WIRED

Babylon was meant to make healthcare easier. For some in the NHS, it has done anything but. Now, as the London-based startup prepares to expand outside of the capital, a number of GPs and officials are expressing concerns about the strain the firm is putting on the health service.

To date, the presence of Babylon’s GP surgery in London has forced the NHS to reallocate millions of pounds in funding to mitigate for the disruption it has caused. Its expansion plans have been blocked before being allowed to proceed. But concerns linger with clinicians questioning the GP surgery’s impact and the effectiveness of its much-hyped artificial intelligence platform. And, at the centre of all this, is the UK’s health service. After years of budget cuts, policymakers now see technology as something of a panacea for the NHS to plug gaps and improve efficiency. But for staff on the frontline and in back offices, all the disruption is taking its toll.


The story of Babylon centres on a GP clinic in Fulham, South West London. In late 2016, Babylon started working with Dr Jefferies and Partners practice and converted it into GP at Hand. Since then, more than 40,000 people across London have joined the Babylon-owned NHS practice with the vast majority leaving their existing GP, creating one of the largest and fastest-growing surgeries in the UK. Patients seemingly love Babylon, but behind the scenes the NHS is struggling to cope.

That struggle is hidden in a complex system of documents and procedures that detail the impact Babylon is already having. The sheer size of the GP at Hand clinic in Fulham means that the local NHS authority, the Hammersmith & Fulham Clinical Commissioning Group (CCG) is having to pay for the care of scores of new patients, even though the majority of them are based in other parts of London. Documents show the CCG has struggled to cope financially with the strain put on it by Babylon, with other CCGs and NHS England forced to bail it out. Last month, Hammersmith & Fulham warned the cost of the practice would leave it £10 million out of pocket for the current year.

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Other documents from the CCG show that the healthcare it is able to provide could be at risk if the bailouts from elsewhere stop. “Should the mitigation not materialise there will be a material worsening of the financial position of the CCG, potentially jeopardising other health and care services in Hammersmith & Fulham,” the body’s risk register reveals.

Since its launch, GP at Hand has quickly become one of the England’s biggest GP practices. To do this, Babylon has taken advantage of structural changes to the NHS that allows people to register at a doctor’s office outside the area where they live. This means the GP service, which uses video-conferencing to connect patients to doctors, has been able to rapidly register thousands of people. The influx of sign-ups means GP at Hand has ten times more patients registered than the practice it took over from. It’s also become one of the largest in England, with government data showing that of the 7,000 registered GP practices there are only 23 bigger than Babylon’s.


The rapid rise of Babylon’s GP practice has also raised concerns about cherry-picking. GPs are allocated a set amount of money from the NHS for each patient they register. Easy, low maintenance, patients are worth less than those who require more treatment. Babylon was initially prohibited from registering patients that may cost more to provide healthcare for.

Babylon’s GP at Hand app also includes an AI component, a symptom-checking chatbot that has attracted criticism for apparent inaccuracies in diagnosis. A December 2018 Forbes report claimed medical staff inside the company have been concerned about the results it produces. At the time, Babylon said it had a safety-first culture but that “no clinical probability analysis can be right all of the time”. Critics of the service have consistently claimed to have found flaws in Babylon’s AI – a claim the company has previously countered by arguing it “regularly conducts clinical audits” of its referrals to GPs, updates its AI systems regularly and works with the Medicines and Healthcare products Regulatory Agency

Last year, one ex-staff member, who asked not to be named, said the company’s AI was overhyped. “They separate their branding and marketing very much from their clinical side and they stay away from validation in clinical trials,” the former staff member said. “They really don’t want to do that: they see them as expensive and boring and time consuming.” A spokesperson for the company said this was “ridiculous”, adding: “Why would any company or establishment refute the accolade of a peer-reviewed clinical trial?” The company is working on clinical trials with medical institutions around the world, the spokesperson added.

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Mobasher Butt, Babylon’s medical director, says that the company is happy to release data, and isn’t averse to peer review, but claims peer review isn’t always necessary. “I think people get really fixated on peer review,” he says. “The trouble is the methods that we have today are quite limiting.” While a randomised control trial is the “gold standard” for medical science, he claims, it would take several months or a year to produce. “But we’re developing and improving our technology and the versions of the symptom checker every two months.”


As a result of the concerns around Babylon, Hammersmith & Fulham CCG is paying market research firm Ipsos Mori £250,000 to analyse what impact GP at Hand has had on the NHS. But while that’s being worked out – the report is due to published this month – the company is courting new patients across London and continues to plan a national expansion.

Those plans stalled in July last year when NHS leaders in Birmingham said patients flocking to be registered at the London practice were destabilising local GP practices. In February of this year NHS England approved the expansion plans. Babylon has also threatened to sue the independent health regulator, the Care Quality Commission (CQC), over a critical report.

But Babylon still has plenty of fans. The company doesn’t release user numbers, but its two NHS apps have been downloaded by more than 110,000 people from Google’s Play Store. Health secretary Matt Hancock also claims to use the “revolutionary” and “brilliant” system. In November, Hancock was featured in an Evening Standard advertorial sponsored by Babylon. His appearance resulted in Justin Madders, Labour’s shadow health minister, calling for an urgent investigation into whether Hancock broke the ministerial code for conflicts of interest. Hancock’s office refused a request for an interview for this story, though has previously said he “holds no portfolio for any particular company or brand and regularly champions the benefits of a range of technologies”.

Babylon CEO and founder Ali Parsa Dan Burn-Forti

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Babylon was founded in 2013 by Ali Parsa, a former banker at Goldman Sachs who previously co-founded Circle Healthcare, the first private company to run a NHS hospital. Parsa has a PhD in engineering physics and is not a medical doctor. Three years after he stepped down as Circle chief executive (but stayed on the board), the company was taken public. In January 2015, Circle pulled out of Hinchingbrooke Hospital hours before it was rated inadequate and described by the CQC as having “significant failings”. The CQC said there were “substantial and frequent staff shortages” in A&E and it had concerns about how the hospital was run. In response, Circle said a “number of factors” had played into its decision to step away from Hinchingbrooke. It said there had been an increase in A&E patients, a lack of places for patients waiting to be discharged and its funding had been cut by more than ten per cent.

Then came Babylon. If the company is able to reach a scale where it operates across the UK, it could fundamentally change the way the NHS is structured and how it operates. At its core is a simple idea: let patients hop on a video call with a GP rather than wait for an in-person appointment. Patients can use the app’s chatbot to talk through their symptoms and consultations with a doctor are free if you make GP at Hand your registered GP practice. Video chats are available 24-hours a day and Babylon says they are usually available within two hours of booking.

GP at Hand takes advantage of two different NHS systems: General Medical Services, which is how GPs are funded by the number of patients registered, and out-of-area registration. Since 2015, the latter has let practices register people who don’t live in the local area, so long as they have a local connection. For GP at Hand, anyone who lives or works within 40 minutes of its five London sites, or within London’s transport zones one, two or three, can sign-up.

GP at Hand isn’t designed to be a one-off service. To get free access to the the video consultations people must leave their local practice and register with the GP at Hand clinic in Lillie Road, Fulham. On the occasions where a video call won’t suffice, patients can travel to the clinic in Fulham or Babylon’s four satellite clinics in Canary Wharf, Fulham, King’s Cross and Westminster.

But leaving a GP practice and joining GP at Hand means that NHS funding has to change – and the system isn’t used to big shifts. Babylon’s business model has put significant pressure on the Hammersmith & Fulham CCG. In October 2018, eight complaints to the Advertising Standards Authority (ASA) led it to rule that Babylon’s ads were misleading and made it unclear that patients were required to leave their GP to join Babylon. “The ASA took issue with this claim, insisting for example that Babylon add smallprint highlighting that ’access in minutes’ is dependent on the user registering for the service,” a spokesperson for the company said. “Babylon has adopted this change, but we credit the British consumer with more than enough intelligence to have worked this out without needing smallprint.”

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To understand why the size of Babylon’s practice is an issue, you need to understand how GP funding works. Most GP practices have a few thousand registered patients – the average of all 7,000 practices in England is around 8,500 patients. This takes into account the very large practices and the very small. Each registered NHS GP patient gets the practice a set amount of money that’s calculated by an NHS formula. As of January 2019, GP at Hand had 41,690 patients on its books at Lillie Road, according to NHS figures. In April 2017, the practice had 2,500 patients. In November 2017 when NHS England started to let Babylon sign-up patients from across London, it had 4,700. And that huge shift means Hammersmith & Fulham CCG is paying for them – despite a large portion of those patients not being based in the borough. In November 2018, around 11 per cent of Babylon’s patients lived within Hammersmith and Fulham.

The CCG now breaks down its budgetary position into two sets of numbers, one including GP at Hand and one not including GP at Hand. Some neighbouring CCGs offered to put aside £1m as part of a “risk-sharing” agreement that was needed to bail out Hammersmith & Fulham CCG. In May 2018, its governing body said it would need £18m; before GP at Hand, it expected to run at a small surplus. “The plan requires £18m of external support from NHSE [NHS England] to cover the GP at Hand accelerated costs,” documents reveal.

“The financial impact on Hammersmith & Fulham CCG is a result of how much of the total budget allocation for each patient NHS England are willing to release in the case of GP at Hand patients,” a spokesperson for the company says. They continued to say the budget impact that GP at Hand has is a matter for NHS England and that there shouldn’t be any problems for the CCG as long as the money is provided in a timely way. Butt says the matter of “financial flows” was a matter for the CCG and NHS England.

And other CCGs aren’t happy about being expected to foot the bill for GP at Hand. “It’s really unfair,” says Jackie Applebee, a GP and the chair of Tower Hamlets Local Medical Committee. The tension is created when the money follows patients moving between practices. In some ways it’s no different, Applebee says, to a large block of flats being built in an area, causing a sudden spike in the number of local patients. Because money follows the patients, it will eventually flow from wherever they lived previously to their new GP. However, that increase in list size can be planned for as it causes a one-off patient increase. That’s not true with GP at Hand: as it continues to grow, the CCG has no chance to catch up. It’s as though new flats are constantly being put up in Fulham, with no end in sight.

The long-term implications are unknown. Now that Babylon can expand to other cities and register more patients it runs the risk of increasing the initial deficit to the NHS by signing up more patients. At present, NHS England is paying the extra money that Hammersmith needs and Fulham CCG to cover Babylon’s expansion. A spokesperson for the CCG said it is “in discussions” with Babylon and NHS England about the financial situation.

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Another issue is the kind of patients using GP at Hand. According to figures from Hammersmith & Fulham CCG, three quarters of people signing-up to GP at Hand are between 20 and 34 years old, with 18 per cent aged 35 to 64. Only a small number of older people or children have signed up. NHS England figures show around 83 per cent of GP at Hand’s patients are aged between 20 and 39. Across all GP practices in Hammersmith and Fulham (including GP at Hand) just 49 per cent of patients fall within the same age bracket. “I think all the criticisms of them cherry picking are absolutely valid,” says Applebee. “It’s a low intensity workload with that particular cohort of patients.”

Each person registered to a GP is worth at least £87.92, which is provided as a base payment set by NHS England, with additions depending on age, sex, extra needs and costs of delivering the service. The Londonwide Local Medical Committees says the average London practice receives £146 per patient per year, although that includes the weighted base payment as well as revenue from taking on extra work, such as minor surgeries. The weighting system means Babylon – and any other GP with an easy population of patients – gets paid a bit less, while those left caring for the complex cases are paid a bit more.

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So while Babylon makes less money from easier patients, it’s also attracting easy patients from other local surgeries that are in turn left dealing with more complex cases. While they get more money for more complex patients, the burden placed on clinics with a more complex base of patients can be considerable. On its website Babylon says it receives, on average, around £90 per patient – just above the minimum base payment the NHS provides.

But the skewed patient list isn’t entirely a problem of Babylon’s making. When GP at Hand first launched, NHS England restricted who it could register, banning pregnant women and anyone with complex mental health issues. That requirement was removed in November 2018, though documents from the Hammersmith & Fulham CCG argue that it still might not be “appropriate” for complex patients to register out of their home borough. Babylon’s website says it has a dedicated team that helps with complex patients and that its service may not be suitable for all patients.

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That cherry picking, intentional or otherwise, can have other impacts. In February, GP at Hand patients were reportedly waiting weeks for travel vaccinations – a service that requires an in-person appointment that younger, fitter patients are more likely to make use of. Butt says the delays were an "isolated” incident. “Around 85 per cent of cases can be dealt with entirely through the virtual consultation or through self of services, such as our AI symptom checker,” he adds. “Obviously, there are always going to be certain things which need an in person visit, vaccines being a good example.”

That particularly applies to people who may need to access additional medical services. The location of patients to their GP practice can matter, and it complicates funding. If your GP is in Fulham but your mental health provider or cancer treatment is miles away in Wandsworth, for example, things can quickly become confusing. There are also concerns that GP at Hand patients unable to get to one of its satellite offices will simply attend a local walk-in centre or go to A&E.

Applebee says that when GP at Hand’s clinics are spread across London they are also disconnected from other parts of the social care system. “All the other things that go along with general practice, like district nursing, social work, schools – everything works in a geographical community,” she adds. “GP at Hand has no idea what goes on in my part of Tower Hamlets, they don’t have the relationships with palliative care, or schools or the local cafe.”

A Babylon spokesperson said the company had “no choice” over who applies to join GP at Hand, adding that it does “not cherry pick”. Butt says GP at Hand has a complex care team to help manage such cases. "Clearly there comes a point at which they may need care to be provided in the immediate vicinity of their home, then we might recommend that they find a local provider at that point and our complex care team would help them find the appropriate place of care,” Butt says, adding that this could involve going into hospice or finding a local GP instead of GP at Hand.

The pitfalls of remote care have raised alarms in other parts of the NHS. When Babylon asked to open a satellite office in Birmingham to expand GP at Hand, it was initially denied on the grounds that a single location may not be able to handle the required in-person activity, such as screenings. In July 2018, Paul Jennings, the CEO of the Birmingham and Solihull CCG said he objected to Babylon’s expansion plans "on the grounds of clinical safety". Jennings wrote to Hammersmith & Fulham CCG arguing that the expansion could have wider consequences. “This new digital offer in effect could potentially significantly de-stabilise a number of local practices if a large number of patients (particularly young adults) register with GP at Hand,” he said.

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Earlier attempts to expand to Manchester and Birmingham were also blocked, as were attempts to set up nine additional offices in London. In September 2018, the Health Service Journal reported Babylon had contacted at least 17 CCGs around the UK. Documents provided in response to Freedom of Information Act requests showed that those CCGs included Southampton and Leeds. To date, no announcements have been made regarding either city.

On February 13, NHS England approved the expansion of Babylon into Birmingham. (The British Medical Association said the decision was “disappointing” and “premature”. One day earlier, Babylon announced it was looking to raise about $400m to help it grow.

Another issue is patient churn. Figures show that one in four patients who signed up for GP at Hand eventually deregistered and went back to their original practice. As of March 2018, of the 4,606 people who left southeast London practices for GP at Hand, 941 came back, according to figures from Lambeth CCG. That churn causes extra work for GPs. Butt says churn rate was previously higher than it is now, but didn’t share specific figures. “That may have been because some patients didn’t necessarily recognise that they were leaving their NHS GP and that this was going to become their NHS GP,” he explains.

An October 2018 report from Hammersmith & Fulham CCG also suggests that growth in patient numbers at GP at Hand has slowed, with new registrations offset by patients leaving. NHS Digital statistics show that the practice attracted 2,500 new registrations in both November and December 2018 and passed 41,000 total registrations in January of this year. Butt says Babylon “would be willing to consider” capping patient signups or slowing growth of GP at Hand to ease NHS funding issues. But the situation is messy – and it will continue to be messy until a way of funding new GP business models within the NHS is worked out.

"I think it’s really important we look into these things,” says GP and researcher Sam Finnikin. “At the minute patients are being experimented on – and not in a good way. I worry about that, and I don’t think we know that these are safe and effective technologies.”

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Updated 22.03.19, 12:00 GMT: The Londonwide Local Medical Committee was initially called the London Medical Council

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