David Oliver: Lessons from the Babylon Health sagaBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2387 (Published 05 June 2019) Cite this as: BMJ 2019;365:l2387
All rapid responses
When some time has elapsed following the introduction of GP at Hand there will no doubt be some analysis of outcomes. I suspect those outcomes will show the app to be successful in delivery of healthcare but there will need to be caution in the interpretation of this.
Assessment of the people using GP at Hand is that, despite being younger and having fewer health problems than conventional users of GP services, they were higher users of services such as NHS 111 and urgent care. Butt and colleagues, in their response to Dr Oliver, tell us: “the overwhelming majority of our users joined our practice because they couldn’t access a GP at their previous practice.” This implies that GP waiting times will not readily put them off from discussing potentially important symptoms. This contrasts with the approach of the journalist Matthew Parris who was dissuaded in this way from reporting a skin condition. In addition, they are clearly capable of using such a system and comfortable doing so.
When Babylon’s users develop cancer they will be more likely to have operable disease and their survival rates will be superior to the rest of the population. It will be fallacious to conclude that this is because of the way GP at Hand works, it is more likely to be because they have attributes that ensure they get prompt attention to their presenting symptoms.
1] Parris M. The Times 7th July 2018
Competing interests: No competing interests
I thank Drs Butt, Grimes and Noble for their response
I should start by saying that my original column was well referenced with all linked references freely available on line. As with all my columns, it went through a second reader, sub-editing and legal check.
I also note that the respondents have not tried to dispute many of the issues I raised. These include problems with the AI symptom checker, Dr Butt’s previous on the record comments about the limited utility of peer review or clinical trials to this technology, nor the significant local financial challenges associated with implementation of the model. Nor have they contested the ruling against the company made by the Advertising Standards Authority, nor its claims for instance around the App vs the MRCGP exam. Nor have they taken issue with any of the 6 lessons I set out about how things need to change for future adoption of such technology by the NHS.
I did not specify what the structural reasons were around financial flows which had caused local financial challenges within West London, merely that they had occurred. However, I did emphasise (as did the independent evaluation by Ipsos Mori) that infrastructure, logistics and consideration of opportunity costs for other service users or services should be an important consideration. I did not make any claims about the size of the capitation for each GP at Hand patient. I was also aware of the Care Quality Commission Report but didn't cite it because it was not material to my lines of argument.
As for what the evaluation by Ipsos Mori said (and it came to some wide ranging conclusions, which can't be reduced to an argument either for or against the service in a binary fashion but must be seen in the round) – for instance about the GP at Hand case mix and use of services compared to what might be expected for such a relatively young and healthy demographic – well the findings can be seen in the report and it’s executive summary. Readers can judge for themselves 
The distillation of those findings in pieces by expert health journalists in the BMJ  headlined “Patients are less sick but use services more”; Health Service Journal  “Babylon Health GP at hand Evaluation Delivers Mixed Verdict” and Digital health  are also freely available. Their emphases may be slightly different from those set rather selectively in Babylon’s rapid response to my column.
Pieces describing some of the financial problems associated with the initiative, from Digital Health , Wired  and the Health Service Journal  are also referenced.
For those interested in more detailed commentary on the wider issues around marketing, the symptom checker app, advertising and advertising standards several pieces are available including these from Wired  and Forbes Magazine . There are many, many more sources I could have cited and the Babylon team are welcome to rebut them one by one if they like.
Finally, readers who want to see the official code of practice for evaluation of health technologies from NHSX  and the NICE guidelines on evaluation of new health technologies from NICE  can see whether the story of the development, market entry, belated and bolted on evaluation, marketing and advertising of Babylon Health meet all the criteria. I don’t think they do. Nor do I think the Babylon respondents’ emphases around the findings of the Ipsos Mori report quite matches my own impression on reading it.
 Ipsos Mori. Evaluation of Babylon GP At Hand. Final Evaluation Report. May 2019. https://www.hammersmithfulhamccg.nhs.uk/media/156123/Evaluation-of-Babyl...
 G Iacobucci. GP At Hand. Patients are less sick than others but use services more. Evaluation Finds. BMJ May 24 2019 https://www.bmj.com/content/365/bmj.l2333
 Rapson J. Babylon GP at Hand Evaluation Delivers Mixed Verdict. Health Service Journal May 24th 2019 https://www.hsj.co.uk/technology-and-innovation/babylon-gp-at-hand-evalu...
 A Downey Funding Model for GP at Hand not appropriate. Ipsos Mori Review Finds. Digital Health May 29 2019. https://www.digitalhealth.net/2019/05/gp-at-hand-funding-not-appropriate...
 Burgess M, Kobie N. Major concerns raised about Babylon’s Impact on the NHS. Wired. 26th April 2016 https://www.wired.co.uk/article/babylon-health-gp-at-hand-nhs-inquiry-an...
 Heather B. Service cut warnings over NHSE GP at hand bailout fears. 12th March 2019 https://www.hsj.co.uk/technology-and-innovation/service-cut-warning-over...
 Burgess M, Kobie N. The Messy, Cautionary Tale of how Babylon Disrupted the NHS. Wired. 18th March 2019 https://www.wired.co.uk/article/babylon-health-nhs
 This Health Start up won big government deals. But inside, doctors flagged problems. https://www.forbes.com/sites/parmyolson/2018/12/17/this-health-startup-w...
 Department of Health and Social Care: Code of Conduct for Introduction of data driven healthcare Updated Feb 2019 https://www.gov.uk/government/publications/code-of-conduct-for-data-driv...
 National Institute for Healthcare and Clinical Excellence. 2019. Evidence standards for new health technologies. https://www.nice.org.uk/about/what-we-do/our-programmes/evidence-standar...
Competing interests: No competing interests
Dr David Oliver’s article, ‘Lessons from the Babylon Health saga’, raises some interesting questions but appears to have confused a number of issues.
First, despite Dr Oliver’s assertion, Babylon GP at Hand does provide the full GMS services, just as conventional general practices do. If his concern is that patients living beyond practice boundaries are not contractually eligible to receive home-visits, GP at Hand offers them anyway.
The big and obvious difference between Babylon GP at Hand and the vast majority of other practices is that our service is provided 24/7 every day of the year and not the standard 8.00am-6.30pm Monday to Friday (plus extended hours where separately commissioned).
The overwhelming majority of our users joined our practice because they couldn’t access a GP at their previous practice. With us, appointments are usually available within two hours, patients can replay consultations, see their medical notes and have a lot more control over their health - and all at no extra cost to the NHS. Patient satisfaction matters, so when the independent Ipsos Mori report showed 85% of our users rated us as good or better,  that’s worth listening to.
Second, GP at Hand is funded just like any other NHS practice - through the Carr-Hill formula which allows for variations in patient age, gender and health. That’s why we are paid on average £91 per patient, which is 40% below the national average of £150. And as the evaluation by Ipsos Mori showed, despite our patients being higher users of services before joining us, within 6 months A&E visits had dropped by 3.8% in comparison to new patients at other practices. We have over 51,000 patients so we would expect nearly 2,000 saved A&E visits, and with each visit costing £160 that equates to over £300,000 (over £6 per patient) saved by the NHS in six months alone.
There has been a funding issue, though this is entirely about money flows between commissioners. It is very positive news that this is being resolved between the CCG and NHS England. Administrative systems clearly shouldn’t stand in the way of patient care, nor prevent people exercising their right to receive high quality NHS care from the providers they choose. After all, patient choice is embedded in the constitution of the NHS. 
It’s also important to note that the Ipsos Mori report said “patients were previously registered at a large number of CCGs and other practices. This indicates the impact on any singular practice or CCG would be minimal if the patients now registered with BGPaH were indeed subsidising patient care through the Global Sum Allocation Formula in their old practices.”
We support independent review and, as well as the Ipsos report, we were recently assessed by the health regulator the CQC which rated our services as Good, with 39% of patients able to book an online appointment with a GP within 30 minutes and 89% within six hours. 
In terms of GP stress, the Ipsos report says we have a “highly satisfied workforce who gave “overwhelmingly positive feedback” and “could have a positive impact on the recruitment and retention of a group of GPs who may not remain in or enter into general practice otherwise.”
Provocative articles are useful for ensuring debate, and lessons can be learned, but rather than a one-sided view, they should include the facts if a commentator is seeking to educate and inform.
No one is in doubt that NHS staff face formidable challenges from an ageing population and the changing expectations of patients. Inflexible infrastructure and funding systems shouldn’t compromise patient care by limiting innovation and change. Babylon GP at Hand is helping to make NHS money go further and achieve more for patients.
1 Ipsos MORI. Evaluation of Babylon GP at Hand: final evaluation report. May 2019.https://www.hammersmithfulhamccg.nhs.uk/media/156123/Evaluation-of-Babyl....
2 NHS Constitution. https://www.gov.uk/government/publications/the-nhs-constitution-for-engl...
3 CQC report 21 May 2019. https://www.cqc.org.uk/sites/default/files/new_reports/AAAJ1557.pdf.
Competing interests: All authors work for Babylon. Dr Keith Grimes: "I run VR Doctors, which is an online forum for people interested in clinical VR (unpaid), am a digital champion for Lantum (unpaid), NHS locum GP (self employed) and very infrequently offer paid digital health consultancy (none ongoing)"