Everyone agrees something dramatic has to be done to help the NHS. It is crumbling and the canary in the mine is general practice. I work as a psychiatrist but my GP colleagues are almost all frazzled, overworked and frustrated at not being able to give the care they want to their patients. They’re quitting in their droves. So it makes sense that politicians, desperate for a quick and easy answer to an overwhelming and complex problem, have leapt on technology as a solution. And, in particular, on the idea of an app that offers a GP consultation via your mobile phone.
In theory, it sounds great: the patient can dial up, speak to and (via phone camera) see a doctor, who could be anywhere. The poster boy is an app called GP at Hand, run by British start-up Babylon. The big question, of course, is how effective such consultations can be, given that the doctor is unable to take your blood pressure or stick anything down your throat. I have been able to test this service for myself — and what I have experienced left me worried.
The first time was when I suddenly developed lower back pain. I have private health cover through my partner’s job and with this comes access to Babylon’s private version of the app, identical to its GP at Hand one. I got through to a GP who admitted that she didn’t know what the problem could be. As she was unable to do a urine test, she suggested I took antibiotics — just in case. The prescription was emailed over. I felt uneasy. I didn’t like the idea of taking something without there being a clear reason why, especially not antibiotics. I apologetically phoned up my regular NHS GP surgery and within an hour I was sitting in front of a doctor, who tested my urine. The result showed no, not an infection — so no need for antibiotics. In fact, it was a kidney stone which I eventually passed. So: misdiagnosis and the wrong prescription through the app.
Then, a few months ago, I used Babylon again. I was due to fly to Spain for a friend’s birthday the following day and had got my hair cut. The barber noticed that I had a rash on the back of my scalp — I was shocked at how bad it looked when he showed it to me in the mirror. It was mid-afternoon and I reasoned that I’d never get an appointment with my GP before my flight the following morning. I logged on to the Babylon app on my phone instead and was offered an appointment in an hour’s time. Not bad.
The time of my appointment came and went. Nearly 20 minutes later the GP finally called. There was a problem with my account and she had been on to technical support to find out why. Some technical glitch had meant that I’d been deregistered and I was unable to ‘verify’ my account. Despite having had it for more than a year, it kept asking for me to upload a picture of my passport — but didn’t save it. This, it seems, meant the GP had struggled to get through to me.
The next problem was trying to show her the rash. It was in an awkward place to hold the camera and I couldn’t tell if the doctor could even see the problem. She wasn’t sure. Whatever it was, she didn’t think it was infected. Perhaps a steroid cream? She seemed at a loss to know what else to suggest. The appointment ended and I waited for the prescription to be emailed over. And waited. I had some things to get from the pharmacy anyway and it was closing soon, so I made my way there. Then I received an email from Babylon saying my account hadn’t been verified. I replied saying it was and in fact I’d now done this several times. I wanted to scream.
This was followed shortly afterwards by an email written in poor English: ‘They may be an issue as to why your ID is not verifying hence why I ask for your ID to be sent over to myself and unfortunately we are unable’ — it stopped abruptly there and I heard nothing more. I never got the prescription.
In the morning, just before going to the airport, I took a chance and called my real GP again. Sure, they said, pop in, which I did. She examined the rash closely — in fact it was infected, so she strongly advised against steroids and prescribed an antibiotic instead.
Many of us in the NHS worry about all this — and not because we’re well served by the status quo, or worry that our jobs will go to robots. We’d love the answer to the NHS’s woes to be as simple as downloading an app. Matt Hancock, the Health Secretary, has announced he is making the digitalisation of the NHS one of his top priorities. But doctors are concerned that, far from saving the NHS, it might prove to be the nail in its coffin.
Much of the lauded medical technology is untried, untested and has major (and fairly basic) flaws that aren’t being addressed — as my experience shows.
But there are also problems that go far beyond glitchy technology. At present, GP surgeries receive a fixed fee for each patient registered with them. Most patients are healthy, and seldom make appointments: they offset the cost of those who do. But it’s the younger, fitter patients who are more likely to register with an online GP. This risks leaving regular GP surgeries with the sickest, frailest and most complex patients who are also the most costly. Almost all of the patients registered with GP at Hand are aged under 45, and two-thirds live in highly affluent areas.
As well as snapping up the easiest patients, there’s good evidence that digital GP services drain GPs away from surgeries too. They offer more flexibility, a fairly decent hourly rate and they allow doctors to work from home. This of course puts further pressure on already understaffed practices.
And whose care is being prioritised here? If apps such as Babylon’s are used by the young and wealthy, who place little demand on the NHS anyway, they simply aren’t the patients who need help most. The priority must be to find ways to improve the care of those with complex needs, the elderly, the frail and the mentally ill. GP at Hand went live across Birmingham recently. It’s not clear whether this will help or hurt the city’s most elderly and vulnerable.
You’d think for a service that is being feted by the great and good of Westminster, embraced by our health service and rolled out across the country, basic due diligence would have been done. You might understandably assume that some clever team had figured out whether online medics offer value for money, for instance, and whether the service is safe — as they do with new drugs and treatments.
You’d be wrong. A study from Imperial College London that looked at video consulting found that ‘its safety and clinical efficacy in primary care remains largely untested’. The nature of video consultation could also lead to increased antibiotic prescribing, the study found. None of the services’ websites made any mention of appropriate use of antibiotics and ‘the uncertainty inherent in video consultations, where examination is impossible, might be expected to result in increased antibiotic prescription due to clinicians feeling a need to “play it safe”,’ it said. Concerns were also raised that because of the limitations of video consultations, there is a tendency to refer patients on or advise going to places such as A&E.
What the GP at Hand model shows us, I think, is what an efficient use of doctors the current model of GP care actually is. A source in the NHS told me that GP at Hand currently has around 500 patients per GP. Yet the average GP in the NHS covers 1,600 to 1,800 patients each. That means GP at Hand is actually considerably less efficient than your average surgery, certainly as far as doctor-to-patient ratios go.
And how many conditions can genuinely be dealt with virtually? Think of the oral contraceptive pill, for example. It’s a quick and easy process to prescribe it, but the doctor needs to check the patient’s blood pressure first, which you can’t do virtually.
Then there’s the attrition rate: one in four patients who joined GP at Hand has left. This is the kind of statistic that, if it were a regular GP service, would trigger an inquiry.
As a doctor, perhaps the biggest question is whether the care these services deliver is actually any good. This is where I have real concerns. The bottom line is that both times I’ve used Babylon’s app, I’ve had the wrong diagnosis and the wrong treatment. What’s worse, the medication I was prescribed for that rash would actually have made my condition worse, because steroids exacerbate skin infections. This is a basic failing. Thank goodness that prescription never did turn up.
I have worked in the health service for more than 20 years and I know that there is waste and mismanagement. I know also that technology can make things work more efficiently and cut costs. I think there’s a place for apps, but this will not save the NHS. It provides a nice, convenient alternative to seeing a doctor, but it can no way replace physical GP surgeries. And the way it has been rolled out risks undermining NHS GP practices and hastening their decline.
Dr Max Pemberton is a columnist for the Daily Mail.