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A new initiative for a private company to deliver NHS care in London was launched last month. Catchily titled GP at hand, it promises access to your GP remotely through a video consultation from your hand-held smartphone or tablet. It guarantees a same-day appointment; but if you need to see a health professional in the flesh, you can go to one of six clinics located in London.
GP at hand is run by Babylon Healthcare Services Limited, a commercial outfit that can be traced back to a holding company in Jersey. Heading up Babylon is Ali Parsa, ex-Goldman Sachs banker and former Chief Executive of Circle, the company at the heart of the failed experiment to privatise the management of Hinchingbrooke Hospital near Cambridge, and which resulted in compromised patient care and a costly bill for the taxpayer. Amongst Babylon’s investors is Demis Hassabis, founder of the DeepMind company which was recently caught up in a controversy with the Royal Free NHS Trust over concerns about inadequate protection of patient data.
Patients will register with GP at hand as their GP practice. Every patient registered will come with an allocation of public money that will effectively be the payment to GP at hand for providing NHS primary care.
This allocation of money per registered individual is one of the main ways that GP practices are funded, and is often called a capitation fee. The fee is set by the Department of Health, and adjusted for individual practices to accommodate factors such as the estimated level of disease burden and socio-economic deprivation of a GP practice’s patient list.
The way GP practices are funded is actually more complex. For example, they are also paid for achieving certain targets, or providing additional specialised services. However, a key feature of the funding model is that budgets are set for populations, rather than individuals. Thus, the capitation fee of all individuals on a GP practice list is combined into a single (and larger) budget that is used to plan and provide services.
Traditionally, the practice list is made up of a mix of people (old and young, healthy and unwell) who live nearby. Such a system affirms two key traditional principles of the NHS. Firstly, that NHS funding is pooled to allow the healthy to subsidise the costs of treating those who fall sick or are injured. Secondly, that healthcare services are organised around geographic areas to enable better integration and coordination with local hospitals and local authority services.
GP at hand is set to undermine this model of primary care. It is looking to register patients who live or work within anywhere within 35-40 minutes of one of the clinics - either home or work, provided they are happy to see their doctor remotely by video and willing to travel to one of six clinics in London should they need a physical consultation. One way that private companies maximise their profits is to seek to ‘cherry pick’ low-cost patients who are generally healthy and young while excluding patients with complex needs who will need higher levels of care. This concern was raised by the Chair of the Royal College of GPs, Helen Stokes-Lampard, who said in response to the launch of GP at hand that “we are really worried that schemes like this are creating a twin-track approach to NHS general practice and that patients are being ‘cherry-picked”. Indeed, its own promotional material discourages older people, pregnant women and anyone with ‘complex’ social, physical and psychological needs from registering, noting that the NHS feels these groups would be "less appropriate" for the service.
It’s not hard to see how this cleaving of populations between those who are relatively young and healthy and those who may need physical consultations, home visits or urgent treatment could result in a widening of inequities. A divide will also be created between companies like GP at hand who will run a profit driven system of care for selected clients, and traditional GP practices who will remain committed to the principle of holistic and integrated care for all in their local community.
In theory, the fee paid to GP at hand could be reduced to reflect their younger and healthier client list. Currently, we don’t know what fees and payments GP at hand is getting from the NHS. However, we do know that the setting of more specific risk-adjusted capitation fees would be complex and costly. We also know that for-profit companies will be expected to game the system in their favour, and that attempts to regulate such behaviour will add further costs for the taxpayer (with no guarantee of success).
GP at hand is perhaps the logical extension of controversial changes made in 2013 which allowed individuals to register with GP practices outside the local area of their home, such as where they work. Although ‘commuter practices’ and ‘electronic practices’ like GP at hand might be more convenient for some individuals, they can diminish the efficiency of the health system as a whole.
This is not to say that we should deny or ignore developments in information technology and artificial intelligence. The ‘digital health revolution’ has the potential to improve healthcare, including for the frail, elderly and chronically unwell. And one can argue that new technologies should be disruptive of old models of service provision.
But technological disruptions should also be socially managed to avoid unwanted effects or inadvertent harms. They should also be harnessed to improve the quality of the healthcare system as a whole and for everyone, not just cheapen the cost of delivering care. And they should not be a Trojan Horse for private capital to exploit the NHS and undermine those features that make it fair, trusted and hugely respected across the world.
The NHS should work with private digital companies. But not through this particular model of primary care, and perhaps not with a company that can be traced back to a holding company based in Jersey and to the Hinchingbrooke debacle.
openDemocracy asked Babylon for a statement responding to the concerns raised in the piece. They responded that “Babylon’s mission is to put accessible and affordable healthcare in the hands of every person on earth” and that they were “leading the way in using technology to make it more accessible to all”, adding ''This new NHS service makes it easier for patients to see a doctor quickly at anytime and from anywhere and doesn’t cost the NHS a penny more. It’s a win win.”