GP at hand is a new digital healthcare app undergoing trial by the United Kingdom’s National Health Service (NHS) in certain areas of London. Powered by babylon, a private digital healthcare company that operates its own app along similar lines, the technology allows patients to enter their perceived symptoms and then book an appointment to see a doctor online, through their cell phone, at any time of day or night. While there are a number of private healthcare apps offering a similar service, this one differs because it is being offered as an alternative NHS practice to traditional local general practitioners (GPs or family doctors). Patients can register to use GP at hand as their primary clinic. That has led to the accusation that the app is not intended as a supplement to local health services (which, in the NHS, are largely free of charge), but as a replacement for them.
How it works
As with its London parent company babylon’s app, GP at hand works by allowing people to book an appointment to talk to a qualified general practitioner within two hours via their cell phones or computers. A doctor calls back at the appointed time and discusses the patient’s symptoms. The doctor might also ask for the patient to show them physical manifestations of those symptoms, such as rashes or lumps, or to perform simple checks such as feeling their own glands. If the internet connection drops, the doctor will call back.
The appointment is recorded and can be replayed at any time, and the doctor’s notes are also available to view.
The app also employs a triage system — an interactive symptom checker that asks questions and offers suggested answers about the symptoms being experienced. This aspect of the service has been developed, according to babylon, by a team of doctors and scientists using the latest artificial intelligence technology.
If the symptoms are considered by the algorithms to warrant further investigation, the patient is offered an online appointment, or an appointment in person at a clinic participating in the trial. NHS prescriptions are processed just as they would be at a traditional doctor’s appointment, and referrals to specialists can also be made.
The service, because it is being offered on the NHS, is free of charge at the point of use. babylon says that data is encrypted and secure, and that over one million people have used the service — with 92% of all medical issues resolved after one digital consultation.
In the UK and elsewhere
The babylon app, on which GP at hand is based, has won a number of major awards. The Wall Street Journal named Babylon Healthcare Services Ltd. in its list of “Tech Companies to Watch,” and UK IT Industry Awards 2015 awarded it Mobile App of the Year. It also claims a 94% satisfaction score among users. The fact that a consultation can be had from anywhere has made it popular with many whose busy schedules make it difficult to take time away to see a doctor in person.
babylon claims that the company was founded in 2013 with one purpose alone — to offer accessible and affordable healthcare to everybody on the planet. Its founder and CEO, Ali Parsa, says that developments in digital technology have made it the right time to try.
Although only currently available in the United Kingdom and Ireland, there are plans to roll out the technology in Rwanda, plugging huge gaps in the healthcare infrastructure there, particularly in remote communities. According to the company, almost 10% of the adult population registered with the app (called babyl in Rwanda) in the first six months, with over half a million registered users there. Parsa argues that, in a world where 50% of the population have little or no access to healthcare but where cell phone use is becoming much more widespread, it made sense to put healthcare on people’s cell phones so that it can be delivered no matter where those people are.
The babyl app is localized for Rwandan use, operating in both the English and Kinyarwanda languages, the latter of which is spoken by nearly the entire population and is a dialect of Bantu. Consultations also take place in both languages. Frequently asked questions, and terms and conditions, are available in Kinyarwanda on the English language app. Another localized aspect of the babyl service is the way in which conditions are designated for consultation. In line with the Rwandan Ministry of Health’s preferences, musculoskeletal, dermatological and ear, nose and throat issues are dealt with by video, while gastroenterological, respiratory and mental health conditions are dealt with by audio consultation. At present, 25 doctors (and associated back-office staff) serve the 600,000+ members signed up to the technology.
In the UK, the Quality Care Commission, the independent health regulator has rated babylon highly and said that the services are safe and effective. Charles Alessi, senior adviser at Public Health England, called the GP at hand app “a true NHS primary care service” allowing people to take control of their own health. Dame Barbara Hakin, formerly a national director in NHS England, referred to the capacity she saw in the service to alleviate some of the stress on the health service caused by a recruitment shortage. A common theme in the praise offered for the service is that it “empowers” patients, and should be embraced by general practitioners who consider themselves innovative.
A service that offers almost immediate access to doctors at a time when many are waiting three weeks or more to see their regular doctor seems like something that would be universally welcomed. One major problem is that access is not available equally to all. A quick look at the app’s terms and conditions shows that people with “complex mental health problems or complex physical, psychological or social needs” might not be suitable users of this technology. The list of groups cautioned to consider other options also includes pregnant women, elderly and frail people and people with conditions such as dementia. London-based general practitioner Naureen Bhatti has argued that any real practice that was so selective in the conditions that it sought to treat would possibly be shut down by NHS England. She also fears that, as practices such as hers are paid per patient treated, the loss of relatively healthy patients to digital healthcare providers leave practices such as hers, in an area which is now part of the GP at hand trial, financially vulnerable.
Another common criticism is that many more vulnerable populations, such as the elderly or people whose English language skills are not good, are left behind. babylon says that it can make translators available if given notice, but even the very act of registering is a barrier for those who do not speak English well. Multicultural communities are often already the poorest in the UK, and the replacement of traditional general practitioner services by digital technology (as is feared by some GPs) is seen by many to leave already-vulnerable communities even further isolated. The same holds true for the elderly, or the poorly educated, or those with learning difficulties, many of whom are digitally illiterate.
At present, the babylon and GP at hand apps are only available in English and minority languages can only be catered for by requesting a translator or a general practitioner who speaks the language, which isn’t always possible. Notice has to be given, which means that vital time can be lost while an appropriate translator is found. There is no indication of plans to serve the needs of ethnic communities, where many may speak little or no English and are thus vulnerable, with the addition of more languages to the app.
A major drawback of the service, in the eyes of its critics, is that there is just no substitute for being physically examined in person by a well-trained and observant medical professional. Subtle clues can be overlooked quite easily in an online consultation. More strikingly, the app’s triage service uses algorithms that can lead it to misdiagnose obviously serious complaints. In one recent example, published on social media, a fictitious 48-year-old, 40-cigarettes-a-day smoker who woke with pain radiating from his shoulder and down his arm was reassured by the app that his malady was probably something that painkillers would treat, and that there was no need to see a doctor immediately.
Babylon claims that its symptom-checker program has been rated better at identifying serious conditions than a check with a registered triage nurse or a junior doctor. For author and general practitioner Ben Goldacre, however, the app is another example of largely technologically ignorant managers at large institutions being sold the modern-day equivalent of snake oil, blinded by a slavish devotion to everything digital and “innovative.” In particular, he criticizes what he sees as the “closed science” involved — where there is no published evidence for the efficacy of the service and no reviewable source code.
Quality going forward
There are legitimate and profound concerns to be addressed when technology such as this is rolled out in circumstances where it can be seen as posing a threat to the continued existence of traditional doctors’ practices — particularly because the loss of such practices would leave the most vulnerable, those with conditions or characteristics deemed unsuitable by the digital healthcare provider, without easy access to free healthcare provision.
The quality of assessment from a remote location, with technology that can be unreliable, by doctors who will not be familiar with the patient, must inevitably be inferior to an in-person examination. In fairness, babylon/GP at hand does offer follow-up real-life examinations when they’re considered warranted, but that presupposes that the initial consultation was thorough enough to find such a consultation warranted. There are certainly major questions to be asked of the quality of triage on offer by the app’s algorithms.
A proposed trial of the technology in northwest London was recently aborted because of suspicions that some patients were “gaming” the system to get quicker access to general practitioners by overplaying their symptoms.
Mobasher Butt, one of those involved in launching the NHS trial of GP at hand, is dismissive of the critics. He points to the fact that NHS England has vetted the service, as have the Quality Care Commission, and argues that it is patronizing to claim that vulnerable populations such as the elderly are being left behind. He believes that people welcome the technology, and that there is no point trying to fight the advent of an age of digital healthcare.
It is fair to point out that many patients are indeed very happy with the service — it offers them convenience in a life lived at a hectic pace. It is also correct that in communities with little or no access to healthcare, particularly in developing countries such as Rwanda, such technology offers a massive potential to plug a gap that has cost many lives and led to much misery.
However, it is not digital Luddism to suggest that even the most cutting-edge digital technology is no replacement for a traditional physical examination by a trained professional. In situations where the latter is at risk of being made less available, particularly in the context of universal free healthcare provision, perhaps more thought should be given to the cost associated with assuming that everything digital is inherently superior.