Enthusiasts predicted the plan would relieve the pressure on hard-pressed GPs. Critics saw it as a sign of creeping privatisation and a data-protection disaster in waiting. Reactions to news last month that Amazon’s voice-controlled digital assistant Alexa was to begin using NHS website information to answer health queries were many and varied.

US-based healthcare tech analysts say the deal is just the latest of a series of recent moves that together reveal an audacious, long-term strategy on the part of Amazon. From its entry into the lucrative prescription drugs market and development of AI tools to analyse patient records, to Alexa apps that manage diabetes and data-driven experiments on how to cut medical bills, the $900bn global giant’s determination to make the digital disruption of healthcare a central part of its future business model is becoming increasingly clear.

Why Amazon is moving into health

Few doubt new digital technologies have roles to play in the huge challenges healthcare systems are facing. Amazon has many detractors, but even they concede it has been highly successful in improving customer experiences and cutting costs. Yet the company’s move into healthcare raises some fundamental questions. What precisely are its ambitions? Can we trust it with our sensitive health data? And are its commercial imperatives compatible with the core values of the NHS, or do they threaten its very existence?

While Amazon’s recent focus on health has caught the attention of observers, its interest in the sector is far from new. As far back as 1999, it bought a big stake in online retailer Drugstore.com. The company’s early bid to move in on the prescription drug market ultimately failed due to a combination of regulatory hurdles, logistical challenges and defensive moves by rivals.

Amazon came back for another go in June 2018 when it paid close to $1bn for online pharmacy PillPack, which has licences to supply prescription drugs across the US. The global healthcare market is worth more than $7tn, and health spending consumes a huge proportion of the GDP of major economies – 17% in the US, around 11% in France and Germany and 10% in the UK.

Consumers are starting to expect the same level of flexibility from healthcare as they get from other industries Anurag Gupta

“First and foremost, Amazon sees a highly inefficient, highly regulated and potentially very lucrative multitrillion-dollar global healthcare market,” says Jeff Becker, a senior tech analyst at US market research company Forrester. “While most other companies are put off by the high barriers to market entry, organisations of the size and complexity of Amazon are not dissuaded, and see a major financial opportunity.”

Meanwhile, health systems across the world are under pressure to reform to maintain care levels in the face of major challenges. The NHS faces an ageing population, rising demand for services, a funding squeeze, the continued social care gap and serious staffing problems.

Patient expectations are also changing

Thanks to digital transformations in other areas of our lives, we expect to get what we want quickly, conveniently and affordably in ways that take account of our personal needs. “Consumers in the UK can order something at midnight and take delivery the next day,” says Anurag Gupta, an analyst at global research consultancy Gartner. “They’re starting to expect the same level of service and flexibility from healthcare as they have got used to from other industries.”

Amazon doesn’t like to go into detail about its long-term vision, but a series of recent launches, acquisitions and appointments reveal a clear and ambitious strategy. In January 2018, it formed a not-for-profit joint venture with banking giant JPMorgan Chase and multinational conglomerate Berkshire Hathaway. Later named Haven, its public pronouncements have been vague and modest, stating that it aimed to better use data and technology to provide improved, cheaper healthcare for the three companies’ 1.2 million employees and their family members.

Suspicions that this is far from the limit of Haven’s aims were confirmed in June last year when it announced its new CEO was Atul Gawande, a renowned surgeon, Harvard Medical School professor, writer and ambitious reformer with a firm belief in the power of data to deliver safer, more efficient and better integrated healthcare.

Analysts say Haven is in reality a test bed for new forms of employee healthcare benefits, experimenting in areas including improving GP access, remote patient monitoring and digital care delivery and reducing prescription drug costs. “The idea is to apply Amazon’s culture of taking the friction out for consumers end-to-end and bring that to healthcare,” says Becker. “I think Haven is an incubator for a next-generation healthcare delivery model, which, after testing, will be made available to general consumers.”

Amazon’s choice of partners in Haven is also instructive. Berkshire Hathaway’s multibillionaire CEO Warren Buffett has described healthcare as the “tapeworm” of the US economy. JPMorgan Chase is one of the world’s biggest banks. Together they would be well placed to create and sell lower-cost payment plans for other companies or advise them how to do so, based on an in-depth understanding of insurance risk and Haven’s experimentation.

Amazon Prime for health

Last year, Amazon unveiled Amazon Comprehend Medical, a cloud-based service that uses machine learning to extract information from medical data including patient records and provide new insights. In April, Amazon began offering PillPack’s service – medications packaged by dose and time – with free delivery to its Prime subscribers.

Meanwhile, last month’s NHS-Alexa deal is just the tip of a very big iceberg. Amazon has announced new Alexa applications under development, including ones that manage health-improvement goals, handle blood-sugar readings and book appointments. Crucially, it says it has created ways for Alexa-enabled devices to handle patient information that conform to US privacy laws.

Amazon consistently refuses to discuss its healthcare plans. Neither it nor Haven responded to multiple requests for comment for this article. In mid-2017, it was reported that the online retail giant had set up a secretive lab to explore tech-driven healthcare disruption called Amazon 1492, presumably named after the year Columbus first arrived in the Americas as a signal of its paradigm-shifting ambitions.

Becker and others believe the company is working towards the launch of an Amazon Prime service for healthcare. The company already knows a lot about its customers, including their reading preferences, education levels, approximate weight if they buy clothes, search histories, and the eating habits of customers of its Whole Foods subsidiary. Add to this data from AI-powered extraction from medical records, Alexa, fitness trackers and connected medical devices like blood-pressure monitors and glucometers, and Amazon will know those who sign up inside out.

A Prime Health virtual doctor could decide whether you need a human doctor or just to stock up on tissues, for example. Appointments could be much simpler and quicker to book. Patients with chronic diseases or those recently discharged from hospital could be remotely monitored at home, while medication could become cheaper and quicker to access. Alexa could provide alerts and personalised health advice, and even reward healthy choices.

“These elements are being deployed incrementally, and I think when we step back, what we’ll see from Amazon is fully curated digital-first healthcare that, for example, only brings in your GP when and where it makes sense,” says Becker.

He is not alone in his analysis. Silicon Valley venture capitalist John Doerr, a friend of Amazon founder Jeff Bezos, told a conference in November: “Imagine what it’s going to be like when he [Bezos] rolls out Prime Health, which I’m convinced he will.”

Illustration by James Melaugh.

Amazon and the NHS

But aren’t Amazon’s ambitious, data-driven plans more relevant in the US than in the UK, where all have access to free-at-the-point-of-delivery, more or less comprehensive care? In fact, NHS patients have been using virtual GP services for some time. The most high profile is London-based Babylon Health, which has more than 50,000 registered patients and recently launched in Birmingham.

The incentive for companies like Amazon is to increase profits, which puts them at odds with the goals the NHS Jeff Becker

Most observers expect digital healthcare providers, both big and small, to work with rather than in competition with NHS providers, as they are already doing. “These changes are relevant globally,” says Becker. “There would be real benefits to the UK public in some of the digital innovations inspired by the kinds of incubator models being generated in Haven. Like the NHS-Alexa deal, I think it will be a partnership rather than an alternative.”

Others, however, believe the commercial imperatives of the tech giants conflict with the public service values of the NHS. “What does return on investment look like in healthcare?” asks Mathana Stender, a Berlin-based tech ethicist. “The incentives of companies like Amazon are to increase market share, share prices and profits, which puts them at odds with the underlying goals of a public health system like the NHS.”

Some fear that free-market tech evangelist politicians would be more than happy to cut NHS funding and invite private companies to fill the gap. However, Matthew Honeyman, of health thinktank the King’s Fund, says those primarily interested in cutting costs shouldn’t expect quick gains. “These kinds of transformations do bring efficiencies and productivity benefits, but our research suggests these take years to come through.”

Can I trust Amazon with my health data?

The most widespread concerns relate to data protection. Last month it was revealed that contractors working on quality control of Apple’s Siri voice assistant regularly hear recordings of confidential conversations, including doctor-patient discussions. In 2017, London’s Royal Free hospital was rebuked for failing to comply with the Data Protection Act when it handed over the personal data of 1.6 million patients to Google’s DeepMind as part of efforts to develop an early diagnosis system.

Amazon has promised that UK patients who asked Alexa for health advice would have their data encrypted, but critics demand more specifics on how patient data is protected. “We need more detail and transparency about how people’s sensitive data will be processed and used when they ask Alexa a question,” says Honeyman.

Others say there are privacy risks even if big tech companies do make stringent efforts to protect patient data. “Even using the most sophisticated anonymisation techniques, given enough data points, it may become possible to de-anonymise individuals in future,” says Stender, also a fellow at the Centre for Internet and Human Rights at the Viadrina European University in Frankfurt an der Oder.

Healthcare is widely considered a “digital laggard” compared with other sectors. But the pace of change is quickening. Amazon and the other major tech companies have become rich and powerful in large part by realising the value of and monetising data. Critics highlight what they say is their poor data protection track record, and warn of irreparable damage to our privacy if the same approach is applied to personal health data. Few doubt digital disruption can bring big gains in healthcare. Less clear is whether Amazon and its ilk can or should be trusted to play central roles in the new era of data-driven healthcare they are carving out for themselves.

It’s not just Amazon

Jeff Bezos’s firm is far from alone in looking to disrupt healthcare with data and technology. Apple is rolling out its Health Records feature designed to make it easier fo users to visualise, use and store medical data on their iPhones. The latest Apple watches have ECG sensors that can alert users if they have potentially dangerous irregular heart rhythms. The Google-owned company DeepMind last month claimed its AI algorithm could predict acute kidney injury – which kills 100,000 people per year in the UK – 48 hours before it happened. Startups are working on everything from smart pill bottles and clinical-grade home diagnosis kits, to mental health tracking and personalised nutrition plans tailored to specific health needs.

Government ministers including self-proclaimed techie, health secretary Matt Hancock, and other health leaders agree that data and tech can transform healthcare for the better. A Department of Health and Social Care policy paper published in October last year outlines a strategy built on open standards, data security and interoperability of modular systems.

Since 2016, NHS England has been awarding grants of up to £10m to digitally advanced NHS trusts to create blueprints for others to follow. Early examples include integrated care records, an AI-driven sepsis early warning system, an online platform for patients to play an active role in managing inflammatory bowel disease, and the use of Alexa in adult social care.