NHS England has made a commitment to make digital primary care available to everyone. But if the future of primary care is digital, then it will need to be a different model to that currently delivered through Babylon GP at Hand. By Geraldine Clarke, Josh Keith and Adam Steventon.
The recent independent evaluation of the impact of Babylon GP at Hand showed signs the service is providing good quality care to currently registered patients – generally younger and healthier people from more affluent areas. Notably, few of these patients had long-term conditions, and those who did reported feeling confident managing them.
While the findings are positive, they were based on a population that is unrepresentative of those using general practice. There are 14.2 million people with two or more long-term conditions in England, who account for over half of all GP visits nationally. Rates of visits are particularly high amongst those who are overwhelmed with managing their long-term conditions, who account for nearly a quarter of the total.
The NHS faces a huge challenge to provide good care for patients with complex needs, and the question is still open as to whether technology can help and how.
Good patient experience
It’s clearly excellent news that patients using Babylon GP at Hand were positive about the quality of care they received during their last general practice appointment: 93 per cent said they had confidence and trust in their healthcare professional; and 87 per cent thought their healthcare professional was “good” at treating them with care and concern, with 90 per cent feeling listened to and 88 per cent reporting being given enough time to discuss their concerns.
A majority stated the quality of care was better than that experienced at their previous practice. However, satisfaction was lower in relation to face-to-face appointments suggesting that satisfaction might be driven by “convenience of the service for its users” and ease of booking appointments.
However, patient experience does not correlate perfectly with clinical outcomes and the evaluation was unable to make any firm conclusions in this area. Outcomes of patient consultations could not be examined as Babylon GP at Hand was “unable to provide data” on onward referrals or presenting conditions. Nonetheless, a high proportion of patients’ felt their needs were mostly met in their last general practice appointment (90 per cent).
Twenty-eight per cent of patients have de-registered from the practice since July 2017, compared to one in six in London elsewhere
Of additional concern is the high de-registration rate – over a quarter of patients (28 per cent) have de-registered from the practice since July 2017, compared to one in six in London elsewhere. The reasons for this require further investigation, especially in light of the fact that, of those patients surveyed who had stopped using Babylon GP at Hand, or said they intended to, more than half (51 per cent) cited unhappiness with the quality of care.
A note of caution regarding the patient survey in general is required because only 6.4 per cent of individuals surveyed responded. While the authors of the evaluation say this was “sufficient for analysis purposes”, those with extreme opinions one way or another are more likely to have responded.
No clear differences
One concern about Babylon GP at Hand is that it might lead to increases in demand for primary and secondary care. The evaluation concludes that Babylon GP at Hand patients were “not using more secondary care resource after registration” and “may be using the Babylon GP at Hand service more than would be expected” in comparison to similar patients. Our own view is that the evaluation was inconclusive as to whether the model led to any impacts on the rates of primary or secondary care usage.
The chief limitation of the quantitative analyses relates to the inability to control for fundamental differences between individuals who self-select for Babylon GP at Hand and patients who remained at other practices, partly caused because of gaps in the primary care data, and partly by the inherent difficulty of measuring the factors that might have motivated patients to join Babylon GP at Hand.
As a result, it is not possible to interpret, or be certain about the extent to which differences in service use can be attributed to the Babylon GP at Hand service, then to other factors. On a related note, this also highlights the challenges of evaluating service transformations (digital or otherwise) when evaluation is not built into the design or rollout.
Positive workforce experience
One of the most striking and encouraging findings was that GPs working for Babylon GP at Hand reported satisfaction in terms of work-life balance and opportunities for support, development and monitoring. There were concerns, however, that the working arrangements may limit “the opportunity for young clinicians to develop their generalist skills”, particularly given the unrepresentative nature of the registered patients.
Still, the evaluation raises useful learnings about the aspects of the model that attract GPs to work for Babylon GP at Hand, which will contribute to an ongoing debate surrounding workforce policy and planning supported by recent changes to the GP contract.
What about the wider model applicability?
While there are positive findings from the evaluation, there are reasons to doubt that the model as it currently operates will work for many patients:
- Continuity of care with the same GP has been shown to produce better health outcomes as well as lower rates of unplanned hospital admissions and might be crucial for older people with multiple health problems. Following the evaluation, it remains unclear whether a model like Babylon GP at Hand can provide continuity of care. Many of its patients actively chose ease of access over continuity of care, and were happy with the choice they have made. Yet other patients might feel differently.
- Patients registered with Babylon GP at Hand may have longer journeys for face-to-face appointments than other patients. The evaluation showed that most patients were aware of this fact when they registered, but on the whole had not considered what they would do if they were too unwell to travel for a face-to-face appointment.
- While internet penetration continues to rise, there are significant gaps – for example, Ofcom found 35 per cent of those aged 65-74 are not using the internet, and the 2019 Consumer Digital Index states 11.9 million people (22 per cent) do not have essential digital skills. There are substantial portions of the population who could not use a digital-first offer.
Patients registered with Babylon GP at Hand may have longer journeys for face-to-face appointments than other patients
These are just some of the issues which limit the type of patient able to use the Babylon GP at Hand service and raise, as indicated in the report, “potential implications for health inequalities”.
We are not suggesting the model for general practice needs to be the same for everyone. But if digital technologies are going to transform health care in the way that has been claimed, then they will need to work for a broader population than has so far participated in Babylon GP at Hand. While the evaluation provides useful evidence, it remains unclear whether technology can help with the most urgent challenges faced by the NHS and its patients.