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GPs buried under trusts' workload dump

The real problem with Babylon

Editor's blog

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I hesitate to add yet more commentary to what has already been written about the ‘GP at Hand’ service, but I feel that it reveals some fundamental truths about what general practice is for.

In case you missed the headlines, a service was launched last month by the private healthcare company Babylon that will see NHS patients offered the opportunity to register with what amounts to an online GP practice.

London is currently plastered with adverts promising patients they can ‘book an appointment within seconds’ via the service’s smartphone app, and have a video consultation with an NHS GP ‘in under two hours’. It is all perfectly legitimate, above board and arguably more convenient for some patients. But it has generated white-hot rage among GPs. Why?

Because although Babylon says the service is for ‘people of all ages whether you are in good health or not’, its site lists 10 types of patients that the service may be ‘less appropriate for’. When Pulse asked what this means, Babylon clarified that patients – such as those with complex mental health issues, learning difficulties or pregnant women – will have to ‘seek advice’ before registering. It is not clear what the advice will be, but it will come from Babylon itself.

There is a certain battleworn pride in the ethos of general practice that no one should be left behind

This is the reason so many GPs are angry, because it undermines a fundamental principle of NHS general practice: fairness. Everyone can come through the surgery door, no matter how ‘complex’ their needs may be. No one is offered advice about being ‘less appropriate’ for any service.

The funding practices receive is roughly equal for each patient, with healthier people who attend less often effectively subsidising the sicker ones so that those in most need are prioritised. That is how the system is meant to work. How on earth can the NHS approve a service that pulls the rug out from under this delicate balance?

Let’s be honest, if GP practices could ‘cherry-pick’ their patients, perhaps some would. But I get a sense from the GP outrage over the Babylon service that there is a certain battleworn pride in the ethos of general practice that no one should be left behind. This ethos is, rightly, a professional badge of honour but one that is widely taken for granted and misunderstood outside the NHS.

Yet this model is under siege. This time last year, Pulse devoted what has turned out to be a very prescient issue to examining the hidden privatisation of health in the UK, unearthing private hospitals taking on more NHS worktrusts cashing in on private patients – and an explosion of private online GP services, including Babylon.

If any conclusion can be drawn from this sorry mess, it is that we need much greater support for the publicly funded basis of general practice to preserve equity of access and protect vulnerable patients. As overworked practices struggle, patients wait longer for GP appointments and public dissatisfaction grows, private services will seize their chance and this kind of two-tier service will only get more common.

GP at hand may be the first of its kind, but I doubt that it will be the last.

Nigel Praities is editor of Pulse. You can follow him on Twitter @nigelpraities

A Babylon spokesperson said: 'Our service is run under a GMS contract. The GMS contract sum is largely determined by the Carr-Hill formula, a formula which generates a weighted patient list according to a set of calculations about the expected workload generated by a patient, including factors of age, sex and additional needs of patients. This translates to more funding for registered patients who are older and less funding for younger (and hence on average healthier) patients. What this boils down to is that patients have a choice of how they want to receive their care.'


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Readers' comments (18)

  • Surely a clear case for GMC referral

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  • The issue is that Babylon appears to be getting the same payment for a less time consuming, easier and consequently cheaper service than other GP practices. So their model of care iobviously ncreases the profit for the owners of Babylon. This in time is likely to be compounded by the fact that Babylon advertise and poach the easy patients from existing practices.This increases the income divide between itself and other GP practices and makes NHS general practice even more unpopular, hastening its demise.

    I see nothing wrong with telephone and video consultations. Our practice has been doing this for years. However we never discriminated between patients that are easy to manage and those that take longer. That is the issue. If the NHS is going to allow GPs to cherry pick there needs to be a huge difference in payment to reflect this

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  • From HMG’s Treasury macroeconomic perspective health care should generate GDP or at least be cost neutral. This works by keeping workers fit enough to work and so increase their productivity. Decreasing morbidity and mortality for ‘others’ is a drain on the economy.

    The government unsuccessfully attempted to increase GDP by trying to sell the NHS to other countries at the Olympics with Danny Boyle’s extravaganza:

    So the government are trying anything to reduce the costs of the NHS. Demand for healthcare will increase. Healthcare workers are expensive. Getting patients used to receiving virtual healthcare will enable the government to employ cheaper healthcare workers from third world countries without increasing immigration. Their ultimate model is to use AI instead of humans and to decrease the costs of training by employing workers trained only to perform individually simple tasks that AI combined with robots are incapable of delivering.

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  • My instinct is that it was approved to test the water about item of service payment per consultation. People may like the service but the NHS can't afford it so the patient will be asked would they contribute for the convenience of the service. Short step then to charging everyone like the dentists did.

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  • Macaque

    Babylon improves accessibility by bringing the clinicians to your smartphone. One of the technical limitations of this is not having a surgery around the corner when you need a face to face appointment. So, it make sense to limit certain type of patients!

    Maybe Babylon Health is not for the ageing 'baby boomers' but it's the future of healthcare for the tech savvy, on the move 'millennials'.

    It is just £5 a month if you want to use Babylon service privately.

    If I get a chance I would work for Babylon, as I will have control over the number of patient encounters per day! I am very tired of 12 hour days and the bitching/politics/ parasitic behaviour of the GP partners. In my book general practice is privatised as each surgery is a private business! LOL

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  • Exactly right; well done for highlighting it better! If only well people can register (cherry picking like this is specifically forbidden in the GMS contract) your practice will be able to manage with less staff; and everyone from whom you've stripped the subsidisers, will collapse, unable to fund the staff needed for the complex patients. How Babylon got this far without this (and a contract conflict) being highlighted, is concerning.

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  • Just Your Average Joe

    Babylon is a private company not a NHS GP service - poaching from precious NHS resources.

    Nigel I feel you are missing the point or underplaying it.

    Advertising has never been permitted in the NHS, nor has poaching patients from your colleagues practices in blatant underhanded ways - ultimately likely to lead to destabilisation of those practices and potential folding of essential services for all other patients.

    Yet adverts for this Babylon service are plastered everywhere and are already stealing patients from other practices - but only the nice and simple ones who probably need almost no real effort to look after, and minimal resources, hence the set up of this service.

    I am not a Luddite and am willing to embrace change within the NHS - but there has to be a fair and level playing field for all - and services which are non discriminatory for patients - or the same advantages available to all NHS GP practices (though this is not good for patients).

    For every fit and young patient of working age they steal - they are paid the GMS fee - which is taken from another practice. The all you can eat buffet contract currently in place in Primary care - is set up on the foundation of payments for patients is a standard set fee(aware of some weighting - but this is in reality a million miles from true cost to practices of the needy).

    If those patients rarely attend, and cost minimal resources, then that time and resource subsides the frequent attenders, young and unwell, elderly and palliative, and housebound - most of which need huge costs or time and manpower. They are only financially within GP's ability to look after as the subsidy from young/fit patients allow at economies of scale cross payment for that service to continue.

    Loose resources as Babylon takes the cherry from the cake - and the young/fit are no longer available to subsidise the ill/needy, then you would not have resources to maintain GP's or nursing/support staff.

    The remaining patients demand and need would outstrip what the practice can safely offer, and may mean they simply would be swamped with lower staffing levels, and some patients could no longer be seen at home, just because there are not enough hours in the day, and too many complex patients left - leading to potential burn out, and higher hospital and A&E attendances as services start to fail.

    Many overwhelmed practices would find it equally helpful to be able to tell patients wanting to register that they may not be suitable for the practice - turning away the pregnant, the needy, vulnerable, the elderly, housebound and palliative. All the patients who need lots of time and care.

    Since Babylon have a NHS practice to support them, they should be providing this back up services for any patients not suitable for their on-line service.

    No Babylon is not the final straw to break Primary care in its current format, but it could be another large and deep cut, of those thousand small cuts that are slowly bleeding it out.

    There is solution where Babylon subcontracts its services - and as example its 5 pound a month (60 pound a year private fee) could be subsidised and negotiated with a practice, to subcontract out this additional option for patients within their own practice to have access to on-line services, but that would be down to a practice to sign up to this, and would be less destabilising to the whole GP market.

    This would be harder for private companies such as Babylon to penetrate the market and is likely against the politicians privatisation agenda - required as part of the dormant trans-atalantic trade treaty with the US.

    Allowing Babylon to continue as it is - is breaking the stability within primary care - and will eventually lead to severe harm to vulnerable, elderly and housebound patients as the service as it is will become non viable, and a move to payment by interaction - which insurance and private companies desire will be closer to realisation, but financially impossible for the NHS - eventually leading to privatisation by the back door (exactly as some politicians have planned all along).

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  • Vinci Ho

    (1) As I always say , sign of the times . A virtual market was created , whether we like it or not , both demand and need have gone up exponentially. Both will have to be met by supply. Question is what kind of supply and how to provide that.
    (2) Being a generalisation X , I would argue need is far more important than demand . Hence , logically,providing the supply for need should be rewarded more. ‘Cherry picking’ is an issue here because there is no such grading of reward . One can be so liberal about a market but if certain virtues are not maintained, liberty will simply take equality for granted as seen in globalisation up to now.
    (3) I would be happy if all the minor/trivial patient problems encountered are passed to somebody else for televised consultation(phone calls , whatever) if the our practice incomes remain the same. I can concentrate with more of my time ( my new resource) to deal with patients in need .
    (4) Whether one wants to work in a job to provide supply for demand or need is entirely a personal choice and judgement. We are where we are , it is my opinion that some politicians (Lord Vader , Ozzy , some Lib Dems etc) could never repay for their historic sin even if they died ten thousand times.........
    (5) Following through the progress of the new Scottish GP contract , my mixed feelings remind me to be open minded about changes. I agree that people don’t like changes but changes are part of life.

    Still , I would stick to this quote:

    ‘’Arguments about justice and rights are often arguments about the purpose, or telos, of a social institution, which in turn reflect competing notions of the virtues the institution should reward and honour .’’
    Michael J Sandel on Aristotle's ideology
    What are our ‘new’ telos and virtues of NHS general practice.

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  • Vinci Ho

    What are our ‘new’ telos and virtues of NHS general practice?

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  • Vinci Ho

    Being a generation X.....

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  • The answer should be:
    1. Risk profile your nhs subsidised population each year. Your ‘NHS subsidy’ for the year is set. Providers choosing to take on such patients must keep them registered for the year.
    In reality it would be £25 or so for the fit and well patients and £1000 for most complex nursing home patients.
    2. Top up payments are allowed.
    3. Each patient’s subsidy would be recalculated each year.

    You would then see as many adverts for ‘unwell complex patients welcome’ as you joe see for ‘gpathand’.

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  • Access breeds excess!

    I will be interested to see how they cope with unleashing the demand Genie!

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  • Bornjovial

    I agree that no one should be allowed to openly discriminate like this new service.
    Vinci Ho is as usual right on the theology of the need (as determined by us) and want ( as determined by patient).
    Never the twain shall meet!!!
    However in a changing society how to improve access to "want" without pushing the overall financial envelope?
    I disagree anyone is allowed to openly cherry pick (I say openly as I have seen some GP`s have practice areas which exclude the deprived areas....)
    However managing patient want is a issue esp in cities where continuity is important for lesser number of patients.

    Also if the cost of healthcare is not reaching the working population who by definition will contribute to productivity of the country (which is lower than most comparable countries)then the cost spent is not recovered indirectly via productivity, taxes etc.

    Maybe they can have a new iPMS contract for internet only companies which can have such exclusions but be paid far less to increase the GMS value to traditional brick and mortar (B&M)GP surgeries. iPMS contractors should pay the going market value whenever their patients attend a B&M surgery to compensate for their loss of business. It brings it own issues as there will less B&M surgeries due to the same.

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  • A patient of mine was informed his complex medical needs rendered him ineligible for the service. He is 45, has uncomplicated hypertension, and is on one drug.

    The finances here don't easily add up. £5 per month = £60 per year. Ease of access is likely to mean demand is high; in general practice it is currently 6-7 appointments per year; there is no great evidence that AI algorithms change appointment-seeking behaviours, so let's be cautious and assume 5 appointments per year. That's £12 per appointment. Let's say 10 minute appointments - though hard to see how that is safe over a videophone - and 6 per hour. Income for Babylon = £72. Hourly rate for GP OOH and Hub work where I am is £90. Babylon can only make a profit if the consultation rate drops significantly (unlikely), the AI algorithm directs significant numbers of patients elsewhere (eg to A&E) or the terms and conditions the GPs work under are seriously degraded to reduce their costs.

    Babylon apparently raised £50m from investors for this. The technology and the algorithms are simple and relatively inexpensive. The rest will be for aggressive marketing, and a fighting fund to support Babylon through its losses whilst it gains market dominance - which will then enable it to either raise prices or reduce costs.

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  • this a sure sign general practice is going to end in our lifetimes. Because Jeremy thinks I'm too expensive.

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  • And Simon Stevens hasn't got a clue what to do

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  • Excellent analysis

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  • Tantalus

    It’s the same problem that the hospitals faced with treatment centres; they cream off the simple stuff for a tidy profit leaving the traditional service struggling with the complex with no simple work to subsidise it.

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