Sustainability of GP at Hand model questioned in major independent report

Babylon GP at Hand's controversial digital-first model may be unsustainable if rolled out across a wider population, even with a 'fundamental, large-scale redesign of primary care', a report suggests.

Smartphone consultation (Photo: Towfiqu Photography/Getty Images)
Smartphone consultation (Photo: Towfiqu Photography/Getty Images)

An independent report on the impact of GP at Hand on patients, the wider health service and the workforce - carried out by Ipsos Mori on behalf of the CCG hosting the service - was unable to conclude whether the service was affordable and sustainable in its current form.

It warned that the model required 'considerable numbers of GPs' to sustain and that a national rollout of digital-first services may need 'fundamental large-scale redesign of primary care services, which may require substantial changes in the way in which primary care is funded'.

Despite GPs working for the service - largely remotely, from home - reporting satisfaction with the work-life balance it offered, the report highlighted 'significant questions about possible transferability and scalability of the model to other areas and wider groups of patients'.

CQC rating

Findings from the report commissioned by Hammersmith and Fulham CCG come just days after the CQC published its first-ever rating of GP at Hand's digital service - with the service rated 'good' overall.

The ability for GPs to 'work part-time, flexibly and remotely, means that it is an attractive offer for some GPs with positive implications for recruitment and retention', the report found. Patients were also largely satisfied with the service - with the majority having 'actively chosen access over continuity of care'.

But the report warned that 'it is clear that the GP workforce required to deliver the service will need to continue to grow at a significant rate to support further expansion' - and that if large numbers of GPs moved to the service it would have 'implications for the size of the workforce available to work in traditional general practice'.

The report also highlighted that GP at Hand had attracted predominantly young, wealthy patients who use NHS services with above-average frequency despite being healthier than the average for their age.

Younger patients

A total of 94% of GP at Hand patients were aged under 45, the report found - and two thirds live in areas with 'high proportions of relatively affluent categories'. GP at Hand patients were also 'healthier than those at other practices in the CCG, even after adjusting for age', and appeared to be 'using the service more than might be expected given their age and health status'.

BMA GP committee chair Dr Richard Vautrey said the report - delayed since March - backed up concerns expressed by the BMA about GP at Hand. He warned: 'To sustain this pattern of demand the report concludes the service would need far more GPs than are currently working – something that would be unaffordable without the significant extra backing this service receives.

'This is therefore not primarily about the technology but a pattern of healthcare delivery with a focus on relatively affluent and healthier people having access to a service with a higher GP-to-patient ratio, which ultimately widens health inequalities for everyone else. While we'd all like a GP on hand every hour of the day, the wider system cannot deliver that without a massive increase in funding and workforce expansion.'

The Ipsos Mori report confirmed figures reported exclusively in March by GPonline showing that more than one in four patients who have signed up for the service have de-registered. It found that since July 2017 28% of patients who joined had left - compared with a London average of one in six.

Quality of care

Around half of patients who quit the service returned to their previous GP practice, the report found. Key reasons cited by patients who left the service were dissatisfaction with quality of care, wanting to book a face-to-face appointment without a digital appointment first, and a change in health needs.

Although the report found that 'continuity of care does appear to suffer in this model', it says that this 'is not perceived to be an issue by the majority of its current users who either don’t desire continuity of care, or have managed to achieve it to the extent that they do'.

But it adds: 'Taking these points together, it seems that the model meets the needs of a specific segment of the population for a limited set of needs. It raises questions about the extent to which the service is valid for a more diverse and multi-morbid population whose care needs may generally not be suited to the digital medium or who are entering the service with a relatively low level of activation.'

Despite the young, affluent, healthy profile of patients registered with the service, the report found they were 'historically higher users of A&E and 111 than would be expected' - and that their use of these other services had reduced after joining GP at Hand.

'This may suggest that the service makes a useful contribution to the health system, in terms of reducing inappropriate use of other services,' the report said - although it pointed out that 'it may be that joining any new practice has the same effect'.

Overall, GP at Hand uses around 124 GPs to support its registered list of more than 50,000 patients, the report says. These GPs 'tend to be younger and are therefore likely to be less experienced than the general GP workforce', with most working 'exclusively remotely from home one to two days per week, whilst also working somewhere else, often as locum GPs'.

Work-life balance

The report found that GPs were attracted to working for GP at Hand 'because it was seen to offer a better work-life balance than traditional practice, and for the chance to work in an innovative service'. These GPs also 'expressed frustrations about working in traditional general practice, particularly linked to long hours and increasing workloads'.

Doctors working for the service were 'particularly positive about the processes in place to monitor and develop their performance' and about support and development opportunities. Remote working meant GPs lost out on relationships with colleagues, but the fact that many of these GPs also worked elsewhere helped 'guard against feelings of isolation'.

The report highlighted concerns, however, that because GP at Hand doctors 'often live (and work) outside of the communities to whom they are providing care', there were 'implications for their understanding of the community and the local services'.

Babylon medical director Dr Matthew Noble said: 'This independent report shows that GP at Hand is loved by all types of patients as they can now access a GP when they need to. I’m particularly pleased that the report has shown how our GPs enjoy their work, aren’t becoming burned out and how our digital-first approach may even be a way of encouraging GPs to stay in the profession and to help recruit more doctors into general practice.

'The findings show Babylon GP at Hand isn’t just of great benefit to patients and GPs, it is also saving the NHS time and money. When you consider that the average A&E visit costs £160 and the average outpatient appointment £125 then you can see how quickly Babylon GP at Hand and digital-first services can have a positive impact for the NHS.'

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