• NHS England details how urban “digital first” practices receive payments meant for rural GPs
  • Three GMS payment changes proposed that would cut digital practices income by 19.5 per cent
  • Further changes likely as leaders grapple with impact of digital providers on primary care

NHS England has responded to growing outcry over the rise of “digital first” GP practices, with a raft of changes that would cut NHS income for these services by a fifth. 

The national commissioning board indicated further changes to GP payments were also likely as it tries to accommodate the growth of digital practices, such as GP at Hand, while minimising the disruptive impact on other NHS services.

The planned changes are part of a wider set of GP contract reforms unveiled on Wednesday, that have been described as the biggest since 2004.

Papers presented to NHS England’s board on Wednesday proposed three changes (see box) to General Medical Sevice payments that, taken cumulatively, were expected to cut the NHS income of a theoretical “digital first” practice of the future by 19.5 per cent.

If the changes were introduced tomorrow the impact would be smaller, with the practice most affected taking a 9.6 per cent cut and about 2000 others taking a hit of less than 0.3 per cent.

The changes would not lead to a total reduction in GP funding, with any payments cut from one practice distributed to other GPs.

The paper also detailed how, under the current system, digital practices’ ability to attract out of area patients means they automatically receive additional NHS income, originally designed to support rural GPs or meet the high cost of caring for London patients.

Speaking at the board meeting, NHS England national director of strategy and innovation, Ian Dodge, said the changes were intended to “support the sustainable and faster development of the digital first model”.

He said they were not “solely in response” to GP at Hand’s rapid emergence, but acknowledged the London based practice was currently the main player in the market. 

In a statement, NHS England said the changes would “ensure that the way we commission, contract and pay for care keeps up with the opportunities digital innovation offers – ensuring that new technology is safely integrated into health and care pathways, whilst not unfairly destabilising existing services”.

Planned changes

Rurality payment

This payment was set up to provide extra funds to support rural GP practices whose patients have to travel long distances.

However, “digital first” practices, which are usually urban, can also access these payments by attracting out of area patients, who might live far away from their physical practice, but can access services remotely through an app. 

NSH England has proposed to change how this payment is measured, penalising practices with out of area patients who, on average, travel a longer distance than its in area patients. This is expected to cut these payments for digital practices but not rural GP practices.

For a “digital first” practice with out of area patients travelling, on average, five times further than its in area patients, this was expected to lead to a 4.5 per cent reduction in core General Medical Services income.

Out of area patient payments

GPs are currently paid the same for in area and out of area patients but are not required to provide emergency primary care or home visits for the latter group.

For digital practices with a high proportion of out of area patients this means a reduction in costs, which typically shifts to the clinical commissioning groups where the patient lives, with no corresponding reduction in per patient income.

NHS England has proposed cutting the payment for out of area patients by £17 per patient, effectively a 20 per cent reduction in the per capital global sum, to more fairly reflect where the costs lie.

For a “digital first” practice with four out of five patients from out of area this was expected to lead to a 13.9 per cent reduction in core GMS income.

London payment

Practices based in London are currently paid an extra £2.18 per patient in recognition of higher health costs in the capital. 

However, London based digital practices can potentially attract patients living outside London, by offering remote care, allowing the practice to earn the extra payments for non-London patients.

NHS England has proposed limiting this payment only to patients living in London, rather than all patients for a London based practice.

For a “digital first” London practice with 50 per cent of its patients outside of London, this was expected to lead to a 1.1 per cent in core GMS income.

Other possible changes

While there are no firm proposals, NHS England also floated a reduction in the 46 per cent bonus to GP practices for new patients in their first year. 

Traditional GP patient lists had been relatively stable, but digital practices face few geographic constraints and can attract new patients with unprecedented speed.

NHS England also said the market forces factor may need changing, with the linked payment shifted to where a patient lives, rather than where a practice is based, to reflect the fluid nature of a digital practice’s list.

”Digital first” practices are defined as GP organisations that primarily deliver care remotely using digital tools, such as e-consultations or video calls via a patient’s smartphone, overcoming some of the geographic constaints of traditional practices.

The most high profile and successful to date is GP at Hand, a Hammersmith practice that has partnered with tech company Babylon Healthcare to deliver most of its care digitally, including via video.

GP at Hand’s practice list has expanded eight fold in as many months, attracting disproportionately younger patients, most of them from outside the Hammersmith and Fulham area.

The British Medical Association and Royal College of General Practitioners have both criticised the service for cherry picking healthy patients from other practices, fragmenting care and undermining the GP payment model.

Babylon, on behalf of GP at Hand, declined to comment when approached by HSJ for this story.

In a statement, British Medical Association’s GP committee chair, Richard Vautrey, said he was glad NHS England had responded to concerns about GP at Hand “unfairly exploiting the out of area arrangement”, but stopped short of endorsing the changes.

“We will need to consider the various proposals carefully to avoid adversely impacting other practices who are delivering the full range of services to their patients”, he said.