When the National Health Service goes digital

Healthcare Technology
A digital-first primary care approach by the National Health Service (NHS) in England promises quicker access to general practitioners (GPs), attractive working conditions for staff and cost savings for the organisation. However, to roll out the strategy nationwide, the digital services will need to be properly integrated into the rest of the NHS primary care services, not least because face-to-face appointments will still be needed in some cases.

The NHS Long-Term Plan sets out that by 2023/4 every patient in England should have access to digital-first primary care. In 2017, Babylon GP at Hand (BGPaH) started providing NHS primary care in London allowing patients to book video consultations. The platform also provides in-person services should patients require them at sites in and outside of Hammersmith & Fulham Clinical Commissioning Group (CCG) area. Patients needed to live within a certain proximity to BGPaH’s GP surgeries or work in London zones 1 -3 in order to be eligible. 

Popular with younger users

The BGPaH service has allowed NHS patients to speak to a doctor often within half an hour, as opposed to several days or weeks as it is sometimes the case with in-person appointments at GP practices. 

Patients registered at BGPaH were younger than patients at the average practice in London and nationally, the independent evaluation report of the pilot noted. The vast majority of BGPaH patients are aged under 45 (94%). Large numbers of older patients with more complex health needs shunned the digital service. However, this may change over time.

“The early adopters are unlikely to give up the digital channel when they get older, especially if it continues to improve,” says Tom Hester, Vice President, Healthcare at Lockton. “If a digital option becomes popular and is rolled out nationwide, eventually the user profile will become more diverse as time goes by,” Hester notes.

Convenience and easier access to GPs were the main reasons for joining BGPaH regardless of differences in patient demographics, the report noted. Access to a GP was regarded as more important than all other considerations, it added.

“It was to be expected that digital first services would appeal to a younger demographic,” says Umang Patel, Clinical Director at Babylon.

Patel adds that many older patients hesitated to sign up for the digital first service, but once this is done, this age group also appreciates its advantages. “If you can use WhatsApp you should be able to handle BGPaH. Particularly people who may find it difficult to travel to and from GP surgeries should find it a useful solution,” he adds. 

Taking pressure off GP clinics

Digital (video or telephone) consultations were by far the most frequently used aspect of the BGPaH service, with face-to-face appointments being used far less frequently. This could mean that surgeries will become less busy and face-to-face appointments more frequently available if BGPaH were scaled up in England.

“Clinics would be able to focus on the more complicated cases and the more vulnerable patients, which is what the NHS was originally created for,” Hester says.

BGPaH also offers an artificial intelligence (AI)-powered interactive symptom checker which asks the user questions to analyse their condition, gives medical information and triage advice on what to do next.

While patients in the qualitative interviews did not feel that the symptom checker could replace the need for a consultation with a GP and they would seek a second opinion in most cases anyway, over time, the online symptom checker may gain in importance.

“The platform is a great way of learning from data,” Hester says. “Technology is constantly improving and the system will become more effective and accurate over time. While the assessment of the symptom checker may in most cases need to be reviewed by a GP, it will save time and enable more patients to get treatment,” he adds.

AI technology is progressing fast in medical imaging and diagnostics. Already today it can screen patients for diabetic eye disease (diabetic retinopathy) without the need for a second opinion from an expert.

“AI can find patterns in data that can reveal new indicators for conditions a human could never develop,” Hester says.

Science is creating ever more diagnostic applications that can be used with conventional cameras such as the ones included in smartphones. In combination with a traditional urinalysis dipstick a smartphone can now monitor a range of urinary infections. Users just need to take a picture of the stick with their smartphones and the test detects infections and pregnancy-related complications. Computer vision algorithms calibrate the results to account for different lighting conditions and camera quality.

Furthermore, analysis of retinal images and voice patterns using neural networks could potentially help identify risk of heart disease, according to researchers. 

Impact on the NHS structure

GPs appreciate the autonomy, flexibility and independence BGPaH offers, compatibility with family life, and the potential for development and career progression, according to the evaluation report. The majority of GPs work exclusively remotely from home one to two days per week, whilst also working somewhere else, often as locum GPs.

But the BGPaH evaluation also raised some concern over the continuity of care provided as the model entails a constant change of GPs for patients. However, Patel dismisses this concern:

“There is a romantic view about the patient-GP relationship, but demographics in big cities are fairly fluid so most people don’t have a very strong relationship to a single doctor,” says Patel. “And Babylon allows appointments with a particular doctor in some cases such as with long-term diseases,” he adds.

One of the weak points of the BGPaH pilot may be the fact that face-to-face appointments had to take place at one of five locations across London, which caused some bottlenecks as BGPaH patients exceeded 54,000, the report suggested. In qualitative interviews some patients complained about the number of clinic locations available for face-to-face appointments, waiting times to book an appointment and the amount of distance travelled.

Digital services cannot replace all face-to-face appointments. In cases of pregnancy, for example, an in-person appointment may be essential.

“This particular design was selected to allow Babylon to take full ownership and responsibility for the patients and a complete integration of medical services,” Patel explains.

However, this may have to change in the future, according to Hester: “For the system to work nationwide, patients may eventually need to stay registered at their local GP while using the digital service first, which would then give the patient a face-to-face appointment at their local GP if necessary,” Hester says.

The new set-up would, however, require full integration of the computer systems and records from Babylon BGPaH with the local general practices where the patient is registered.

The digital services could, potentially, also help improve access to GP services in underserved areas. But a nationwide roll-out of the digital-first strategy will require a reorganisation of the way the NHS is funded.

The BGPaH has generated a £23m unmet liability for its commissioner, Hammersmith and Fulham CCG, which, under current rules, is required to meet all health costs of patients registered with the practice, even those that live outside northwest London.

“If BGPaH was rolled out nationwide as part of the digital-first primary care strategy, the funding of the service should be carried by the whole NHS as it reduces the pressure on the whole system,” Hester says.

“Any cost savings produced by the digital service could be reinvested to improve the primary care services,” he adds. 

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