, but CCGs may sign off on proposals for networks serving a population over 50,000.

Pulse reported this week that GP at Hand has almost 50,000 patients registered, but only 10% of those patients are based in Hammersmith and Fulham.

Chief executive of Londonwide LMC Dr Michelle Drage said this move by Babylon will ‘destabilise all current NHS services in London.’

She said: ‘It looks like they intend to disrupt the system to the point of destruction, with the consequence of further destabilising all current NHS services in London as GP, community and hospital funding moves to covering people in clearly defined geographical areas.

‘In accordance with the Network DES, negotiated nationally between the BMA’s GP Committee and NHS England, commissioners have been clear to local GP practices that their networks must exist inside contiguous boundaries.

‘We ask the CCG, NHS England and the Secretary of State - who is a registered patient and public advocate for Babylon GP at Hand - will all GP practices and networks be governed by the same rule book?’

Pulse recently reported that Hammersmith and Fulham CCG are facing a £31.8m deficit from the growing patient list size with GP at Hand.

A spokesperson from Londonwide LMC told Pulse that there are currently six networks planned in the Hammersmith and Fulham area and that GP at Hand had not expressed any interest in joining those networks.

A Babylon GP at Hand spokesperson said: ‘With the strong links already formed with community providers, and nearly 50,000 registered patients, Babylon GP at Hand is well placed to be a primary care network.

‘This network may of course also include other practices that share the vision of highly accessible, high-quality care.’ 

He added: 'The NHS has called for primary care networks to make it easier for patients to see a GP and for GP practices to be open for longer – this is exactly what Babylon GP at Hand does, patients can see a GP, often within 30 minutes, 24 hours a day, 7 days per week, every day of the year.

'The NHS wants practices to share information and technology, make it easier to get advice from health professionals, book appointments online, have remote testing and use online consultations. They want to ensure that whoever you see in your area, the health professional has access to your medical history so they can give the care you need. In short, primary care networks are about improving care for patients, not restricting them, and Babylon GP at Hand does all of these things very well.'

The deadline to submit paperwork is 15 May and Babylon are on track to meet the deadline, Pulse understands.

A spokesperson from NHS Hammersmith and Fulham CCG said: ‘The practices within Hammersmith and Fulham CCG continue to have discussions about network configuration. As expected, some of the emerging networks are more defined at this point than others. As you will be aware the CCG has a facilitation role and we are encouraging practices to have discussions about form and function to ensure that the network criteria and aspirations for the five-year framework are met.

‘This includes the Babylon GP at Hand practice, and we will continue to facilitate discussion on network options with the practice, neighbouring practices, the Hammersmith and Fulham GP Federation and NHS England.’

The GPC have previously said the greenlight for the GP at Hand expansion to other cities before the independent review on the service was ‘simply beggars belief.’

Readers' comments (15)

  • To be fair their 'area' is just the area of the practice, which is within one local boundary. The practice can register out of area patients, just like any other practice in the entire country can.

    I am not a fan of Babylon - and I think the problem needs addressing.
    It needs addressing properly, by making sure the funding is appropriately linked to illness or workload rather than patient numbers. Babylon are not the only culprits, there are many practices who are driving up profits through poor care by driving up the number of patients per GP - and then not offering enough appointments to meet the demand.

    So in summary the network les is not the way to address the problem, just find a better way to do it.

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  • The issue is equity of access and bad discriminatory practice. The principle of the NHS is equity. Babylon does not provide equity of access and so is currently not working within the NHS ethos. Video consults themselves are a good idea as they are better and safer than a phone call.

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  • For CCG read PCN

    From patient advocate to gatekeeper: understanding the effects of the NHS reforms

    Clare Gerada
    Br J Gen Pract 2011; 61 (592): 655-656. DOI:

    For over two decades GPs have been encouraged to engage in the financial, as well as clinical responsibilities of health care. While it makes sense for GPs to be involved in health planning, such as expanding the number or location of surgeries and services, acquisition of new technology, and so forth, it does not make sense for GPs to spend their time negotiating contracts with other doctors, managers, and hospitals, and even less to bear financial risk for their expensively ill patients. Firstly it turns GPs into rationers of care and away from their professional role as patient advocates. Secondly, it does not save money. Experience with managed care in the US shows that it increases the need for administrators and managers. Finally, putting clinicians at financial risk does not improve quality.1

    Clinical commissioning groups (CGCs) are similar to North American health maintenance organisations (HMOs), with the UK government allocating resources to CGCs based on the number of enrollees (patients registered with constituent practices), from which secondary care services will be bought. Originally conceived as a way to pre-pay for preventive care in addition to acute and hospital care, not-for-profit HMOs were introduced in the 1970s.2 Despite their progressive origins, they were rapidly transformed in the 1990s into for-profit corporations.

    HMOs profited by avoiding sick patients in increasingly deceptive ways; for example, by cherry-picking the healthy, dumping high-cost patients from their plans (known as ‘recession’), and limiting referrals and treatments on financial rather than clinical grounds. This new breed of HMOs created opportunities to control medical care before it was delivered, diverting 20-30% of revenues to overhead and profits along the way.3

    HMOs, as with CGCs, will create perverse incentives, as well as placing barriers to joint working between primary and secondary care practitioners.


    While primary care physicians are put at financial risk to reduce care, specialists (in hospitals, any-qualified providers, and third sector specialists) will be dependent on the number of patients and intensity of services (treatments, imaging, hospital days) for their funding, not, as with the system pre-NHS market reforms, on grants from the national purse. Thus, as in the US, specialists will have an incentive to increase activity, inevitably leading to over treatment and over investigation in an attempt to increase revenue and pay their overheads (including staff wages).

    Thus, primary care physicians will be pitted against hospitals and other secondary care providers in a market-based scheme that diverts funding from clinical care to overheads and profits. The complexity of putting restrictions in place on who, where, when, and why patients can be referred; the implementation of referral management and gatekeeping systems; performance management and utilisation review; and even firing of practitioners with more than the expected number of expensively-ill patients, along with the many other functions that will be required of CGCs, will come at a high price. In practice, CGCs will have to hire new firms (the giant insurers from the US are already in line) to manage such a complex array of tasks, and based on the US experience, they may be expected to consume 20-30% of funds for their services.

    CGCs, as with HMOs, will implement risk-stratification systems, identifying potential high-cost patients and high utilisers of health services, whose care will be outsourced to third parties, such as disease management companies. Patients with complex comorbidities may find their care being managed by a multiplicity of disease management systems, all designed, not to improve their care, but to increase the management firm's profits. Care to the patient will be fragmented4 and continuity compromised due to the perverse funding arrangements. Mergers between different CGCs will be inevitable, as the unpredictability of ill-health (for example, small numbers of patients requiring high-cost treatment) takes its toll on the budgets of smaller CGCs, or worse still, CGCs will become bankrupt. GPs will become corporate employees, expected to perform according to rules dictated by the CGC hierarchy.


    CGCs will inevitably impose different schemes on participating practices and patients, with the move towards personal health budgets (vouchers for year-of-life care) and away from budgets based on geographical populations facilitating this. Fit, healthy, and younger patients will be targeted in the hope that their cost utilisations will be less, leaving more profit for the CGC, either to reinvest in clinical services, or as is currently proposed with the Health and Social Care Bill, to provide financial reward to the participating clinicians. As the new Act is removing Parliament's duty to provide a comprehensive health service, CGCs will be able to determine what services they provide as standard (that is, free-at the point of use), with other specialist services dependent on co-payments despite their disastrous consequences for care.

    Evidence from the US shows that co-payments reduce access to necessary care as much an unnecessary care, and, in the only randomised study in this area ever performed, disproportionately increased death rates among the poor and chronically ill.5 Furthermore, they increase bureaucracy and don't save money: the US has the highest cost-sharing in the world and also the highest healthcare costs.

    The NHS works. It produces some of the best health outcomes of any modern health system. It is a universal service, with risk pooling across the entire population. GPs are paid according to capitation, and financial incentives, where they exist, are to keep patients well. Before the market reforms of the 1980s, hospitals were paid a grant to cover their budgets, with no incentives to increase activity or maximise costs by up-coding or gaming. Rather than trying to implement the US's failed market-based model and put corporate profits and bureaucrats at the centre of our health system, the UK government should improve and protect the NHS and its achievements in providing health and security to our nation by ending the experiment with market-based care and focus on what matters to patients: continuity, access, caring, and coordination.

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  • What REALLY would work would be a national health service where care was rationed by clinicians being able to say "Sorry I don't think you need that" and patients not being able to DEMAND treatment. Not perfect, but reasonable. We are so scared of patient demand and the threat of complaints we bend over backwards offering everything a patient insists on which is crippling the NHS. Proper rationing, and support for clinicians who say no to patients, would be the best answer.

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  • interesting article from Clare - suprised about the parallels now as it was published 2011.
    as for support to say no - never going to happen

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  • GP@ Hand is in no way a network. It's supposed to be a collection of practices in a geographic area who collaboratively organise local services. How can you have a network of one(!) particularly when they're serving patients up to 45 minutes away? It makes a joke of the whole premise of PCNs.

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  • What will come next is offering patients registered with them the ability to 'top up' their care for certain services (first it will be physiological treatment, physiotherapy and fast access to specialists). This top up will be via a top-up insurance. To begin with everyone will feel winners - GPs will have more money, less work, and patients will think they have more care for only a little extra money per year. Then the down side. GPs will become production line doctors - patients removed to the NHS if they cost too much. We will all be losers except for Babylon. I worry about this - and its all made possible sadly through

    a) Tariff being the same for out of area and in area
    b) Ability too register out of area patients
    c) PCNs allowing for commissioning budgets to be held (primary and lucrative secondary care0
    d) PCNs not insisting [as I argued above] for geographical foot prints - only. No compromise

    I predicted all of this in 2010 when I became Chair.
    I asked Primary Care at DH - 'whats stopping a single handed GP registering 1 million patients on a single list, delivering care through a combination of digital [remote] and face to face done through a network of GPs located in pharmacists etc. I was told 'it could never happen'. I knew it could and there was nothing in the legislation to stop this. There still isn't.

    But it can be stopped if we get red lines in place

    a) Geographical only PCNs
    b) No top up 'co payments' allowed unless nationally sanctioned and therefore universal
    c) Reduce tariff for out of area patients to 10% of in-area
    d) robust governance of PCNs - including not allowing single providers


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  • Vinci Ho

    Interestingly , there is an interesting , analytical article on Sky News today about the digital/technology mentality of our honourable incumbent Health Secretary :

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  • This is nothing to do with Digital - digital will make AP a billionaire as he will sell it to highest bidder. The issue is the owner of GP@H will then own a massive GP list and with it the secondary and primary care budget. We worry about privatisation - its happening under our very noses and yet we cant seem to stop it.

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  • The answer my friends, is blowing in the wind.

    We need to ensure geographical foot prints for PCN's and Federations.

    We must integrate with secondary care - i.e. either create joint vehicles (with GPs as majority Board members) or find some other route and there must be a law that does not allow co-payments (unless universal applied).

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