Board papers from Hammersmith and Fulham CCG, published ahead of its primary care commissioning committee's meeting next week, show that GP at Hand submitted a request on 22 June 2018 to ‘vary their sub-contracting arrangement’ by adding a site in Birmingham. The site proposed is owned by Badger Medical Limited, which provides GP out-of-hours services in the city.
However, Birmingham and Solihull CCG formally objected to the contract variation ‘on the grounds of patient safety’, in a letter from its chief executive Paul Jennings to Hammersmith and Fulham CCG.
The letter raised concerns about the ability of GP at Hand to integrate with locally agreed pathways and said Birmingham and Solihull CCG would need extra assurances about how the service would remain ‘safe and effective around safeguarding issues, medicines management and delivery of local policies as well as dealing with complex patients.’
'The overall assurance framework is not yet robust or tested for a national service to be delivered from a single practice outside of Birmingham,' the letter added. Mr Jennings also said the proposal could ‘significantly de-stabilise a number of local practices.’
The Hammersmith and Fulham CCG board papers concluded that ‘there is evidence of concern regarding the risk to patient safety' and recommended an objection to the move ‘at this stage’.
The papers said that the CCG would need further information from GP at Hand to provide assurances on the safety of patients in five areas, including clinical capacity, clinical leadership and governance and knowledge of local pathways, ‘for any objection to be lifted'.
The papers also said: 'Birmingham and Solihull’s point regarding the lack of a robust assurance framework to test a service provided in different parts of the country from a single practice in London, has been noted and further discussion is currently taking place with colleagues across regions in England about how this may be achieved.' This raises the prospect that GP at Hand could expand elsewhere in the country once such a framework is in place.
A GP at Hand spokesperson said that it was 'surprised and disappointed' by the board papers. The spokesperson said GP at Hand had provided detailed assurances about the clincal safety of its service, adding that it was able to deliver safety levels 'far higher than traditional general practice.'
GP at Hand also said there were several inaccuracies in the papers, which it would be writing to the CCG to correct.
GP at Hand expansion
The board papers reveal that the arrangement proposed would mean that patients in Birmingham who registered with GP at Hand would become the responsibility of Hammersmith and Fulham CCG.
GP at Hand had said that patients in Birmingham would be able to register with them if they lived or worked within 30-40 minutes of the new site, although they did not provide a detailed definition of this, the board papers revealed.
The papers said that GP at Hand had not ‘fully described in detail or given assurance of the management, governance, clinical leadership structures and how they will work in practice now the model has expanded to another part of the country.’
However, GP at Hand had confirmed there would be a dedicated lead for all clinical and admin matters relating to patients living in Birmingham, the papers said, and that it would ‘"prudently" manage the number of Birmingham residents registering with the service in the early stages… to enable them to manage any challenges they encounter.'
Impact of GP at Hand
Patients who register with GP at Hand are required to quit their existing practice and sign up as out-of-area patients with the Lillie Road practice in south west London, which hosts the service. Patients who sign up can receive video consultations remotely, or face-to-face consultations if needed at locations around London.
Last month, Ipsos Mori was handed a £250,000 contract to investigate the impact of GP at Hand. Initial findings are due this autumn, with a final report expected by March 2019.
In his letter to Hammersmith and Fulham CCG, Mr Jennings requested that GP at Hand's plan to expand into Birmingham should be 'refused until this work has reported'.
A spokesperson from GP at Hand said: 'We are surprised and disappointed by the paper to the Hammersmith and Fulham CCG committee, having provided detailed assurances about the clinical safety of our service - including its expansion to Birmingham.
'The GP at Hand service has already been subjected to more scrutiny than any other practice. For example, there is an ongoing NHS clinical review of the GP at Hand service led by senior NHS England doctors, which continues to provide assurance about the service. With immediate 24/7 access to GPs, fully-recorded consultations and high levels of staff motivation and engagement, safety levels far higher than traditional general practice are able to be delivered.
'The paper contains several factual inaccuracies, which we will of course be writing to the CCG to correct, as well as providing explicit confirmation on the points raised in the paper. Most concerningly, the lack of a commissioning "assurance framework" is cited as a major reason for not approving the expansion.
'Your readers, and the public at large, will want to know why commissioners have been so slow to put such a framework in place, given GP at Hand’s intention to expand has been widely known and reported for more than six months. People may speculate as to whether this is down to a lack of preparation, or the vested interests of a few seeking to block the expansion of GP at Hand for their own financial benefit or ideological views.
'The reality is that patients and GPs are flocking to GP at Hand because they recognise the potential that high quality, digital-first 24/7 NHS GP services bring. The 200 GPs who have already joined Babylon do so because they are treated with respect and not put under the levels of pressure all too common in other practices.'