The rise of online GP consultations in the NHS has divided the opinion of health sector-insiders. Critics condemn the threat to traditional practices and risk of harming vulnerable patients, while proponents praise their convenience and cost savings.
Babylon Health has been the focal point of many of these debates. The London-based startup is best known as the provider of GP at Hand, an app that offers AI-powered diagnoses and online consultations with doctors that is currently available to anyone who lives or works within 40 minutes of five affiliated London clinics.
The service has grown rapidly since it launched in November 2017. Around 48,000 people have now registered with GP at Hand, making it one of the 10 biggest general practices in the country and it recently gained approval to be rolled out in Birmingham. Babylon has ambitious plans for nationwide NHS adoption, but critics worry about the effectiveness of its treatment and its impact on the NHS.
Doctors have warned that it is disrupting regular NHS services and risking patient safety and Babylon has also had run-ins with regulators. In 2017, the company tried and failed to prevent the publication of a Care Quality Commission (CQC) report that found "the service was not providing safe, effective, or well-led services but was providing caring and responsive services".
Paul Bate, Babylon's director of NHS services and a former executive director of strategy at the CQC, is confident these concerns have now been addressed. He argues that the system facilitates, rather than replaces doctor-patient interaction.
"We know that something like 90 percent of GP appointments can be safely carried out without the need for the GP and the patient to be in the same room," Bate told Techworld from deep within the bowels of London's cavernous Printworks, the venue for Privatar's In:Confidence conference last week.
"That's much better for the person using the service because they don't have to travel and it's also great for the GPs. It's a better experience for them. Now, there are exceptions. It's digital first, not digital only. If you're a woman who needs a cervical smear for cancer screening, then that is a face-to-face appointment straight away, and there is zero point in us doing anything digital for taking blood, for example. But the vast majority of the time, you can do things digitally, so we ask. That's the model."
Babylon has already attracted supporters in high places. Health secretary Matt Hancock controversially endorsed GP at Hand specifically in a September 2018 interview with The Telegraph, describing it as a "revolutionary" service that should be "available to all, not based on their postcode".
His comments followed reports that NHS England had blocked Babylon's efforts to offer services in Birmingham. The plan included a physical practice in the city but keeping the host service in London, which raised concerns that users of GP at Hand wouldn't receive invitations to national screening programmes as they would be sent to the right address.
Hancock responded by calling for the NHS to change its rules to help the likes of Babylon develop digital solutions and navigate an often bureaucratic and suspicious path into public healthcare provision. NHS England has since retracted its objections, giving Babylon the green light to expand to the UK's second city. Bate believes having a health secretary with a self-professed "unsurpassable enthusiasm" for technology could benefit Babylon's plans to expand its NHS offering.
"As the secretary of state says, if there are barriers to integration or to innovation, the right answer is to take down those barriers," said Bate. "So we were really excited that we were able to expand out beyond London. To have the largest practice in the country, even though it only serves one city currently, just shows the scale of interest there is. It will not be for everybody, but the point is choice.
"Now that we have been enabled to go live in Birmingham - and we very much hope and expect other cities to follow quickly - that's a really positive statement, from the government and from the NHS as a whole, that it wants to see innovative providers of safe healthcare services like Babylon offering their services, and then let people choose."
The expansion to Birmingham is just the start of Babylon's NHS ambitions. The company claims that scores of practices have expressed interest in offering GP at Hand to patients, while healthcare journal HSJ reported in September 2018 that Babylon was speaking to 17 CCGs about its digital services and planning to extend its GP partnership into Southampton and Leeds.
Babylon is entering a potentially lucrative market. The virtual consultation market will grow from 19.7 million consultations in 2014 to 158.4 million by 2020, according to market intelligence firm Tractic. It has also received significant backing from NHS England, which announced in November 2017 that it would contribute £45 million over three years towards the costs for online consultation systems for GPs.
Critics worry that this investment isn't going to the right place. Digital services typically appeal younger, healthier users than sick, elderly patients with more complex and costly healthcare issues, leaving the NHS with less funding for people with greater needs.
Bate is keen to reassure NHS organisations that Babylon Health won't disrupt their services.
"I would assure them that it's great care for patients," he said. "That's the starting point: clinically safe, effective, high-quality experiences for the people using the services. If I go back to 1948, when a leaflet dropped through every family's door - and it genuinely did, at the inception of the NHS - and on the front page of that leaflet, there is a box and in that box, it says 'one: choose your doctor'.
"It's a very explicit answer, because right from the very beginning of the NHS that has been part of the offer, to choose your general practice. And that's enshrined in law. So I don't start from the point of saying does this or doesn't this disrupt the existing practices, but I start with what's the best way to get great healthcare to many people and do it in a way that the NHS feels comfortable and safe about a taxpayer-funded service."
Harry Evans, a researcher at healthcare think tank the King's Fund, believes recent changes to GP contracts have partially addressed this by providing less money for new patients, but adds that the switching of healthcare providers may necessitate a different operating model.
"It's up to GP at Hand if they decide to go and set up their own GP practice, but if that service is something that a significant proportion of the London population wants, couldn't we be providing that through a different model?" he said.
"If you want to go see a GP out of hours, it's commissioned by local Clinical Commissioning Groups. Couldn't we be doing that for video consultations as well if that's something that we think is worth providing? We shouldn't get trapped in the mindset of thinking that all of these problems are unsolvable. They can be solved, but they may well be unsolvable if we want to keep our current model, GP practice, and have video consultations. In which case, we need to think about a different way of delivering that."
Fears of privatisation
Babylon also offers private GP consultations and campaigners worry that it is blurring the lines between public and private healthcare and leading to the development of a two-tier primary care treatment model.
Bate believes that the concerns are misplaced.
"It isn't privatisation," he said. "Almost every single practice that I am aware of is a profit-making body, and that has been the same way in primary care since the very start of the NHS. That's how the NHS was set up for primary care. That's what a general practice partnership is.
"The NHS founding principles are free at the point of need and taxpayer-funded. There is no change to that. Babylon and GP at Hand becomes an option for people to choose. They don't pay for their care. There is no change to the funding structures. I think what we do see is a very small number of quite vocal naysayers, often with quite strong vested interests, who like to jump on whatever they feel can get most interest.
Evans agrees that there is a role for private digital companies in the NHS, but is concerned about the way that their services are commissioned.
"It's usually people outside the NHS that bring the innovation because the NHS is used to doing things the same way," he said. "We need to be open to that innovation and learn how to use it. But what that shouldn't mean is just trying to replicate what's already being done in the private sector.
"I think there's an important role for industry in the sector for doing that, but what it does mean is that the NHS needs to be an intelligent buyer of those products. That's the problem at the moment. I think there is a skills gap, and there are too few people doing analytics and innovation, but I don't necessarily think that's because in an ideal world they would be developing that stuff that the private sector is developing. I think it's because they need to be able to know what they should be buying from the private sector and currently don't have the skills to do that."