A look at GP at Hand

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.

CHD prevalence at Lillie Road

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!

It is worth checking as well whether this is something about the population Hammersmith and Fulham CCG although we have already seen that most of the Lille Road patients come from outside the area. The pyramid below included all practices except Lillie Road. The wikipedia page for Hammersmith and Fulham suggests this a borough full of young and single people and this is borne out in the population figures. There is also quite a lot more women than men registered with a GP although it is possible that this is due to fewer men registering with a GP. Contraception and cervical screening can be a reason for young women to join a practice more actively than men when moving around.

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.

University practices are peculiar unusual.

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.

50 comments:

Ian said...

From what I hard, students in Manchester must registerer with a new GP each year as they move about the city, due to most GP being unwilling to keep people who have moved on the books. (The additional payment in the first year someone is registered may also drive this.)

I expect many students in Manchester and "mobile" people in London don't tell the GP they have moved due to this problem. Hence if anything GP At Hand may be picking up the people who care more about being registered with a GP. (Universities practices may also get many people not registing until they want access to health care.)

If you look at the locations of their "treatments centres", it looks like they are aiming at people wanting GP care near work not home. I expect many of their customers live in "shared houses" (HMO) with no socal or family connection to where they live. One person I know in this age group chooses where to live so she is on the same Tube lines as Church and Work, with no regard for distance.

It is a shape it took a private company to provides services to a group of people that "conventional" GP practices would not give a good service to.

Note nothing above talks about "chat blob" or AI, or "Video consulting", as I expect all that is needed for any GP to complete for these customers is a willingness to see them near their work, and use the phone when an examination is not needed.

jeya sofia said...

You are providing a post that is very useful for developing my knowledge and I learn more info from your blog.

Azure Online Training
Azure Online Courses
Pega Online Course
Google analytics online course
online social media marketing course
selenium online training
full stack developer course online
Google adwords online course
Pytest Online Training
Google Cloud Online Training
RPA online training



Jhon Michael said...

ed Hat Certified Engineer is a professional who has expertise in handling the Red Hat Enterprise Linux System. The Certified Engineer takes care of various tasks such as setting kernel runtime parameters, handling various types of system logging and providing certain kinds of network operability. The professionals must have the ability to install networking services and security on servers running Red Hat Enterprise Linux.

Red Hat Certified Engineer

Lisa King said...

Wow such a well researched and formatted article. But I have a confusion as if it is academic writing or else you are posting a blog post. It must not be that formal in tone. Have a look at the https://www.essayking.co.uk/do-my-essay/ . As you will get to know about the theme and how to deliver a perfect content.

HRM Dissertations said...

I am a Research Associate and part time PhD student at Stanford University looking to join an education forum and community.

Business Dissertations | HRM Dissertations | Finance Dissertations

Anonymous said...

I have been searching for a long time for this kind of topic. You have discussed something unknown facts and it is right " Road demographics are not similar to its neighbors". I could read this site with a VPN that I have brought with nordvpn coupon code so can easily visit your site.

Edison hope said...


Hello everyone .... Yes, you can travel to Turkey , But you need to apply for a visa before you can travel to Turkey. You can find out more about the requirements and eligibility criteria on our Turkey e visa page. We explained everything in detail....

Mike Johnson said...

I guess you can make a video about it for youtube and get many likes for your video from this site https://viplikes.uk

Nelson Lyall said...

Thank you for these GP at Hand statistics. I really liked the chart in which you presented the results. It would be nice if you share the secrets of creating such a laconic charts with so much data. The company in which I work is also related to the health and this knowledge would help me a lot in order to form beautiful reports. At the moment, after searching a little, I found a couple of guides for creating similar charts on Instagram, but only similar charts are created in them. By the way, many of these videos have posted by accounts that have from 52 to 57 thousand of followers, and I'm sure that their authors are always buy instagram followers to quickly gain their amount.

Kenya evisa processing time said...

Your given information is very useful for us... Thanks for sharing this with us... The Kenya evisa processing time is fast. You can get a visa within a few days. And the visa on arrival for Indian passport holders in Kenya is also available, so make a plan with your friends and family, get a visa, and enjoy the journey. Hurry up nature is calling you.

Lucas mia said...
This comment has been removed by the author.
EU Citizenship Guide: Everything You Must Know said...

Your information is incredibly valuable to us. I appreciate you sharing. The EU Citizenship Guide: Everything You Must Know serves as a comprehensive resource for individuals seeking to understand the intricacies of European Union citizenship. Covering a wide range of essential topics, this guide offers valuable insights into the rights and privileges that come with EU citizenship.

Mark Wood said...
This comment has been removed by the author.
Mark Wood said...

Wonderful , I want to say a big Thankyou for this special post. If you're a citizen of Kazakhstan planning to visit India, here's what you need to know. India Visa for Kazakhstan Citizens. Utilize the online process to fill out the application form, attach the required documents, and pay the applicable fee. Allow some time for processing. Once approved, you're ready to explore India. Adequate preparation ensures a seamless online visa process.

jofra archer said...

Your guidance has been invaluable, and it's greatly appreciated. India Travel Tips for First Time Visitors. Ensure you have the necessary visas and travel documents in order, and consider vaccinations before you go. Be cautious with local cuisine to avoid stomach issues, and dress modestly, especially at religious sites. Bargaining is common in markets, and using reputable transportation options is advisable. Show respect for local customs, traditions, and beliefs, and be patient in diverse situations.

Brian said...

Great post! Easy to understand and very helpful. Looking forward to reading more from you. To reunite with loved ones, apply for family visit visa KSA. Ensure a hassle-free process by following the necessary steps and requirements for a successful application

David Miller said...

I'm truly grateful for your generosity in sharing these with us. I'm committed to taking part in the upcoming event, as this topic holds a special appeal for me. Best Luxury Yacht Rentals in Istanbul in 2023. In 2023, Istanbul offers an array of luxury yacht rentals for those seeking opulent maritime experiences. Cruise the Bosphorus in style and enjoy stunning views of the city's iconic landmarks.

Tunisia largest museums reopens to public said...

This blog post is a breath of fresh air amidst the digital landscape. The author's profound understanding and compelling writing style make it a journey of enlightenment. Each term acts as a pivotal point in the quest for comprehension. I eagerly await more insightful content. Keep up the exceptional work!

Henry Evelyn said...

Your website is a goldmine of information. It's absolutely fantastic. I'm eagerly anticipating more posts like these from you. Your website's theme is also quite pleasing. Your effort is greatly appreciated. types of airports in Kenya. Kenya boasts a network of international and domestic airports that serve as gateways to its diverse landscapes and vibrant cities.

visa Turkey Saudi Arabia said...

Your blog post conducts an intellectual symphony, each paragraph a harmonious note in the grand composition of ideas. The eloquence in your prose constructs an intricate tapestry, guiding readers through unexplored territories of contemplation. A literary masterpiece transcending storytelling, it leaves an indelible mark on the reader's intellectual canvas.

Turkey online visa said...


Your blog post embarks on an intellectual journey, a symphony of ideas orchestrating a captivating narrative. Each paragraph is a brushstroke, contributing to an exquisite canvas of thought. The eloquence in your prose guides readers through uncharted realms, leaving an indelible imprint. It's a literary masterpiece, transcending storytelling and igniting profound contemplation.

Mexican Caribbean Tempts Nomads Free High-Speed Internet said...

Howdy! I'm here for the first time on your blog! We're a group of volunteers launching a fresh community project in the same field. Your blog has equipped us with invaluable information to guide our endeavors. Exceptional work on your part!

Brazil visa for US Citizens said...

In my inaugural visit, I'm captivated by the wealth of interesting content on your blog, particularly the vibrant discussions. Given the numerous comments on your articles, it appears that I'm not the only one deriving enjoyment from the experience. Keep up the good work!

Johanson said...

Regularly engaging in blog writing is something I do, and I genuinely find your content to be exceptional. This captivating article has sparked my interest. I've ensured to bookmark your website and stay updated with new details, typically on a weekly basis. Additionally, I've subscribed to your RSS feed. Azerbaijan visa for british can obtain a visa online or on arrival for short stays. The e-visa process is straightforward, requiring an application and fee payment through the official portal.

Egypt e visa for Indian cost said...

Immersed in your blog post, it felt as though I was journeying through the corridors of human cognition, with each thought emerging like a bud of introspection. Your narrative artfully nurtured deep reflection, compelling me to delve into the nuances of thought. Thank you for crafting such a resonant piece that echoed my own inner musings.

How much cash can I carry for Umrah from India? said...

Your blog is a hidden gem I'm glad to have found! The topics you explore are not only relevant but also thought-provoking. Your writing style effortlessly combines depth with accessibility, making each post a joy to read. I find myself continually inspired and enlightened by your content. Thank you for sharing your passion and knowledge with the world!

apply for Indian e visa from Australia said...

Despite your smooth delivery, I'm finding this topic rather perplexing and extremely broad. It appears too intricate and overwhelmingly expansive for my comprehension. I'm keenly anticipating your next post, and I'll make a concerted effort to get the hang of it! Remarkable, what an enlightening website! This platform provides indispensable insights, keep it up.

Ethiopia visa Sweden said...

"What a fantastic read! This article really got me thinking with its fresh perspective. The writer's engaging tone kept me hooked from start to finish, and I couldn't help but agree with every point made. Plus, the actionable tips shared here are gold! It's not often you find content that's as informative as it is motivating, but this post nails it. Major props to the author for packing so much wisdom into such a succinct piece. Can't wait to pass this along and keep the discussion going!"

Johanson said...

Writing blogs is habitual for me, and I truly appreciate your exceptional content. This intriguing article has sparked my interest. I've made it a routine to bookmark your website and stay updated with new details, typically on a weekly basis. Furthermore, I've subscribed to your RSS feed. "e visa for Bahrain offers convenient online application, simplifying travel processes. Obtain your visa swiftly, enhancing accessibility and promoting tourism. Experience Bahrain's rich culture hassle-free with e-visa convenience."

Turkey visa for Mexican citizens said...

Making the transition from newspapers to the internet for my daily reading has been a thrilling journey! 📰➡️🌐 Wanted to drop a quick note to say how much I'm enjoying your articles. Any other online havens you'd suggest for exploring similar topics? Thanks a bunch! 🙏

Saudi Umrah visa from USA said...

Your blog is an absolute treasure trove of wisdom and inspiration! The way you effortlessly blend engaging storytelling with profound insights is truly commendable. Each post leaves me enlightened and eager for more. Thank you for consistently delivering such high-quality content that nourishes both the mind and soul!

Egypt visa for UK resident said...

Your blog post encapsulates the essence of human contemplation, leading readers through a maze of thoughts and emotions. Your eloquence paints a vibrant canvas of ideas, stirring a chorus of reflections within. Thank you for sharing such profound insights and igniting a flame of inspiration within my soul.

eta Kenya single entry visa application form said...

Your blog is a breath of fresh air, offering respite akin to a cool breeze amidst a scorching day! Your content intricately weaves together depth and simplicity, rendering even intricate concepts effortlessly comprehensible. Your storytelling prowess is enthralling, whisking readers away on exhilarating adventures with each post. The meticulous attention to detail and strategic use of visuals significantly enrich the reading journey. Bravo on your remarkable work – you've secured a loyal follower eagerly anticipating your forthcoming pieces!

can i travel to Turkey with schengen visa said...

This article presents a thought-provoking take on a subject that's frequently sidelined. It delves into the intricacies, illuminating facets seldom explored. The prose is captivating, ensuring readers remain captivated throughout. The inclusion of personal anecdotes adds a relatable dimension, enhancing engagement. In sum, the piece not only educates but also ignites a sense of curiosity, prompting further exploration.

How much is a Tourist visa for India from UK? said...

🌌 This blog post completely captivated me with its enthralling content, offering a profound examination of its subject matter that held my interest until the final word. The author's adept management of intricate concepts is evident throughout, resulting in a truly enlightening experience. I especially appreciated the seamless flow of the narrative, which made it effortless to follow and remain engaged. 📝🔍

US Issued Nearly 54000 E2 Visas in 2023 said...


🌈 Thank you for sharing such an amazing post! Your writing is truly exceptional, and where else could one find such valuable insights? With a presentation coming up next week, I'm eagerly looking for content as enlightening as yours. Your passion and expertise shine through your work. The world needs more writers like you, unafraid to voice their beliefs. Keep following your heart! 💖

How to check Indonesian e-visa status said...

🌟 We've journeyed from another digital realm and found ourselves here, pleasantly surprised. Engaged by the content, so we're becoming devoted followers. This tip is a beacon for those just setting sail in the blogosphere. Short, but oh-so-informative—thanks for sharing this essential advice! 🚢

how much is a visa to India from UK said...


Wow, this post really got me thinking! The insights you've shared are truly eye-opening and thought-provoking. Your perspective adds a refreshing twist to the conversation. I appreciate how you delve deep into the subject matter, offering a unique angle that I hadn't considered before. Your writing style is engaging and concise, making it easy to follow along and absorb the information.

Indian visa for US green card holders said...

Your website's remarkable loading speed is a testament to your expertise as a webmaster. It's as if you've discovered the secret to digital efficiency. Additionally, the content is outstanding, showcasing your in-depth understanding of the subject matter. Your dedication to providing valuable insights is palpable, making discovering this blog feel like finding a hidden gem on the internet!

documents required for Cameroon visa said...

Your blog is a goldmine of captivating insights! The seamless fusion of expertise and lucidity is truly impressive. You have a remarkable knack for captivating readers, ensuring they're engrossed from beginning to end. Your writing style stands out amidst the crowd, offering a refreshing perspective. Applause for consistently delivering enriching content that's both informative and delightful. Eagerly awaiting your next post!

Egypt tourist visa for Australian citizens said...

That's frustrating! Spent ages composing a detailed comment, only for it to disappear upon submission. Ah well, rewriting it seems daunting. Anyway, just dropping by to commend your terrific blog! 👏


william said...

In your blog post, you embark on a captivating literary journey that effortlessly traverses the realms of intellect and emotion. The seamless blend of profound insights and relatable anecdotes is truly remarkable. Do australia need visa for Turkey Yes, Australian citizens require an visa to enter Turkey for tourism or business purposes. The Turkey e-visa allows Australians to apply online, streamlining the entry process. With simple application steps and essential documentation, obtaining a Turkey visa ensures smooth travel arrangements for Australians visiting Turkey

Turkey visa for chinese citizens said...

Your blog serves as an enchanting sanctuary brimming with knowledge and ingenuity! The meticulous examination of various subjects with lucid precision is genuinely admirable. Each post unfolds like a voyage of enlightenment, leaving readers enriched and invigorated. Your steadfast dedication to disseminating invaluable insights is palpable, rendering your blog an indispensable asset for seekers of wisdom. Gratitude for consistently providing stimulating content that inspires and educates!

Azerbaijan visa for Pakistan said...

This blog post truly resonates with me! Your ability to articulate complex ideas in such a clear and concise manner is commendable. I find myself nodding along with every point you make, as your insights hit the mark every time. Your writing exudes authenticity and expertise, making it a joy to read. I eagerly anticipate diving into more of your thought-provoking content in the future. Keep up the fantastic work.

India e visa online said...

Your post is absolutely fantastic! Discovered your blog and was thoroughly impressed by your captivating content. Subscribed to your RSS feed and eagerly awaiting your next installment! A big thank you for your dedication to this blog. Your creative writing abilities have motivated me to begin my own blogging journey. 🌈📝

Kenya eta visa status check online said...

Your post is absolutely fantastic! Your blog's captivating writing style is simply irresistible. Subscribed to your RSS feed and eagerly anticipating your future posts! Much gratitude for your commitment to this blog. Your creative talent has encouraged me to start my own blogging journey.

Madagascar visa for indian passport holders said...

Your insights are a beacon of light 🕯️, guiding me to bookmark your weblog for regular visits. I'm eager to embark on the journey of learning with you. Best of luck with your future endeavors! This topic definitely deserves more discussion, despite the discomfort it may bring. Here's to breaking the silence! 🌈

how do i get a visa for India from Australia said...

Your post effortlessly engages readers with its unique perspectives and stimulating discussion. The way you seamlessly weave together various ideas keeps the momentum going, ensuring readers are fully immersed from start to finish. Your talent for making intricate concepts accessible is truly admirable. This piece undoubtedly elevates the discourse surrounding its subject matter.

Online visa application Saudi Arabia said...

Incredible post! Your knack for breaking down complex ideas is truly admirable. Your friendly tone creates a welcoming atmosphere, making readers feel right at home. Your insights are both enlightening and entertaining, keeping me engaged from start to finish. It's refreshing to find content that's not only informative but also enjoyable to read. I'll be eagerly awaiting your next piece. Keep up the outstanding work.

Ethiopia evisa for uk citizens said...

I'm in awe of your blog! Subscribed to your RSS feed and eagerly await more of your amazing content. Shared your website on all my social networks; it's priceless to me. If only all bloggers crafted content as remarkable as yours, the web would be a much richer landscape.