One of the things that I was interested to look at when the QOF data came out last year was how GP at Hand performed. A lot has been written over the past year or so about this service, which uses a chatbox app as the first point of contact. For all of the QOF year in question the service had restrictions which have since been lifted about registering patients with long term conditions. This has led to concerns that GP at Hand has "cherry picked" patients who are younger and fitter, leaving other practices to deal with patients who have more pathology.
This has been denied by GP at Hand. Actually, as we will see, there is little doubt that they have a younger patients but they argue that the is resource neutral under the Carr-Hill formula which adjusts the practice Global Sum according to the age and sex of patients. This was introduced in 2004 along with the rest of the GMS contract. At the time it caused significant swings in income with particularly large reductions in income to practices with large numbers of younger patients. Practices which served university students were particularly badly affected. GP at Hand claims that it gets only 65% of the average GP funding per patient.
There is no significant adjustment in the Carr-Hill formula for how sick patients are. This has largely been done through the QOF although the effect has been quite variable over the years as the QOF has waxed and waned. I wanted to see if the QOF data let us answer the question of whether the patients at GP at Hand are healthier than we would expect.
We can start with a quick look at the QOF figures. In the year 2017/18 GP at Hand was based in a single practice at Lillie Road in Fulham. There are very low levels of disease prevalence there. In nine areas they are below the first centile - i.e there are in the bottom 1% of practices for the prevalence of that condition. In only two areas are they above the bottom five percent of practices - depression and mental health.
The data also shows the practice list size. If we look back to the previous year we can see that the list size increase from 2,500 in April 2017 to 24,000 in April 2018. This is such a huge rise that it is pretty much impossible to compare year on year. This is not the same practice that it was a year before. Even if none of the original patients left during the year they form a fairly insignificant number of patients at the end of the year.
As an aside I wondered where are all of these patients are coming from? GP at Hand will register patients from a wide area due to their chatbot technology. We can get a clue if we look at the total registered list size for Hammersmith and Fulham CCG. This has steadily risen over the years with a typical rate of 4-6000 patients. In the year 2017/18 there were an extra 24473 patients in the CCG. I don't know much about London but unless there has been a lot of house building it seems that most of GP at Hand's patients came from outside the CCG area.
We can see from the QOF data that prevalence has plunged at Lillie Road over the year. Some of the register have barely risen despite the huge rise in patient numbers. The cancer register has risen from 51 to just 74. The number of patients with dementia has actually fallen from fourteen to twelve. That, however, is not very useful as we have already seen that the patients are completely different to the previous year. We are not comparing like with like. Clearly the new patients at the surgery are pretty healthy, but are they unusually healthy? We need more data.
Helpfully NHS Digital publish practice list sizes monthly and these are broken down by age and sex (insert your own joke here). We can use this to create profiles of practices and other organisations. Here is a population pyramid for England (which is all that NHS Digital cover).
It may not be a pyramid that that pharaohs would be proud of but there are distinct trends in the population. We can use the data for Lillie Road to see if this is similar to their population, or at least if it is very different. We can produce pyramids for Lillie Road practice and it is remarkably different to the UK population as a whole. The vast majority of their patients are between the ages of 20 and 45 with men tending to be a little older than women on the list. With such a radically different population it would seem rather unfair to compare the surgery against English averages. They are certainly not average!
This is still quite different to Lillie road although it has the emphasis on young adults with very small numbers of children. Lillie Road demographics are not similar to its neighbours. Again it is going to be difficult to make comparisons. Lillie Road seems to be unlike any other type of practice that we already have.
Or maybe not. I mentioned the global sum earlier and that the effect that is having on Lillie Road may be similar to university practices. What about them? I typed the word "university" into the search box on my website and looked at the practices that appeared in the result. After taking out a couple of results that were either not actually practices or were out of England I came up with a list of 26 practices. I then put their populations together and produced a (final, I promise) population pyramid.
Now we seem to be getting somewhere. The shape if familiar although the lines a bit sharper. In general people are even younger in university practices and the chart appears as an even more exaggerated version of Lillie Road. There is also likely to be a degree of selection in universities as young people with chronic health problems may find it more difficult to access university. The effects of both these factors are likely to push down the rate of disease in these populations and, by comparison, this is likely to make the pathology at Lillie Road appear higher. I am not too worried about that as we are trying to see if pathology is lower than we would expect at Lillie Road and most of the biases are in its favour: they will minimise the appearance of cherry picking.
Let's look at the prevalence for the university practices and for Lillie Road. All of these figures are in percentages of the practice population with each of the conditions.
| Area | Lillie Road | University Practices | p value | |
|---|---|---|---|---|
| 1 | Atrial Fibrillation | 0.2 | 0.26 | 0.13 |
| 2 | Asthma | 3.4 | 3.1 | 0.0044 |
| 3 | Cancer | 0.31 | 0.47 | 0.00049 |
| 4 | Coronary Heart Disease | 0.25 | 0.38 | 0.0008 |
| 5 | Chronic Kidney Disease | 0.25 | 0.38 | 0.0013 |
| 6 | COPD | 0.3 | 0.21 | 0.0039 |
| 7 | Dementia | 0.05 | 0.087 | 0.07 |
| 8 | Depression | 3.6 | 5.8 | <0.0001 |
| 9 | Diabetes | 1 | 0.99 | 0.81 |
| 10 | Epilepsy | 0.24 | 0.22 | 0.567 |
| 11 | Heart Failure | 0.083 | 0.1 | 0.567 |
| 12 | Hypertension | 2.5 | 2 | <0.0001 |
| 13 | Learning Disability | 0.088 | 0.082 | 0.86 |
| 14 | Mental Health | 0.77 | 0.35 | <0.0001 |
| 15 | Obesity | 2.6 | 2.7 | 0.62 |
| 16 | Osteoporosis | 0.017 | 0.029 | 0.37 |
| 17 | Peripheral Arterial Disease | 0.054 | 0.067 | 0.52 |
| 18 | Rheumatoid Arthritis | 0.13 | 0.1 | 0.21 |
| 19 | Stroke/TIA | 0.17 | 0.24 | 0.021 |
Eyeballing the data does not suggest much of a difference. In some areas, such as depression the university practices have a higher prevalence and in others, including severe mental health problems Lillie Road is ahead. We can see the same information on a bar chart. The biggest differences are in depression. University practices are a little ahead in diseases related to ischaemic heart disease and dementia. I will cut Lillie some slack in the latter as they are fast growing and patients with dementia, or indeed cancer can be less likely to change their surgery although it is also likely that they are going to be less enthusiastic smartphone users. This is splitting hairs as University practices have about a tenth of the UK prevalence of dementia. These are small differences in small numbers. Using Pearson's Chi-Squared test only nine areas reach significance. Four are higher in Lille and five in the University practices.
I am not a statistician and this is a dig around the data rather than a formal analysis. I was looking for to see if there were obvious anomalies. We don't really know how the existing patients at the practice reacted to the change of management. It is possible there "old" and "new" populations being treated side by side but there is no evidence for this. I have certainly not found evidence of "cherry picking". The practice is no more unusual than a university practice catering primarily for students.
But before we get too used to the idea it is worth remembering that university practices are quite unusual. Their population pyramid is dramatically different to the country as a whole. Lillie Road is still an outlier even if it is similar t some other outliers. It would be quite strange to believe that the success here would automatically translate into other populations. These are patients with very low levels of chronic disease and attract relatively low levels of funding.
I have made no attempt to review the quality of care delivered at this practice. QOF is a pretty blunt instrument for this. Their point score is good at a whisker under 550 out of 559 points. The rate of growth at Lillie Road seems to be slowing but they are also available at more sites across London so that is certainly not the whole story. I hope I have been able to cast a little light on this atypical, but perhaps not entirely unique, practice.
While you are here I would ask nicely that, if you found this interesting, you might take a look at my book "Starting Snomed: A beginner's guide to the Snomed CT medical terminology". It is an easy introduction to this powerful new tool that will be coming to practices this year. It is available now on Amazon and is also available for Kindle and all of the various offers that come with that. Thank you.
