Babylon sought to expand its GP practice chain further across London and to Manchester and Birmingham last year, but scaled back the plans after NHS England “issued a formal objection”, it has emerged.

Details of the revision to the plans for GP at Hand are included in Hammersmith and Fulham Clinical Commissioning Group committee papers, along with a clinical review of the service carried out by the CCG and NHS England.

The clinical review says the national commissioning body “issued a formal objection” to GP at Hand’s expansion plans in September. The service was launched in November, on a smaller scale than initially proposed.

The clinical review raised a number of potential risks, which it described as “novel”, including contributing to health equalities, increasing emergency department attendance among patients without easy access to a GP at Hand clinic, and less co-ordinated care for some patients. The review is included in papers for a November committee meeting. It is unclear when these were published by the CCG.

Babylon told HSJ that the concerns were addressed by its modified plans.

GP at Hand is partnership between a Fulham based GP practice and digital health provider Babylon Health, which was founded by former Circle chief executive Ali Parsa.

A proposal from GP at Hand, also included in committee papers, shows it responded to the review’s concerns by proposing to scale back the expansion from nine physical clinics, including in Manchester and Birmingham, to four, all in London, pending a three month evaluation period.

The service also said it would be willing to restrict registration to patients that lived or worked within 40 minutes of one of its physical clinics.

Babylon is still planning to expand GP at Hand across the country in future.

GP at Hand currently has five locations listed on its website, all in London, and recommends that patients do not register if they feel they cannot reasonably get to one of these clinics.

CCG committee papers from December showed commissioners accepted GP at Hand’s proposed changes, and withdrew the formal objection.

They say it will be subject to an independent review which would consider, among other things, the potential to “destabilise other GP practices” and the “financial risk” to the CCG as commissioner.

While the clinical review said that GP at Hand’s use of technology was “exciting and potentially transformational” with benefits for some patients, it also raised concerns that the service had not been formally assessed.

“The GP at Hand model is novel, it has not been formally evaluated, and may therefore result in unintended consequences,” it said.

The review said because the service was likely to attract younger, healthier patients, its impact on “the stability of the wider primary care provider landscape” and contribution “to inequality in service provision and potentially inequality in patient outcomes” still needs to be evaluated.

According to NHS Digital figures from December, less than 13 per cent of the GP at Hand’s 13,771 patients were over 60 years old (compared to 23 per cent nationally) and 45 per cent were between 20 and 39 years old (compared to 28 per cent nationally).

Other concerns in the clinical review included:

  • The model of registering patients in large volumes at a significant distance from either home or work “arguably represents a distortion of the original intentions of the Choice of GP policy”.
  • Patients were not told enough about the GP at Hand service when registering.
  • GP at Hand had not demonstrated enough clinical capacity to support its originally proposed expansion.
  • Poor continuity of care for people with complex conditions.

The clinical review said its findings were not “conclusive but rather directive in highlighting areas of concern” and recommended further evaluation, carried out by the CCG, into the possible benefits and risks of GP at Hand.

A Babylon spokesman told HSJ that commissioners had accepted its proposed changes to the November expansion “which address the concerns raised in the clinical review”.

“Commissioners have comprehensively signed off our roll out plan and we look forward to working with them to expand GP at Hand across the country.”

What is GP at Hand?

GP at Hand is a service offered by partnership between a Fulham based practice (formerly known as Dr S Jefferies & Partners) and digital health provider Babylon Health.

As well as traditional physical GP appointments, GP at Hand offers free video GP appointments to NHS patients, and other digital services such as a symptom checker, through a mobile app.

The practice subcontracts Babylon to provide the digital element of this service but the company is also represented within GP at Hand, with Babylon medical director Mobasher Butt a partner.

It holds a GMS contract and uses the national Choice of GP policy in combination with its video appointments to attract and register patients, particularly commuters, from outside the immediate catchment of its physical surgeries.

While GP at Hand has been operating out of one site since late 2016, it attracted national media coverage in November last year, when it expanded to five sites across London and significantly stepped up its marketing.

Several medical bodies, including the Royal College of GPs, have raised concerns that GP at Hand eroded the doctor patient relationship, was untested and could create a two track primary care in the NHS by “cherry picking” healthy patients.

The Royal College of GPs chair Helen Stokes-Lampard said the review echoed many of the concerns raised by the college when GP at Hand was expanded in November.

“We agree that the service poses a number of unintended clinical risks for patients that must be mitigated, and that it could lead to inequity between traditional NHS general practice services, and those that are exclusively online,” she said.

“Online consultations via a smartphone offer great convenience for some patients, but they won’t be suitable for others - and they don’t necessarily reduce workload for GPs. If practices do choose to offer them, then it should be in addition to traditional services, not instead of them.”

Neither the CCG or NHS England directly answered questions submitted by HSJ.

However, in a statement an NHS England spokeswoman said the organisation was working with the CCG “to develop a more detailed independent evaluation of the effect of the service as recommended in the clinical review”.

A CCG spokeswoman said: “As with any innovation, the precise benefits and risks remain unknown – it is therefore essential that the roll out of this service is accompanied by an evaluation of the impact, in partnership with local and regional commissioners.

“The report should not be considered conclusive but rather directive in highlighting areas of concern where further action or evaluation are necessary.”