Interview: Dr Mobasher Butt, Pulse's most influential GP for 2018
Pulse spoke with Dr Mobasher Butt, medical director at GP video consultation provider Babylon, to find out about plans for expanding its NHS GP at Hand service and how the GP defends the organisation in the face of criticism.
PULSE: What has been your standout moment of the past year?
Dr Mobasher Butt: There’s definitely been quite a few standout moments.
Our big achievement was announcing the launch of the GP at Hand partnership.
That was launched in November of last year and, and it’s been one of the fastest growing services in the NHS’s history, a really revolutionary new service.
It’s the first of its kind in the whole of NHS’s 70-year history and, this being the 70th year, it’s quite a landmark.
We have had over 50,000 people apply to that service.
It’s a truly digital-first service that allows patients to access NHS care from a GP, 24 hours a day, 365 days a year and it’s been amazing seeing how people have sort of flocked to that service, but also what interesting things that happen when you actually provide access at times that suit patients and when they need that care.
We’ve already seen from some early data that about a third of consultations happen in what would normally be deemed out of hours, but of course that’s just when we have previously chosen to open our surgeries.
Actually when you open it up at times that suit patients it clearly meets a need at those times. That’s helping patients in the UK, and then the other big achievement has been helping patients globally.
We launched our service in Rwanda in 2016 and that’s continued to grow with considerable pace, so we’ve got about 20% of the adult population registered in Rwanda.
I’m also really passionate about improving the lives of our clinicians and we’ve launched a really exciting new adventure in the last couple of months which we believe is probably one of the world’s first digital hubs for doctors, in Soho in London.
So this is somewhere where doctors can go and work together in a team but deliver healthcare in a way that they haven’t done previously, which is through digital technology and delivering virtual consultations.
But it's fostering a team environment and recreating all the great bits of general practice, which is about being able to share best practice and being able to share knowledge
The final thing in terms of big achievements is technology and the kind of progress we’ve made with our artificial intelligence.
It was a really proud moment when we had a big event on the 27th June at the Royal College of Physicians and after months of hard work were able to show that actually the AI is now performing on a par with doctors. Not when it comes to doctors as a whole, but obviously one aspect of what doctors do, which is about diagnosis.
Being able to demonstrate that, at the level that a GP would be expected to work and provide that kind of diagnosis - that now the technology’s caught up – is incredibly exciting.
Especially when you think about countries like Rwanda, where actually doctors are a really scarce resource.
PULSE: How do you measure the success of GP at Hand?
MB: The main thing for us is all around patient satisfaction.
So obviously things like the number of people being registered is a good sign that this was a service that didn’t exist before, has been created for NHS patients and there’s really good uptake.
That shows there was a demand there that wasn’t previously being met. And hopefully what this will do is pave the way for other people to innovate in a similar way so that these kinds of services are available to as many patients as possible.
For me, the thing that’s really telling is patient feedback and, you know, the fact that 90% of people rate their experience four or five stars.
It’s really showing that for all sorts of patients there’s a real need for this kind of service.
I will tackle the question which I’m sure you’re going to ask head on, which is what are these allegations about cherry-picking.
That’s obviously been a rather unfortunate narrative that’s resulted after launch.
The truth of the matter is that NHS England took a conservative approach to say it’s wise to recommend to people, if they are a bit unsure about the service, that they should contact you to make sure it’s suitable before they sign up.
It doesn’t say that they mustn’t sign up or that as a provider we’re free to pick and choose.
But of course we do have a duty of care and responsibility for those patients to make sure they know what they’re signing up for.
The truth of it is we’ve had all sorts of patients sign up, and people with complex care needs - so much so that we’ve developed a whole complex care team.
That is a really good achievement - making sure that these kinds of services are not just for people who are tech-savvy.
This type of technology potentially stands to benefit those with really high levels of care needs the most, because if you’ve got problems with mobility, or maybe you’ve got a really complex chaotic lifestyle, having the ability to access a healthcare professional quickly is really, really important.
PULSE: What are your plans for expanding GP at Hand?
MB: With such great traction in London it would be great to be able to offer this service to patients across the UK.
We already know there’s a demand from patients living in other cities but who are not yet eligible to apply for the service so we would like to definitely roll it out to other cities in the UK.
We would start in England. There is definitely interest from the other nations - Scotland, Wales, Northern Ireland.
Major cities are a good place to start in some ways because we’ve got experience of serving a similar kind of urban population.
However I think it’s also really important that actually the plans also include areas where patients really need this type of service.
If you think about areas that are struggling - where maybe it’s quite hard to recruit GPs because of various different reasons - clearly patients still need health care services in those places.
We know about 85% of cases can be dealt with entirely via virtual consultation.
What that means is that you can potentially deliver care from a different location but then just have a fewer number of GPs who are there in that population to actually do the physical care that’s needed. Rather than having to have a full complement of GPs.
That really helps make sure that surgeries don’t close in areas that really need them but where people are struggling to get GPs into jobs in those areas.
Despite really good efforts from the Government to try and increase GP numbers or training places, the reality is people want to live in certain areas - unfortunately that sometimes comes at a cost to patient care.
We’re ready to expand as quickly as possible. Clearly we’ll do that in a way that is safe and that complies with any requirements from NHS England.
PULSE: When you say 85% of cases can be dealt with entirely through virtual consultation, what have you modelled that on?
MB: That’s literally hundreds of thousands of patient records.
Almost every quarter it’s the same, where we do auditing of how many consultations could be dealt with entirely via the video consultation - as in the patient didn’t need to go see someone face to face, or they didn’t need any kind of referral - so that gives you an idea of how much can actually be dealt with safely through a virtual consultation
It’s not actually dissimilar to what you see in [traditional] general practice, what we’ve been doing through telephone triage for years.
With surgeries that do telephone triage, normally you can deal with about two-thirds of patients just on the phone, and about a third you’d need to invite in for a same-day assessment.
So having the video on top of that - you can see why you suddenly get that extra 20% that you can manage safely via video.
PULSE: Is your plan to continue using Dr Jefferies and Partners in west London as the host practice as you expand to other locations?
MB: Current plans would be to extend our offering from our existing partnership.
We constantly get approached by other partnerships and groups of GPs who are interested in collaborating and so we certainly wouldn’t be averse to thinking about other models for the delivery of digital-first care.
I don’t think there’ll be a single solution that fits all and I think as we expand these kinds of services and technologies to benefit more patients, thinking about different models that work for different localities is really important.
PULSE: How many practices are you in discussion with about moving into partnership with via a GP at Hand model?
MB: I’d say tens of practices. I don’t think it’ll be as much as 100 but I hope that gives you an idea.
There are inbound requests that we get from partnerships, from individuals, from people who sort of say “Look, we think this sounds really brilliant how would we implement something like this in our in our local area, and what would that look like?” ’
PULSE: What barriers are there to the expansion of GP at Hand?
MB: The great thing about the model is that it doesn’t actually cost the NHS a penny more because it’s not like introducing something new that requires a new type of funding.
It’s just about improving the delivery of care and making it more accessible.
There’s no change for the funding formula, you don’t get paid differently, you’re just like any other practice. You’ve got a list of people, your CCG pays you per patient, per year, and the way that that’s calculated is exactly the same as for any other practice.
Like any practice, it’s up to each practice to decide how best to spend that money for their patients, how to make sure that they can provide all the services that their population would need.
What’s been interesting from a lot of the debate that’s ensued after the launch of GP at Hand is it’s very much around funding.
So some people will say “What would happen if lots of young people suddenly went off and registered with GP at Hand, how would we look after old people?”
Now the reality is you get different amounts of funding for younger people and older people.
It’s quite a big difference, so for an 85-year-old female, you get six times more money than you would say for a 25-year-old male.
Now that’s quite a big difference - and of course there’s a good reason for that because the care needs of an elderly female patient would be much greater than a young male patient.
I think some of the arguments that people have been making are saying “we don’t have enough money and we currently rely on the fact that we get money for younger people, but we don’t use it on the young people, we use it on the older people - and that’s how we kind of get by".
Now, in my mind that’s advocating for kind of continuing to fudge the existing funding arrangement.
Basically people are saying it’s not working - rather than saying “well okay if we don’t get enough money per old person then surely we should be advocating for adjustment of the funding formula so that we can meet the care needs of those older people”.
Rather than saying “well it’s quite good that we’ve got young people on our books who we don’t actually ever have to look after but we get money for and we’ll spend that on someone else".
Personally I think it certainly shouldn’t be used as a reason to stop innovation.
If we have problems with the funding formula then we should all work collectively to think about how do we fix the funding formula, not start saying let’s try to thwart innovation in some way.
PULSE: How far has GP at Hand introduced an element of competition to general practice that hasn’t been seen before?
MB: Firstly there’s a kind of an element of competition that exists in primary care anyway. You’ve already got large groups, federations, who might be competing with single-handed GP practices.
But importantly it’s an even playing field. Any practices are able to think of innovative ways to provide care for their patients and there’s nothing about the launch of GP at Hand that precludes anyone else from forming similar innovative solutions for their patients.
We’ve got to think what’s in the best interest for patients and if other people do want to compete - if that’s the right word - and provide equally good services for patients, then in my mind that can only be a good thing because more people will benefit from excellent technology and better access.
PULSE: If other practices aren’t able to innovate, how far does GP at Hand threaten their existence?
MB: There’s nothing to stop anyone from doing innovative things for their patients.
Some practices are doing some fantastic things for patients - providing a digital-first service is only one way of providing excellent care.
There are some practices depended on by their population who are doing some brilliant pieces of work up and down the country.
GPs work so incredibly hard to provide really, really good care for patients and I think if you look at outstanding practices, some of the services that those practices offer and the kind of care that they’re able to give patients is second to none.
I think we should be really proud of primary care in the UK, except that we need to look at all sorts of innovative solutions, of which a digital-first solution is one. But that doesn’t mean practices can’t choose to do other innovative things for patients, which may or may not involve digital technology.
I think it’s trying to get to a place where everyone’s trying to pursue innovation and that could be a brilliant nurse-led clinic, or a brilliant pharmacy-led clinic. It doesn’t just have to be something involving artificial intelligence or technology in the way that we’re doing that.
PULSE: Could the shift towards digital-first primary care result in an end to face-to-face consultations?
MB: I think there’ll always be a place for face-to-face care and I think GPs play such an important role in the community that the provision of care is only one aspect of what GPs do.
We know that even during the process of delivering digital-first care, there are certain things where you have to see a patient - either to perform a certain sort of examination, you might be doing vaccinations, cervical smears, all sorts of things where of course a face-to-face encounter is really important.
So the way I would view digital-first care is it’s a good way of streamlining care, being able to deal with things that don’t need a face-to-face encounter but can be safely dealt with through a virtual consultation - and then freeing up that kind of physical space and physical time to actually deal with issues that really warrant a face-to-face assessment.
PULSE: Are there clinical risks associated with patients seeing their GP through a video consultation first?
MB: The most important thing if you think about safe care is getting access to a doctor quickly.
With the GP at Hand service, most patients have an appointment easily within two hours of booking.
So if we compare that to perhaps what the alternative might be, where either they might struggle to get a same-day appointment or to speak to anyone - actually in my mind it’s the access that’s really important to helping improve safety.
PULSE: What about the risk of GPs missing something about the patient’s condition or non-verbal cues during a video consultation?
MB: People often talk about this - what if you miss something – [but] you often get a better insight into what’s going on.
Don’t get me wrong, you can’t do everything via video and no one is suggesting that. I can’t currently look inside someone’s ear, I can’t listen to their heart, or their chest, so for those sorts of things we absolutely need to see someone face to face.
But when it comes to say, seeing the back of your throat, examining your tonsils, having a look at your skin rash, having a look at your swollen knee, all of that, you can do just as well, but with the added benefit of being transported into the patient’s home - so you see a lot of clues around.
It’s a bit like doing a home visit as a GP. When I visit someone at home I find out a lot of information about that patient, which is very different from when someone’s got themselves ready and they’ve come into the surgery.
PULSE: How far does GP at Hand’s model undermine continuity of care for patients?
MB: There’s definitely a place for continuity of care and I don’t think anyone would argue against that.
We’re able to offer continuity of care through our service - you can book in to see the same GP or therapist. There are certain types of clinical condition where that continuity of care is really, really important.
I think the idea that people have one GP from childhood through to adult life is sadly something that just isn’t true anymore.
What’s more important is that for certain episodes of illness you have continuity of care, so that if you develop depression, someone looks after you from the first consultation through to you being stable, on treatment.
I don’t think you need that GP to be with you for the whole of your life - but they do need access to all your medical records, and they do need to be able to review all of your data and so those are the things which are important.
PULSE: How far do you think traditional general practice should be shifting towards the GP at Hand model?
MB: I think the key thing for everyone is to really be thinking about how do we introduce innovation into primary care so that we can continue to preserve NHS services that the rest of the world looks towards as a beacon of best practice.
I think whether we use technology to do that, whether we use other innovative solutions to do that doesn’t really matter, but it’s important that we continue to progress and for our delivery model of primary care to meet the needs of patients as times change.
PULSE: How do you defend yourself against allegations of cherry-picking patients and destabilising general practice?
MB: The allegations of cherry-picking are just simply not true.
NHS England, at the start of GP at Hand, advised that for certain patients group it would be advisable for them to make sure that they understood the service before signing up.
These categorically are not exclusion groups and it’s very clear on our website that they’re not exclusion groups.
What we’ve seen is quite the opposite, we’ve seen patients with complex care needs present to our service, where actually this is a fantastic service for them because it offers them fast access without having to leave their home.
We simply can’t pick patients. Patients choose us and patients are choosing us in their thousands… We have in the region of around 30,000 patients.
PULSE: Under a GP at Hand style of partnership, how is the funding split between Babylon and the practice?
MB: It depends on what the GP practice expected from Babylon. We could provide a full service where we look after that person from digital through to physical, which is obviously what we do with GP at Hand.
But some practices might be interested in only using our technology - so they might only want to use the kind of symptom checking function to triage patients or they might want to use our clinician portal in which a GP can actually see the person via video.
The bottom line is it doesn’t cost the NHS a penny more. The NHS is paying for a practice to look after its patients and that practice is free to choose how to spend that money.
If a practice decided to commission physiotherapy services or get a pharmacist to deliver more care, there’s all sorts of things that happen in different practices.
It’s not really a question of how much money… the partnership basically just gets exactly the same money as it would if Babylon was not even in the equation, so it doesn’t really make any difference, it’s not like they’re getting more or less because they’re offering a digital-first service.