Digital health: GPs aren’t “Luddites” but want safe, equitable care
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1258 (Published 19 March 2019) Cite this as: BMJ 2019;364:l1258
Digital healthcare is “not about replacing GPs” but about “leveraging the very best technologies such as artificial intelligence and trying to remove the unnecessary [workload] burden that we currently face,” London’s GPs were told last week.
Mobasher Butt, a GP and medical director of Babylon Health, a key player in digital healthcare, said that such services were also “a tool for patient choice” that could let people access healthcare in the same way they did in many other aspects in their lives.
It’s an argument that GPs have been hearing for some time now.
The government commissioned Topol review, published last month, concluded that doctors should be trained in genomics, artificial intelligence, and digital healthcare technologies to improve services and help ensure a sustainable NHS.1
The NHS in England recently launched its own app (digital.nhs.uk/services/nhs-app) allowing patients to book GP appointments, and the BMA and NHS England have agreed a new contract deal that requires all general practices to make at least 25% of appointments available for online booking by July 2019 and to offer online consultations by April 2020.2
Inverse care law
Butt made his comments during a panel debate on how digital health should develop at the annual conference of Londonwide Local Medical Committees, the umbrella group that represents the more than 7000 GPs in the capital.
GPs at last week’s conference generally agreed that technology presented big opportunities but had questions about how it would be deployed in the NHS. The debate heard concerns about the safety and regulation of AI symptom checkers and chatbots, which are used by some app based GP services such as Babylon’s GP at Hand,3 Ada Health, and Your MD.
The debate also raised wider questions, such as how to balance convenience with continuity of care, and the risk that some groups of patients could be disadvantaged by new digital models.
Another panel member was Jackie Applebee, an east London GP and chair of Tower Hamlets LMC, who has been a vocal critic of the effects of the GP at Hand service on the NHS. She emphasised that she was not anti-technology but was concerned that GP at Hand, which allows patients to register only through its app, favoured younger, healthier, and “technologically savvy” patients and thus risked creating “a new version of Julian Tudor-Hart’s inverse care law—providing access for those who need it least at the expense of those who need it the most.”
She also argued that complex care for vulnerable people and those with comorbidities was “best delivered face to face.”
Safety concerns
Applebee said she was concerned that the rush to roll out new technologies meant that a solid evidence base was lacking, and she condemned what she described as a “cavalier attitude” to testing new technology in healthcare.
“Evidence is absolutely vital, and I don’t think it’s good enough to say technology is fast developing and so there isn’t time, because I think there are huge unintended consequences,” she said. “Sometimes we do just have to wait. You can’t get a drug or a surgical procedure onto the market without proper evidence.”
Butt said that Babylon would welcome independent study of its tools, but he added that some traditional research methods such as randomised controlled trials “might not be the appropriate methodology,” because of the fast changing nature of this type of technology.
Panellist Elliot Singer, a northeast London GP and medical director of Londonwide LMCs—and a confessed IT enthusiast—said that he had some sympathy with the industry’s position, noting, “What we think is modern tech today, in a year’s time it’s past its sell-by date.” But he said this must be balanced with the need to ensure safe care and continuity of care. “We need to be pragmatic in our approach,” he surmised.
Ben Goldacre, the doctor and academic recently appointed to lead the government’s Healthtech Advisory Board, who chaired the debate, agreed that independent evidence was crucial. But while he noted the shortcomings of a preprint paper published by Babylon that aimed to show that its interactive chatbot was just as good at diagnosing illness as GPs,4 he said it was disappointing that no academic group had initiated an independent evaluation of Babylon’s symptom checker.
“I’m not so sure that I can blame Babylon for the fact that the academic community hasn’t raised its game and set out to try to evaluate these tools for themselves,” Goldacre said.
Regulation
The conference also saw discussion of the regulation of digital apps and services.
Currently, digital symptom checkers and chatbots are class 1 medical devices, the lowest possible category. They have to undergo a self certification process to operate in the NHS marketplace. Butt insisted that this process was “highly regulated” and subject to ongoing scrutiny by regulators.
But the Medicines and Healthcare Products Regulatory Agency doesn’t have the power to compel companies to self certify their devices. Singer said, “We haven’t put in place the correct regulation to ensure certain standards are put in place before anything comes onto the wider market.”
The Care Quality Commission has responsibility for regulating digital healthcare providers, and Applebee said it was alarming that the CQC’s most recent report judged that 43% of online primary care providers were not providing safe care.5 Common issues cited were overprescribing of antibiotics, inappropriate prescribing for people with long term conditions such as asthma, and inadequate safeguarding.
Such findings demonstrated why caution was needed, Applebee argued. “We are not Luddites . . . but [the technology] has to be safe,” she said.
How can GPs set the agenda?
Murray Ellender, a GP in south London and co-founder of eConsult, an online triage tool designed to help GPs carry out consultations more efficiently, believes it’s important for GPs to be involved in developing new technologies so that they can help shape the way services evolve.
He said that one of the most important things for general practices to understand was that digital tools should not be about creating additional demand. “GPs are all very busy, and I think the challenge to date is born a bit out of fear that you’re just opening up another route in for patients. But, actually, practices have got to think of it as an alternative. You need to replace some telephone and face to face consultations with online consultations. As a practice, you’ve got to think through how you’re going to use the tools.”
Ellender said that around a 10th of practices in the UK had signed up to use eConsult. He believes that the fact that the tool was created by GPs had made it easier to convey its potential benefits to practices. “We have case studies of practices where they’ve implemented this and it’s freed up time,” he said. “If you can show where it’s worked, that’s quite reassuring.”
Becks Fisher, a GP in Oxford and policy fellow at the Health Foundation, said that the most important questions for practices to ask before introducing a digital service were, “What is the problem that we need to solve, and are we clear that we’re trying to do it in a way that doesn’t generate supply induced demand, which is a risk?”
She said, “For example, I would argue that the problem might not be ‘How can we make access more convenient for the worried well?’ But it could be ‘Can we develop an approach that improves care for patients living with multiple, long term health conditions?’”