The fortnightly newsletter that unpacks system leaders’ priorities for digital technology and the impact they are having on delivering health services. Contact Ben Heather in confidence here.

After months stuck in the NHS regulatory bog, digital health company Babylon Healthcare has rediscovered some momentum.

Last Wednesday, the Care Quality Commission gave a broadly favourable rating to both its private and NHS digital GP services, GP at Hand. Given the company took CQC to court to block its last (less favourable) report this is a remarkable turnaround.

Last Thursday, a long-awaited independent evaluation of GP at Hand was published. The results were more mixed (the high level of patient churn was one concern) but there was nothing there likely to halt the service’s long-stymied expansion into Birmingham, expected any day. Or the next city, or the next.

But the most significant development longer term was news, reported in HSJ, of partnership talks between Babylon and University Hospitals Birmingham Foundation Trust. If the talks bear fruit, and both parties think they will, it could drastically change how health services, and not just secondary care, are delivered in the region. And by whom.

But more significantly, it could also provide a radically new model for regional NHS integration, one that will create new winners and losers.

An urgent problem

UHB is among the biggest trusts in the country, delivering most of the acute services in Birmingham and many specialist services not available elsewhere in the West Midlands.

But, like many of its peers, its hospitals are being inundated by urgent attendees. Trust chief executive Dave Rosser told HSJ there is rapidly diminishing space left to run specialist, or frankly any, non-urgent services. Without drastic action, these services will be flooded out and hypothetically the region would simply not have, say, a transplant service any more.

The current NHS answer to these problems is better regional service integration of some form, with GPs and community providers coordinating more effectively to relieve pressure. But Dr Rosser has lost patience with his primary care peers and, indeed, the ability of any existing out-of-hospital services to get better fast enough to create breathing room for his specialist services. Instead, he has gone outside the region to find someone he believes has the technology to do what other providers in the region can’t, or won’t, do fast enough.

Enter Babylon.

The UHB solution

The plan is for Babylon to do three things for the trust which, taken together, would effectively create an alternative digital out-of-hospital service for Birmingham, run by the trust and Babylon.

First off, triage. Instead of a plethora of out-of-hours GPs, urgent treatment centres and NHS 111, the trust wants to use a triage phone app, using Babylon chatbot tech, to divert urgent attendees away from its emergency departments. According to the trust, a lot of people that turn to ED just need reassurance and Babylon has an app for that (although, of course, whether it does safely triage patients is very much a contested question). The plan is for patients both at home and already waiting at the hospital to use the app for triage. Eventually, the trusts want to use the app to refer people straight to one of the trust’s specialist hot units.

Second, the trust wants to use Babylon’s video technology to run remote outpatient appointments (manned by UHB, not Babylon, doctors). The NHS long-term plan says tech like this should help cut outpatient appointments by a third, but Dr Rosser thinks they might be able to shift half of all outpatient appointments to video or phone (one million annually). There are some obvious synergies with the triage app. Instead of NHS 111 telling you to book an appointment with your GP the next day, the triage app could book a video appointment with a UHB specialist based on your symptoms.

And third, there is GP at Hand. Dr Rosser emphasised that talks with Babylon were separate and coincidental to the company’s NHS GP service expanding into Birmingham this year. He also said UHB would not favour GP at Hand in any way or encourage trusts to switch from their current GP practice to GP at Hand. However, trust board papers do discuss streamlining referrals to and from the trust to GP at Hand. If UHB’s new digital triage and video outpatient service, both running on Babylon tech, links more easily into GP at Hand than other practices, this would give the new arrival in the city a competitive edge in luring patients.

Digital integrated care provider

If the three strands work together, UHB and GP at Hand together will essentially be an integrated regional health service; tertiary and secondary care in hospital and a wrap-around digital-first community and primary care service.

It is potentially an extremely radical departure for the NHS, whose historic defining feature is arguably the GP as gatekeeper to secondary care treatment. To date, patients can only leapfrog that GP referral gateway in a few tightly defined cases, not simply by logging on and getting an outpatient appointment with a specialist.

It is also rather different from the various permutations of integrated models explored elsewhere in recent years – even from “primary and acute care systems”, where acute trusts have normally sought to partner with incumbent local GPs.

Of course, this may all come to nothing. The NHS is littered with grand transformation plans that fall woefully short of their ambition. Digital triage and remote outpatient appointments aren’t new ideas. To date, neither has substantially shifted the urgent demand burden (there are concerns the former could increase urgent demand). The financial model for a UHB/Babylon deal is also yet to be thrashed out and could be a stumbling block.

There are a few reasons to take these plans more seriously than most. UHB has extensive – some would argue outsized – power over the Birmingham and Solihull health economy and no compunction about using it. Sustainability and Transformation Partnership partners were kept in the loop on the Babylon talks, but local GPs were not. Dr Rosser seemed unfazed by the “disquiet” the partnership will cause among some GPs and highly motivated to take radical steps to combat what he sees as an existential threat to his trust’s specialist services. The plan, he has said, also has NHS England/Improvement backing.

On the primary care side, whether you love it or loath it, GP at Hand has shown in London that heavily advertising free NHS GP video appointments is an effective way to rapidly attract, although perhaps not retain, patients. If the links into UHB services work, Birmingham patients will be even more attracted to GP at Hand. The company has also demonstrated a knack for sliding a knife between the NHS regulatory cracks and prying open a market.

If the partnership delivers – a big if – other trusts could well consider turning to tech companies, instead of regional partners, when developing models for integrated care. Existing community and GP providers may not be pleased but, as GP at Hand has shown, it may be the patients that ultimately decide.