Editorial Thursday 20 September 2018: Towards integrated tech enthusiasm with Matt Hancock

[AUTHOR’S NOTE – Health Policy Insight's been on a hiatus for a while because, well, life. This column was written for my regular Monday HSJ slot, and delayed due to legal concerns. It now appears, following HSJ editor Alastair McLellan’s barnstorming editorial on the matters in question.]

Those whom the Gods of health policy would destroy, they first make over-enthusiastic about tech solutions.

It was disappointing if not surprising to see ex-Millennium Bug pest controller (and as such, no stranger to tech hyperbole) and current Health Secretary Matt ‘The App’ Hancock let his digital enthusiasm get the better of his judgment this week, by specifically endorsing an individual tech provider’s service (Babylon’s GP At Hand) in a speech at Babylon’s HQ, in front of their logo.

This followed Mr Hancock telling the Telegraph’s Laura Donnelly that “GP at Hand is revolutionary - it works brilliantly for so many patients and goes with the grain of how people access modern services.

“I want to see GP at Hand available to all, not based on their postcode. Where a new service challenges the system, the right response isn’t to reject the new service but to change the system. The current postcode lottery cannot continue.”

Mr Hancock (a registered user of GP At Hand) also used the Telegraph interview to suggest that NHS officials and processes are impeding progress: “Global innovators like Babylon play a vital role in driving change in healthcare and we’re determined to work with them to develop healthcare solutions for our future.”

Mmmmmm. If not mmmmmmmmmmmmmmm.

There have been concerns about Babylon Health’s offering. The Advertising Standards Authority has informally resolved several complaints against the company’s more ambitious claims about its products.

Babylon’s former online claim that its technology was a medical device approved by the MHRA was reworded after an investigation, as the Financial Times reported.

Clinicians also complained that the symptoms of either a heart attack or DVT were diagnosed by the Babylon app’s algorithm as being those of a panic attack. When the FT’s journalist tested the Babylon symptom checker in the guise of a 66-year-old obese male smoker experiencing sudden chest pain and excessive sweating (as in the clinician complaint) they found that the app suggested that nine out of 10 people with similar symptoms were likely to be having a panic attack - and made no mention of the risk of a heart attack.

Babylon has been inspected by the CQC, which found “that in some areas, this service was not providing safe care in accordance with the relevant regulations”.

Specifically, the CQC found that “prescribing decisions were not always made appropriately, based on a thorough medical history and not made in line with evidence based; risk assessed national guidance and best practice.; information was not always shared with a patient’s primary physician to ensure prescribing was safe or appropriate; there was no system in place to give assurance that patients’ conditions were being appropriately monitored”.

Now obviously, the CQC finds comparable problems with other services – NHS and independent sector – not infrequently. However, most of those on the receiving end of CQC assessments do not https://www.hsj.co.uk/technology-and-innovation/revealed-babylon-email-threats-to-cqc/7023030.article threaten the CQC with legal action, or indeed https://www.hsj.co.uk/technology-and-innovation/babylon-withdraws-cqc-legal-challenge/7021339.article pursue and then withdraw such legal action, as Babylon did.

Babylon’s chief executive is Ali Parsadoust, who is previously known to the sector for his tenure in charge of Circle Healthcare. You can find out more about Circle Holdings (the investment company) here, including Ali’s substantial sales of his shares in 2013 before stepping down from the Circle board, having stood down as chief executive in late 2012.

And you can read here about Circle Holdings being taken private by Toscafund Asset Management.

History isn't destiny, of course, but the ambitious originally-stated goal of Circle to be a workers’ co-operative with the staff’s shares in Circle Partnership owning 49.9% of the equity to Circle Holdings’ 50.1% suffered an ignominious death.

I get knocked down, but I get up again
Now Ali is trying again, and that is what entrepreneurs do.

But we should be clear-eyed that there was a clear history of Circle over-promising and under-delivering, both to its shareholding/workers’ co-operative staff and most notably in their failed attempt to run the NHS Hinchingbrooke Hospital, which led to a CQC rating of inadequate.

History may not be destiny, but it is pertinent context.

Babylon probably did not do themselves any favours by attempting to ban my HSJ news colleague Ben Heather from the Health Secretary’s speech at their offices. Fair play to Mr Hancock for insisting that the trade press should be allowed to attend.

Evidence and evaluation matter
It shouldn't need saying that evidence and evaluation matter, but here I am having to say it. Hey-ho.

The use of technology-enabled care services has been reviewed by the Health Innovation Network (South London)’s technology team for the NHS Commissioning Board as recently as April 2017. Its findings are sober.

This review finds that “there is mixed evidence as to the extent to which patients are willing to engage with new technologies, which supports the notion that TECS should continue, for now, to be offered alongside traditional treatments to allow for differences in patient ability and willingness to depart from existing ways of working, with a longer-term view to increasing uptake of new technologies – “[The evidence indicates that patients are accepting of the technology and are willing to use it to self- monitor. Increased convenience and privacy are selling points. However, patients do not want to lose in-person contact completely so a combination of tele-homecare and in-person visits seems best. Little evidence exists to guide providers regarding what is the best combination of telehomecare and in-person contacts. (Bowles and Baugh, 2007)].” Further research should be conducted in this area.“

Quite.

Towards avoiding ‘apptimism’
The National Institute for Health Research has also https://www.nihr.ac.uk/nihr-in-your-area/wessex/documents/Evaluating%20Digital%20Health%20Interventions%20Key%20Questions%20and%20Approaches%20by%20Professor%20Jeremy%20Wyatt.pdf worked in this area, developing a framework for developing and evaluating digital health interventions.

Its conclusions are:
1. The quality of mHealth (mobile health) apps varies too much
2. Our current approaches (user rating, professional reviews, developer self-certification, regulation) are not enough
3. To help reduce “apptimism” and strengthen other methods, we should follow a framework for development and evaluation of apps etc.
4. This will help us build an evidence base of tested theories about digital health components
5. This will support patients, health professionals, health systems, regulators and app developers to maximise the benefits of mHealth
6. We can also use digital tools to make research more efficient – but need to test these tools first

And fortunately, Ipsos MORI have been commissioned by the NHS Commissioning Board to evaluate the impact of Babylon’s GP At Hand, but it won't be finished until March 2019, and published after whatever NHS Commissioning Board processes (and possible legal challenges?) may follow.

So what’s the rush?
Anecdotal reports suggest strongly that GP At Hand is very popular with younger, generally healthy professional people (such as Mr Hancock). There is obviously nothing wrong with providing better access to GP services for this group in principle, and video consultation may be an effective means to deliver it.

The issue concerning many people about GP At Hand is that in practice, there is a significant risk that if sufficient numbers of such low-cost, low-health-need patients subscribe to GP At Hand, the balance of financial and population health risk upon which the financial viability of general practice is currently predicated could be at risk.

More to the point, first movers in tech and software can gain unassailable advantages, thus stunting any potential benefits from a competitive and innovative market. Microsoft, Google, Apple, etc. Picking winners is distinctly un-Conservative.

Mr Hancock is looking like a man in a hurry in this matter. That is perhaps unsurprising, given the febrility of our current politics.

Even so, a Health Secretary should be corralled by his civil servants and advisors into cooling his ‘apptimism’ and tech ardour until we have the evaluation and evidence, not to mention a better understanding of how the risks of financial destabilisation to analogue primary care can be best mediated.

Otherwise, we reach the point where I have to suggest that I should be rolled out across the NHS after a speech by Mr Hancock, like GP At Hand might be. Because let’s face it, I haven't been properly evaluated either.