The fortnightly newsletter that unpacks system leaders’ priorities for digital technology and the impact they are having on delivering health services. Contact Ben Heather in confidence here.

On Monday, yet another digital GP service announced its arrival in the NHS.

Livi is based in Sweden and has footholds in other parts of Europe.

The company already has a partnership with a GP federation in the north west and is now available to patients of a 40-GP practice federation in Surrey.

Video telehealth, which is essentially what Livi and many of its competitors offer, is not a new concept in the NHS.

In 2013, David Cameron got rather excited about Skype GP consultations. But, beyond a few pilots, little came of it.

Five years later that has changed dramatically as a slew of companies try to stake out their claim for digital primary care.

The next 18 months or so are likely to be critical in shaping how patients access these services well into the future. And from whom.

The GP at Hand effect

The approaching digital tipping point has many causes.

Higher smartphone saturation with cheaper, faster data, spillover from the consumer app market, and greater patient demand have probably all played a part. 

But it is hard to ignore the GP at Hand effect.

Digital primary care company Babylon’s partnership with a single Fulham GP practice started aggressively advertising to out-of-area patients offering free video consultations in 2016.

Measured by growth of registered patients, over 30,000 at last count, GP at Hand has been an undeniable success.

But more importantly, it has shown the NHS how digital technology can be used to upend the traditional model of GP services.

Most of GP at Hand’s patients don’t live anywhere near Fulham. Some don’t live in London.

If GP at Hand gets its way the Fulham practice will be registering patients from Leeds to Southampton.

This unconventional expansion has sparked a backlash, from GPs losing patients and commissioners losing oversight of local services.

NHS England now has a GP at Hand working group and is changing payments rules to both control and enable GP at Hand-like services. 

But as well as opposing GP at Hand’s approach, many GPs will be taking a hard look at their own, often woeful, digital services for patients.

The more far-sighted will have concluded something needs to be done fast – Before it is done to them.

Different digital strokes

The GP at Hand model relies on its GMS contract, video consultations and the quirks of the GP payment system to attract as many new patients as possible.

But it is not the only approach.

Like Babylon, Livi also has its own pool of GPs to provide video consultations.  

But its model is based on working with existing GP federations rather than growing a new patient list, specifically by sub-contracting to provide out-of-hours services.

Push Doctor is piloting something similar with Modality Partnership, one of the biggest GP partnerships in the country. 

Now Patient has taken a different approach again, treating video GP consultations as an add-on to its online pharmacy business.

NHS patients that choose to get their prescriptions through Now Patient, which is where the company makes its money, will also get access to free GP consultations. 

On the other end of the spectrum is software that connects patients with their existing GP.

E-consult, a spin-off from the Hurley Group, is among the most successful of this realm, contracting with dozens of clinical commissioning groups.

Consultations are done using an online form, rather than video.

And some GP groups developing digital channels in-house.

South Doc Services, in South Birmingham, was rated outstanding by the Care Quality Commission for its virtual GP telehealth service and app.

The service was set up with money from Mr Cameron in 2013, so perhaps these things just take time.

Which of the above approaches will prevail is anyone’s guess.

But none of it tells us whether digital primary care, essentially digital telehealth, is a good buy for the NHS at all?

Measured by patient demand, perhaps it is. 

When easy to use and properly marketed, these services are immensely popular. Some people are willing to pay for them where they are not provided within the NHS.

An argument gets made that these services are only popular with the young and healthy, the cohort least in need of extra NHS resource.

But this may be the adoption curve at play, with older, less-tech-savvy folk, still to follow. Livi claims their fastest growing user group in Sweden is now woman over-50.

Other questions are more difficult to answer, the evidence scant.

Do these digital telehealth services improve patient’s health?

A review published last year, commissioned by NHS England, found the video consultations were a good option for treating mental health and were no worse than face-to-face for chronic conditions.

However, a study published in The Lancet in 2014 on telehealth more generally found patients were more likely to require additional follow-up care after a phone GP consultation.

Is it cost effective? In 2013, the Department of Health said telehealth was not worth the cost.

What impact will it have on other health services?

Some digital GP services have claimed their service will reduce the burden on other services, such as accident and emergency.

But there is no evidence, at least not yet, for this and concerns have been raised that the opposite could be true.

A specific evaluation of the GP at Hand services, which is scheduled for publication early next year, should (hopefully) provide more clarity. 

But, regardless of its conclusions, the expansion of digital primary care will continue and likely accelerate.