BMJ 2019;366:l4713 doi: 10.1136/bmj.
l4713 (Published 24 July 2019)
Editorials
General practice by smartphone
GP at Hand risks destabilising care for patients with the greatest needs
Martin Roland emeritus professor of health services research
University of Cambridge, Cambridge, UK
Matt Hancock, the secretary of state for health, believes that
embracing new technology is key to making the NHS the best
healthcare system in the world.1 One company, Babylon, is
testing this to the limits by establishing an NHS general practice
in London, GP at Hand, where almost all initial contacts are
through smartphone consultations: only if the problem cannot
be sorted out on the phone do patients travel to one of five
clinics in London for a face-to-face consultation.
For most patients, GP at Hand’s doctors are unable to visit at
home or in nursing homes. Some fear that the new service will
fatally undermine traditional general practice, leaving GPs with
sick and complex patients to look after as fit young patients
move to GP at Hand. Indeed, the new service has proved
popular, with over 50 000 patients now enrolled.
Independent evaluation
Answers to some questions about GP at Hand come from a
recent independent evaluation.2
The evaluation confirms that GP at Hand caters principally to
a healthy, affluent, young, and working population: 98.5% of
patients are aged 20-64,3 two thirds live in affluent areas, and
only 0.1% are cared for by the service’s “chronic care team.”
Registered patients found GP at Hand convenient and used the
service more often than they did their previous practice, also
reducing their previous high use of other urgent NHS services.
However, a quarter of GP at Hand’s newly registered patients
move back to a conventional NHS practice, many within two
weeks.
The most recent inspection by the Care Quality Commission
rated GP at Hand as “good” in most areas but found it needed
to improve its performance in cervical cytology (64% coverage)
and childhood immunisation (73-84% coverage).4 The service
clearly meets the needs of some patients who value a fast
convenient service, but it falls short of providing comprehensive
proactive primary care.
The use of smartphones to provide medical care is not new and
has proved effective in countries with few doctors or very rural
populations. For example, Babylon provides smartphone based
healthcare to over two million patients in Rwanda, as does
Halodoc for two million members in Indonesia. In high income
mr108@cam.ac.uk
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EDITORIALS
countries, specialists have used smartphone consultations to
follow up patients with a wide range of conditions, from
postoperative care and diabetes to end-of-life care.5-7 Indeed,
more than half of Kaiser Permanente’s physician contacts in the
US are now done virtually.8
But could—and should—smartphone consultations replace
traditional approaches to accessing primary care in developed
countries, and will Babylon’s GP at Hand make the NHS’s
current crisis in primary care better or worse? The crisis stems
from a combination of the increasing difficulty that patients
experience accessing their GP, decreasing numbers of GPs, and
an increasing workload, especially of older patients and patients
with complex medical problems.9
Questions over funding
Phone and video consultations have much to offer as an adjunct
to conventional primary and secondary care, and Babylon’s
entry into the NHS is already stimulating other practices to
widen the range of services they offer. There are fears that
Babylon will make the shortage of GPs worse, although the
evaluation found that GP at Hand enabled some GPs to increase
their NHS work, finding it convenient to work part time from
home alongside their work in conventional NHS practices.
However, the current NHS funding formula does not adjust
adequately for the costs of providing a comprehensive primary
care service, and the NHS needs urgently to review its
arrangements that have allowed a private company to cream off
fit young patients from existing NHS practices. If the GP at
Hand model became widespread, it would risk destabilising
care for patients with the greatest needs and those who need
regular proactive care.
Competing interests: We have read and understood BMJ policy on declaration of
interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
1 Hancock M. New technology is key to making NHS the world’s best. Speech delivered
on 6 Sep 2018. https://www.gov.uk/government/news/matt-hancock-new-technology-is-
key-to-making-nhs-the-worlds-best
2 Quigley A, Hex N, Aznar C, et al. Evaluation of Babylon GP at Hand: final evaluation
report. 2019. https://www.hammersmithfulhamccg.nhs.uk/media/156123/Evaluation-of-
Babylon-GP-at-Hand-Final-Report.pdf
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BMJ 2019;366:l4713 doi: 10.1136/bmj.l4713 (Published 24 July 2019)
3 Care Quality Commission. GP at Hand. Inspection report. 2019. https://www.cqc.org.uk/
sites/default/files/new_reports/AAAJ1557.pdf
4 Care Quality Commission. GP at Hand. Inspection evidence table. 2019. https://www.cqc.
org.uk/sites/default/files/evidence/evidence-AAAJ1557.pdf
5 Tofte JN, Anthony CA, Polgreen PM, etal . Postoperative care via smartphone following
carpal tunnel release. J Telemed Telecare 2018;X18807606.
10.1177/1357633X18807606 30428766
6 Vijayaranghavan S, O’Shea T, Campbell-Richards D, etal . Diabetes appointments via
webcam in Newham. Br J Diabetes Vasc Dis 2015;15:123-6. https://bjd-abcd.com/index.
php/bjd/article/view/84.
7 Middleton-Green L, Gadoud A, Norris B, etal . “A friend in the corner”: supporting people
at home in the last year of life via telephone and video consultation—an evaluation. BMJ
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EDITORIALS
Support Palliat Care 2016;bmjspcare-2015-001016.
10.1136/bmjspcare-2015-001016 26850118
8 Barkholz D. Kaiser Permanente chief says members are flocking to virtual visits. Modern
Healthcare 2017 Apr 17. https://www.modernhealthcare.com/article/20170421/NEWS/
170429950/kaiser-permanente-chief-says-members-are-flocking-to-virtual-visits
9 Primary Care Workforce Commission. (chair Roland M). The future of primary care:
BMJ: first published as 10.1136/bmj.l4713 on 24 July 2019. Downloaded from http://www.bmj.com/ on 29 July 2019 by guest. Protected by copyright.
creating teams for tomorrow. 2015. https://www.hee.nhs.uk/sites/default/files/documents/
The%20Future%20of%20Primary%20Care%20report.pdf
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