Digital services: primary numbers

In recent years, general practice has struggled to meet patient demand, while at the same time facing calls to make appointment times less rigid and more in keeping with a 24/7 society. There has been some success with recruitment to increase capacity, but to an extent this has been nullified by retirements. And while there have been extended opening hours programmes, these have further stretched the GP workforce and appear to have failed to satisfy demand.

Alternative providers in the shape of online practices have stepped into this landscape, aiming to improve access and convenience by, for example, offering video or phone consultations. Appointments are often offered within hours of a patient’s request, whereas it can take days in traditional practices.

The new providers have been backed by the NHS in England and the Department of Health and Social Care. According to the NHS long-term plan, the NHS will offer a digital-first option for most patients – by 2023/24 every patient in England will be able to access a digital-first primary care service, it says.

In some cases, the digital-first services are an extension of existing GP practices, while in others they are new online practices. The latter – in the shape of Babylon’s GP at Hand – has been high profile, registering more than 60,000 patients in London.

But the development of the online model has led to a number of concerns. Would technology-based primary care attract mainly younger, more healthy individuals, leaving traditional practices to tend to the old and chronically ill? Could the finances of a CCG be destabilised if there is an influx of patients from outside its area registering with the new providers? In the case of GP at Hand in London, this was potentially the case until NHS England agreed to intervene financially.

GP at Hand

GP at Hand in London is based in the area covered by Hammersmith and Fulham Clinical Commissioning Group, but only around 5,000 of the provider’s 60,000 patients are from the CCG’s area.

According to the finance report tabled at the CCG’s September meeting, at month 4 the year-to-date costs associated with GP at Hand were £6.2m, with a forecast outturn of £19.1m, excluding further list growth. The digital-first provider had an impact on various budget lines – mainly acute and delegated primary care – but this will be fully mitigated centrally in 2019/20 through an agreement with NHS England. The CCG is working with NHS England on a mechanism designed to recover costs from other CCGs.

In May, an independent report for the CCG evaluating GP at Hand found that its patients were generally younger and healthier than an average practice, though they did use the service more than expected.

The report questioned whether the current method of funding GP practices – the global sum allocation or Carr-Hill formula – was appropriate in calculating funding for online services. The formula calculates payments to practices based on its registered patients, adjusted for a number of factors such as age, gender, practice list turnover, additional needs, a market forces factor and rurality.

Though its information on the cost of a digital-first practice was limited, the evaluation said the Carr-Hill formula may not work well in establishing the costs of providing digital-first care – and therefore the appropriate funding levels. It also concluded that the impact on the finances of GP practices and CCGs in other areas of London was minimal as the GP at Hand patients had previously been registered with a large number of CCGs and practices.

Re-examining the rules

NHS England and NHS Improvement have recognised that practice registration, funding and contracting rules had to be re-examined, and they consulted on a number of measures earlier this year. The finalised policy emerged in September. It addresses two major issues – how practices are funded and how CCG allocations will be adjusted to reflect movements of patients between CCGs. The policy seeks to address a range of issues, including preventing problems that can arise when a CCG sees an outflow of patients to a digital-first practice based in another CCG.

NHS England is keen that physical services remain when this occurs. Once a practice registers more than 1,000 patients from another CCG (CCG A), its main contract will be disaggregated. The practice will be awarded a new APMS (alternative provider medical services) contract by CCG A. This would allow them to offer patients normal physical practice services, alongside its digital-first programme.

However, NHS England and NHS Improvement do not believe many APMS contracts will be triggered. Based on September 2019 data, an internal NHS England analysis found that only one digital-first provider would trigger the threshold – Babylon GP at Hand in Hammersmith and Fulham CCG, creating 16 APMS contracts in other CCGs.

If the number of patients registered from a CCG remains under the 1,000-patient threshold, the digital-first practice will be paid under current out-of-area rules. Under these rules, practices receive the same funding and other payments (for enhanced services, for example) as they would for other registered patients.

Ed Waller, NHS England director of primary care strategy and contracts, told the September NHS England and NHS Improvement board meeting that the consultation questioned whether out-of-area patients should have less value in the GP funding formula than in-area patients. The reason is that the obligation to provide home visits is removed for out-of-area patients. ‘We are clear that the proportionality of rejigging the entire NHS primary care allocation system for a small number of patients, most of whom don’t receive home visits, would be totally disproportionate so we propose to leave that as it is,’ he said.

Proposed changes to reduce the new registration payment that practices receive (a one-off 46% of their per capita payment to recognise additional clinical and administrative work) would not be taken forward. It would be disproportionate to the number of patients and risked destabilising some GP practices with a high turnover (student practices, for example), he said.

NHS England believes abolishing out-of-area registration rules or reducing the payment level would act as a disincentive for digital-first providers to register out-of-area patients.

Turning to CCG allocations, the consultation proposed that funding will follow the patient. There will be adjustments to CCG budgets, based on the age and gender of patients registering with digital-first practices and the practices at which they were previously registered, with funding recalculated quarterly. This would reflect patient movements of the sort seen with digital-first practices in London.

Mr Waller said there were several financial considerations, including the speed at which large-scale movements of patients are reconciled between CCGs. He confirmed this will be achieved through quarterly adjustments.

‘That will take account of the demography of those patients, their age and their gender,’ Mr Waller said. ‘It will also take account of the practices’ position from whence they came and the deprivation of the original practice.’

Need for a cap?

Consultation respondents supported capping the amount a CCG could lose through the registration of local patients with a digital-first provider in another CCG. But NHS England and NHS Improvement believe a cap will ‘emerge naturally’ when a new APMS practice is established (when the 1,000-patient threshold is reached). Typically, before the threshold is reached, CCGs would lose or gain a minimal amount, they say. Once the threshold has been passed, a new APMS practice will be created and the resources associated with each patient returned to them. 

The national bodies intend to test the data around the threshold further, but in the meantime, they have recognised that Hammersmith and Fulham CCG is a special case and will continue to make adjustments to support the CCG.

A Hammersmith and Fulham CCG spokesperson says: ‘The overall impact on the CCG finances has been significant. We are working with NHS England to agree a solution that will fully mitigate this position. The allocation changes set out in the digital-first consultation outcome will be one of the mechanisms used to enable this.’

Commissioning of new digital-first providers will be carried out nationally, though in future this could become the responsibility of primary care networks. Digital-first contracts will be targeted at areas of greatest need – under-doctored areas (CCGs in the bottom 20%-25%) or those with the longest waits for GP appointments. Contracts will ensure that digital-first providers offer good access to physical practices if needed, to ensure they integrate with local services.

The new practices will be required to meet three strict criteria. They must: demonstrate that the GPs they will be bringing into the local community are wholly additional; ensure the physical part of their service also covers the most deprived areas of the CCG; and actively promote their service to the most deprived communities.

Reducing inequalities

NHS England hopes the NHS could harness the potential of digital-first providers to reduce health inequalities. This will be achieved through national rules rather than local commissioning. A list of approved providers will be established to limit the bureaucratic burden on local commissioners. Both the list of approved providers and the creation of APMS contracts will be in place for April next year.

GP practices must have in place safe, secure, effective and high-performing IT systems and services that keep pace with the changing requirements to deliver care. To support this, £57.5m in extra funding has been allocated to address weaknesses in the GP IT infrastructure and ensure it is sufficiently robust and resilient to threat.

Generally, the new policy has been welcomed. Hammersmith and Fulham CCG says: ‘There are some helpful changes proposed that will address some of the issues that have been identified by the development of this particular model of digital-first delivery. For example, enabling more patients to be part of local primary care networks going forward.’

It adds: ‘The document sets out proposals to reform patient registration, payment and contracting rules around digital-first providers. NHS England will want to ensure that patients have choice and access to integrated care, and harness the potential of digital providers to help with workforce shortages in a way that helps the most under-doctored and deprived communities.’

Babylon GP at Hand, which recently expanded into Birmingham, says the digital-first policy is a vote of confidence in its services. ‘The proposals will enable patients across England to choose Babylon GP at Hand, and we welcome the commitment to retain our funding levels.’ 

A spokesperson says it is committed to further expansion. But it adds: ‘It is essential that the new policy changes are not implemented in a way that disadvantages digital-first providers. We will robustly challenge any attempt to impose new requirements that are not reimbursed on a par with traditional practices.

‘These new NHS policies will enable more patients to use Babylon GP at Hand and access the services that have made us so popular and we look forward to working with the NHS to make this happen.’

Clearly, digital-first primary care is at the forefront of government, NHS England and NHS Improvement thinking. It is also popular with patients, though, as yet, this may be limited to younger, more tech-savvy sections of the population. The acid tests for digital-first will be whether it can break through to older or more vulnerable patients, truly expand primary care capacity in under-doctored and deprived areas and do so while keeping CCGs and GP practices financially stable.