Online GP consultations threaten to create a two-tier healthcare system

Take of these and I’ll see you in the morning. baranq/Shutterstock.com

Online GP consultations threaten to create a two-tier healthcare system

GP at Hand is a medical practice in London with a difference. Unlike a traditional practice, eligible patients can register online in three minutes and have a video consultation on their smartphone with a GP within two hours. Great for smartphone-owning commuters who struggle to fit a daytime GP appointment around work, but how will it affect those of us who still want to see our usual GP face-to-face?

GP at Hand is a free app that offers most of the services of a traditional practice to those who are eligible to register. Run under a contract with the NHS, GP at Hand is essentially a large practice that does most of its consulting online.

Currently, to be eligible to register for the service, patients must live or work within 30 minutes of the physical location of the practice building. You can also register if you work in central London. Although consultations are carried out online, initially, in some circumstances the patient will be required to be seen face-to-face.

The health secretary, Matt Hancock, recently revealed that he is one of the roughly 20,000 patients registered with the service. He described it as “brilliant”. Overall, patients rate the service very highly.

Although GP at Hand is a convenient way for people to quickly see a GP, we don’t know how safe it is for patients, or what impact it will have on other services, or what the long-term costs are.

Recent research shows that maintaining a relationship with the same doctor is associated with lower death rates in patients. Seeing the same GP has also been shown to decrease the number of specialist referrals made, make it more likely that the patient will follow medical advice, increase patient satisfaction and cut costs for the NHS.

The traditional model of general practice, where patients see the same GP, or GPs, for many years, is at odds with an on-demand service provided via an app. While the doctors that work for GP at Hand will come from a particular pool, and GP at Hand suggests that it may be possible to request the same GP, given the number of users and waiting times, it is unlikely that continuity of care will be maintained between consultations.

Patients with minor problems may value convenience over continuity, but the opposite is true when they have a new health problem they’re uncertain about. By moving funds and staff from the old system to the untested new one, choice and convenience are prioritised over the traditional doctor-patient relationship.

GP at Hand is funded by the NHS using the same arrangement as traditional surgeries. Essentially, practices receive most of their income from a payment for each patient that is on their books, whether or not they have to see or treat them.

Demand and supply

So why is it so hard to see a GP in the UK, and why are large numbers of eligible patients opting for GP at Hand? Ultimately, it is because demand for services outstrips supply.

There is an increasing demand for GP appointments and not enough doctors to meet the rise in demand. Driving this is the fact that the proportion of NHS money going to general practice is falling, and the NHS is failing to recruit and retain GPs.

If a doctor is recruited to work for GP at Hand, it is likely they will be taken from the pool of GPs that are available to work in other practices. In theory, a GP can work for more than one practice or service. In reality, all types of primary care providers are struggling to recruit GPs. GP at Hand does not create a larger primary care workforce, it just helps to rearrange deck chairs on the NHS Titanic.

Is it making primary care more efficient and cost effective? Perhaps for the patient, but probably not for the NHS; there is not enough evidence, yet. Also, more work needs to be done to find out if this service will simply cater for the worried well, creating unnecessary demand.

More worrying is the financial effect apps like GP at Hand may have on existing practices. When a patient registers with GP at Hand, they are deregistered from their previous practice. The NHS payment for having a registered patient moves from their traditional practice to GP at Hand, and so a probably underfunded, overworked GP practice loses one of their more straightforward patients and the payment that comes with them.

Many GP practices are struggling to stay afloat. GP at Hand will cherry-pick straightforward patients and their funding, and leave struggling practices to deal with patients with time-consuming, complex conditions.

Health secretary, Matt Hancock. Andy Rain/EPA

Circumstances change

I don’t doubt that GP at Hand will be beneficial for some patients. These patients are likely to be younger, healthier, well-educated people who see a GP once or twice a year for mostly acute problems, such as knee pain or tonsillitis. But let us not forget that we all get older, our social circumstances and health change, we develop long-term conditions, and we may no longer be right for an app-based service.

I would argue that this is when we need general practice the most. As the GP at Hand fact sheet explains, patients “with complex needs may be advised to register elsewhere”. As a patient with complex health needs, we may become less concerned with convenience and more concerned with seeing someone with whom we have a relationship, someone who understands the complex interplay of our medical problems, social circumstances and personal psychology.

If we fund and resource an untested system for mostly well patients at the expense of a struggling system that works, it will be the elderly, the poor and the sick who suffer.

I am not against the use of new technology in general practice or video consulting per se, but without thorough evaluation of its impact on other services, extra resources and careful planning, we will increase health inequality and sleepwalk into a two-tier primary care system: a technology-based, consumer-driven service for healthy patients, and a further under-resourced traditional GP service for those that need help, and for whom circumstance has relegated from the top tier.

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