General practice in Tower Hamlets, like everywhere else in England, is struggling to survive. As the NHS endures the most prolonged squeeze in its history the proportion of the budget allocated to general practice has fallen from 9.6% in 2005/06 to 7.9% in 2016/17.
GPs are retiring early and young doctors are not choosing general practice as a career. In November 2016 84% of GPs said that their workload was undermining their ability to provide safe patient care.
The advent of GP at Hand can only make this situation worse, if not for themselves, then for most other practices and their patients. GP at Hand is an NHS service, supported by Babylon technology. It is run by Dr Jeffries and partners of Lillie Road Medical Centre, Hammersmith, West London.
Its selling point is that patients can be seen at their convenience for an internet consultation. They also have a small number of locations where they can provide a face to face consultation should it be necessary. One of these places is within an NHS Health Centre in Tower Hamlets, in the shadow of Canary Wharf.
Patients have returned to their local GP only to find they have been de-registered
Patients who register with GP at Hand are told that they will be able to book an appointment in seconds and see an NHS doctor in minutes. What is less clear to patients is that they will no longer be registered with their existing, local GP surgery and in reality lose comprehensive local health services provided by local GPs. We know this, as we have faced complaints from patients here in Tower Hamlets when they have returned to their local GP, only to find that they have been de-registered and signed on with the practice in Lillie Road.
GP at Hand operates by utilising a clause in the GP contract, introduced in January 2015, which allows GP practices in England to register new patients who live outside their practice boundary area. The Government brought this in under its policy promoting patient choice. Some patients may find it more convenient to see a GP near to where they work rather than where they live, however the consequences of this arrangement threaten the risk-sharing on which the NHS has relied for decades. The service appeals to younger, internet-savvy patients. Registration data show that in the first two months of GP at Hand’s operation 10,051 (90%) of the 11,147 patients who signed up were aged between 20 and 44 years old.
In Tower Hamlets we already have a borough-wide online consultation offer for local patients. We have streamlined our registration processes for local people, and have already been working on a local service that utilises this new technology to respond to the demands of a mobile, online generation. We are not opposed to technology where it is appropriate and actively promote it where there is evidence that it is effective. However, we cannot support this initiative, which threatens to destabilise traditional general practice, by attracting the younger, fitter patients who require infrequent, episodic care, leaving the more complex to their local GP.
Whatever the intentions of Dr Jeffries and partners there is no doubt that the consequences will be the diversion of funding from the patient’s existing local practices and patients with complex needs, terminal care and disabilities, to the Lillie Road Medical Centre in Hammersmith.
We also believe that a service that disproportionately signs on the least vulnerable and frail patients is fundamentally against the founding principles of the NHS and its constitution. It amounts to indirect discrimination against the most vulnerable in our society.
Funding will also be diverted from the CCG in which the patient lives to Hammersmith and Fulham CCG, because CCG funding, to provide NHS hospital and community services for all of us, is based on the number of patients registered with a GP in the geographical area covered by the CCG.
Tower Hamlets is one of the most deprived boroughs in the country. Despite this, we manage to provide excellent care to our patients with some of the best outcomes nationally. We have achieved this through working together across practices, having a collective ethos and a common goal to improve population health. We are renowned nationally for our work on social prescribing, integrated care and outcomes, including the best blood pressure and cholesterol control in the country in patients with heart disease and diabetes with evidence of significant reduction in heart attacks, strokes and diabetic complications. We see no evidence of GP at Hand engagement in all the local processes, training and quality improvement that has made this happen.
We rely, as do all NHS GP practices, on risk pooling and the cross subsidy that the capitation fee for younger fitter patients, who consult less often, provides to care for the more complex and elderly. Operating models like GP at Hand threaten this system and risk diverting resources away from those who need them most to those who need them least – a modern day version of Julian Tudor-Hart’s Inverse Care Law.
General practice has been said by the Health Secretary to be the Jewel in the Crown of the NHS. We urge him to ensure that GP@ hand provides the same comprehensive service for patients that local general practices do and amend the out of area registration clause so that it is not able to be used to destabilise general practice thereby limiting the services available for registered patients.
Dr Simon Brownleader is chair of Tower Hamlets GP Care Group, Dr Sam Everington is chair of Tower Hamlets CCG and Dr Jackie Applebee is chair of Tower Hamlets LMC
GP at hand response:
‘It is high time that everyone respected people’s right to choose the NHS GP service that works best for them. That’s what the law, and the NHS contract for primary medical services, requires. The reality is that patients and GPs are flocking to babylon-supported services because they recognise the potential that high quality, digital-first 24/7 NHS GP services brings – to patients and to doctors.
‘200 GPs have already joined babylon, with 95% of those surveyed saying “Usually, I can manage the amount of my work well”. In comparison, the BMA showed in 2016 that 84% of GPs across the NHS reported that workload pressures are either “unmanageable” or “excessive” and having a direct impact on the quality and safety of the care they deliver to patients.
‘A small number of powerful people, with strong vested interests in protecting their own finances and ways of working, are putting their needs ahead of people’s right to choose. As part of doing so, there is a deliberate spread of misinformation – in particular around how NHS General Practices are funded for the patients on their list.
‘We encourage all readers of Pulse to look at the facts for themselves, by reading this briefing on NHS general practice funding. If funding per patient was really a single figure, then why did practices with lists where 0-20% of patients are 15-44 years old receive an average of £191 per patient in 2016/17, whereas those where 15-44 year olds comprised 80-100% of their list received an average of £96 per patient – almost exactly half as much?
‘It is equally misleading to suggest that it is not made clear to patients that they will be removed from their local practice list. Every GP at hand member receives very clear information upon sign-up that they will be de-registering from their current NHS practice. The following copy is prominent, and must be completed by all registrants:
“By confirming, you are consenting to leave your current NHS GP practice. You are free to change your NHS GP practice at any time.”
Plus ticking a box which says :
[ ]I agree to switch my registered GP practice.
‘It is particularly disappointing that those behind today’s letter fail to understand how important a 24/7, highly accessible service is to people of all ages who circumstances make them more vulnerable. From sex workers to those sleeping rough to people working low-paid, zero hours, unsociable shifts that change from day to day, the advantages of knowing they will be able to book and have a NHS GP appointment at a time that suits them, without fear of judgement, should be clear to all.’