NHS England has launched a consultation on digital first primary care – which could see Babylon’s GP at Hand stripped of its primary care network by April 2020.

The consultation on digital-first funding and contracting arrangements seeks to solve four problems: should out-of-area registration rules be reformed to cater for digital providers and primary care networks (PCN); should Clinical Commission Group (CCG) allocation reflect in-year patient flow; should the premium for new patient registration be changed – and only be paid after an agreed period; and should a wider array of digital first providers be available?

The proposed changes would address funding inequalities between local GP practices and digital first providers, while also addressing high patient churn associated with digital services.

Announcing the consultation at the NHSE and NHSI board meeting on 27 June, national director of strategy and innovation Ian Dodge, said: “We’ve seen the emergence digital-first practices directly registering patients in competitions with existing GPs using the current out-of-area rules.

“This means, for example, that the GP at Hand practice in Hammersmith has a wide distribution of patients all across London, which cuts across the need to integrate care in local networks, as well as causing funding issues for Hammersmith CCG.

“We are proposing to fix this issue by creating, in regulations, a new mechanism to disaggregate the practice list automatically when a threshold number of out-of-areas patients is reached within the CCG.

“This would trigger the automatic creation of a new practice list for GP at Hand, in say Tower Hamlets, where they would need to provide premises, be part of a local network and meet all services requirements.”

The consultation proposes to:
    • Amend out-of-area registration rules so when a practice exceeds a threshold of out-of-area patients (possibly between 1,000-2,000), their contract is disaggregated
    • Change the allocations system to allow quarterly recalculation of CCG funding to reflect patient movements of the sort which have been stimulated by registration with digital-first practices in London
    • Make no changes to the GP payment formula for new patients at this point, but only pay if a patient remains registered with a practice for a defined period, likely to be between six to 12 months
    • Use practice entry rules to address inverse care law – NHSE suggests allowing digital first practices to register patients in under-doctored areas, for example CCGs in the bottom 10-20%
    • Potentially remove the need for most local Alternative Provider Medical Services (APMS) procurements by looking to PCNs as the default mechanism for maintaining primary care provision

Key stakeholders, patients and industry have until 23 August to submit their responses.

NHS England chief executive Simon Stevens faced accusations the NHS had no control over GP at Hand’s “Uber-GP model” at the health and social care committee on 25 June.

Sarah Wollaston, committee chair, said the “disruptive” service was “driving health inequalities” and proving expensive. Mr Stevens assured concerns would be addressed in the consultation.

A spokesman for Babylon said the consultation was a “sensible step” towards ensuring digital services suit patients and allowed them to pick a GP practice that worked for them.

“Digital appointments are fantastic, but there are a minority of appointments for which you need to see a GP face-to-face – this is a core part of Babylon GP at Hand’s full NHS primary care service and we are the only digital-first provider with physical clinics,” he said.

“It’s also great to see a new plan that will solve concerns around the funding flows between Clinical Commissioning Groups. There are lots of details to discuss, but this looks like an important step to enable more people to enjoy digital-first services.”

The new GP contract, which came into effect on 1 April, committed all patients should have online access to their full record by April 2020 and all patients should have the right to online and video consultations by April 2021.

At the time is was published, Babylon raised concerns it “penalised” digital providers with changes to the rurality index payment, designed to support practices with a higher than average distance to patients’ homes. The changes would see funding only given for patients living within a GP’s catchment area.

It also set out guidelines for PCNS, including that they must exist within connecting boundaries, within the same clinical commissioning group (CCG) area and serve populations not exceeding 50,000.

But concerns have been raised about digital-first providers ability to adhere to these rules.

In June, Babylon GP at Hand’s application to be a PCN was temporarily approved, with the provider saying geography will be “less of a defining factor” after the NHS Long Term Plan called for GPs to focus on becoming digital-first.

But the outcome of the consultation could see the provider stripped of its PCN status if amendments to the out-of-area registration rules are decided against.

If they are enforced, Babylon’s contract will be disaggregated once the patient list reaches the decided threshold. They would then be required to set up a new contract in another CCG to serve their out-of-area patients.

The PCN application was met with fierce criticism from Londonwide Local Medical Committees (LMCs), which escalated concerns over the application to the British Medical Association’s (BMA) GP council.

The LMCs first raised concerns about GP at Hand’s application in May, saying the move would “destabilise” GP services in London “to the point of destruction”.

GP at Hand was given the green light to expand to Birmingham in June, with their Midlands clinic opening for registrations on 19 June. Patients registered in Birmingham will also be included in the PCN.

MP for Hammersmith, Andy Slaughter, had called on the service and any potential expansion to be suspend until the NHS has a better understanding of how digital services will impact primary care, following previous “serious concerns” about the more than £20m funding deficit the GP at Hand had caused the CCG.