Babylon Health is the most prominent of the new private companies seeking to develop digital technology in the NHS. The company has developed a smartphone app, known as GP at Hand, which uses artificial intelligence (AI) in the form of a chatbot to triage, diagnose and link with a GP for a consultation.
To date, the company has launched products in the UK, Ireland and Rwanda. In 2015, the company launched its GP at Hand App in London, under a contract with the NHS; this has attracted thousands of patients, but also major criticisms of the way it 'cherry-picks' patients and destabilises the local health economy.
Babylon Health’s business focuses on the development of digital technology and artificial intelligence (AI) in healthcare. According to Babylon Health's website its mission is "to transform healthcare for everyone on earth" with the company being founded "with a single purpose: To put an accessible and affordable health service in the hands of every person on earth."
Babylon was founded in 2013 by former investment banker Ali Parsa; until December 2012, Ali Parsa was CEO of Circle Health.
The company's first smartphone app (an AI chatbot) was launched in February 2015 in the UK and is now also available in Ireland and Rwanda. The company also has contracts in Saudi Arabia and China.
By asking a series of questions, Babylon's app can answer medical queries and can put the user in-touch (virtually) with a GP. The app is personalised by the use of a dashboard of the users health statistics acquired either by the phone (exercise regime etc.) or via supplemental devices. Babylon will supply users with blood testing kits for liver and kidney function, thyroid function, vitamin levels, bone density and cholesterol. The results of the tests are then incorporated into the user’s app settings.
In the UK, the company offers a private service via its app; Babylon charges £9.99 a month (minimum of 3 months) for unlimited GP appointments, or £49 for a first one-off GP appointment. Babylon's primary target in the UK, however, is gaining access to NHS patients. The company has a contract with NHS England for its GP at Hand app which was launched as a service in London in 2015; thousands of patients have now registered with the service (see below for details).
A major part of Babylon's UK strategy is expanding this GP at Hand service to other areas of the country. In March 2018, Pulse reported that GP at Hand had lodged 'further subcontracting applications' for 'sites elsewhere in London' and 'the provider has indicated they will seek to expand to sites outside of London in July 2018'. In July 2018, however, Pulse reported that commissioners in Birmingham have rejected Babylon's application to expand its GP at Hand with a centre in Birmingham. A letter from Birmingham and Solihull CCG noted that it 'would like to formally object to the variation on the grounds of clinical safety'. A variation refers to the addition of the Birmingham site alongside the five sites in London, already registered for the app. Babylon has blamed ''the financial and ideological interests of the few" for the rejection of the application.
However, despite objections in February 2019, NHS England gave the go ahead for Babylon Health to expand to Birmingham and a launch took place in June 2019. Patients in Birmingham will be registered at the Fulham practice in London, although the company will have a physical clinic in Birmingham. In October 2019, Babylon announced that it was planning to expand to Manchester with a launch in early 2020. The company plans to open a physical clinic in central Manchester.
The company's future in the UK was boosted in June 2018, with the appointment of Matt Hancock as Health and Social Care secretary. Mr Hancock is very enthusiastic about the use of new digital technology in the NHS and in July 2018 revealed that he is actually a subscriber to GP at Hand and found the service 'brilliant'.
In September 2018, Matt Hancock gave a speech at Babylon's headquarters in which he told an audience of Babylon Healthcare staff he wants to help the company expand “so loads of companies can come do what Babylon are doing” in the NHS. In the same month HSJ reported that via FOI requests the publication had found that at least 17 CCGs had met or corresponded with Babylon; some CCGs that did not reply to HSJ are known to have been in contact with Babylon or GP at Hand. The target cities for GP at Hand are Southampton and Leeds.
Babylon Health has benefited from certain payments available to surgeries that register patients in London and from the rules surrounding registration of out-of-area patients. These benefits may not last much longer, however, due to changes in the new five year GP contract announced by NHS England in January 2019. Two changes to payment rules starting 1 April 2019 will reduce the company's income. The changes will mean that certain extra payments apply only to patient's living in the surgery catchment area and that the London adjustment payment will apply only to patients living in London, rather than those registered to a London-based practice.
However, the most significant change discussed in the GP contract was a review of the out-of-area registration rules. Changes to these could reduce the number of patients Babylon can register, which would have a significant impact on the company's business strategy. NHS England began a consultation on digital first primary care, including the out-of-area rules in July 2019. The consultation addresses four problems: should out-of-area registration rules be reformed to cater for digital providers and primary care networks (PCN); should CCG funding allocation reflect in-year patient flow; should the premium for new patient registration only be paid after an agreed period; and should a wider array of digital first providers be available? Each issue is relevant to Babylon Health.
As a result of the consultation, in September 2019 a joint board of NHS England and NHS Improvement published new guidelines for digital first GP-providers. The changes come into force in April 2020, now when the list of out-of-area patients reaches a certain threshold, Babylon's contract will be split and a new practice list for GP at Hand in another area will be automatically created with a new CCG contract, where the company would need to provide premises, be part of a local network and meet all services requirements. Babylon has around 60,000 out-of-area patients, who will now have to be split into 17 different contracts.
One facet of Babylon's 'strategy' in the market is resorting to litigation in the face of criticism. In December 2017, HSJ reported that the company had failed to prevent the CQC publishing an inspection report of the company's service.
Babylon had filed a legal action in the High Court, challenging the publication of the inspection report; the CQC stated that the report was “not particularly adverse”. The court rejected Babylon's request for an injunction to prevent publication and the report was published. However, the court also heard that the CQC had agreed to remove a large part of the original report before it was published.
In September 2018, HSJ detailed various other attempts by the company to silence criticism and even reporting. These include Babylon's angry reaction to a CCG's board papers that documented doubts about the strengths of its product and Babylon's efforts to exclude HSJ journalists from an event at its headquarters at which Matt Hancock was speaking. The publication's journalist was only allowed in after the intervention of Mr Hancock.
In China, Babylon teamed up with Tencent’s WeChat social messaging platform in April 2018. The deal means the one billion WeChat users can enter their symptoms to Babylon’s app, which will then send back healthcare advice. In Saudi Arabia, Babylon has a contract with the Kingdom to provide its technology to the population.Babylon launched its smartphone app in Rwanda in 2016. In November 2017, a partnership with the Rwandan government and the Bill & Melinda Gates Foundation, led to the launch of app to the entire population of Rwanda. The deal was part of a drive by the government of Rwanda to deliver affordable, accessible healthcare to the people of Rwanda.
By early 2018, Babylon was reported to have more than 1.4m users of its smartphone app. Almost half these are based in the UK, with the remainder spread across Rwanda and Ireland.
According to filings on the UK's Companies House there are three companies linked to Babylon Health:
Babylon Healthcare Services Ltd (company no: 09229684) - the operating company of Babylon Health registered in the UK. According to Companies House its two directors are Ali Parsadoust and Christopher William Bischoff (investment director)
Babylon Partners Ltd (08493276) - with directors Ali Parsadoust and Christopher William Bischoff (investment director)
Babylon International (11210368) - the newest company incorporated in February 2018, with Ali Parsadoust and Christopher William Bischoff (investment director) as directors
In addition, registered in Jersey, with details available from the Jersey Companies Registry is:
Babylon Holdings Ltd, registered at 31 Esplanade, St Helier, JE1 1FT.
In financial filings submitted to Companies House by Babylon Healthcare Services Ltd, this company is a subsidiary of Jersey-based Babylon Holdings Ltd, but the ultimate controlling party is ALP Partners Ltd, a company run by Nedgroup Trust on behalf of the Parsa Family Trust.
Babylon Healthcare Services Ltd is funded via Babylon Holdings Ltd, which issues shares for the required funds.
The most recent financial report filed with Companies House is for the year to the end December 2017. Babylon Healthcare Services Ltd reported turnover of £1,810,072 for the year, up from £945,646 in 2016. Profit for 2017 was reported as £108,358, compared to £56,739 for 2016. No tax on profits was paid in either year.
In January 2016 Babylon raised $25 million via the issuing of series A shares. The financing was led by Swedish investment group AB Kinnevik with other participants including the founders of BXR Group, a multi-billion dollar global investment group; Demis Hassabis and Mustafa Suleyman, the founders of DeepMind, the British artificial intelligence company acquired by Google, and Hoxton Ventures, the fund established to bridge European companies to Silicon Valley.
In April 2017, Babylon raised $60 million in a further funding round. Investors in the new round include, Sawiris, an Egyptian billionaire business family, Investment AB Kinnevik, NNS holdings, and Vostok New Ventures.
According to the Annual Return document (February 2018) filed on the Jersey Companies registry, the listed investors in Babylon Holdings Ltd are: ALP Partners (previously Babylon Partners (Jersey) Ltd - changed in 2013); Hanging Gardens Ltd; Gary Mudie (Chief technical officer Babylon Health); Longsutton Limited; Demis Hassabis (founder & CEO DeepMind); Hoxton Ventures; Kinnevik Online; Ali Parsadout; NTJL ATO Parsa; NNS Holdings; and Vostok New Ventures.
In February 2019, the FT reported that Babylon Health was seeking to raise $400 million for ongoing expansion.
Babylon Health has worked with the NHS on an app to replace NHS 111 and the company also has a contract for the GP at Hand app in London.
NHS 111 trial
Babylon's smartphone app was one of the number of apps that NHS England trialled across England. For six months from the beginning of January 2017, the 1.2 million inhabitants of north central London, including the boroughs of Camden, Islington, Enfield and Barnet, had access to Babylon Health’s app that they could use instead of phoning NHS 111.
The app performed triage for urgent but non-life-threatening conditions. Users typed in their symptoms and the app decided how urgent their medical needs were. After each text, the app, responds with further questions to get more details of the problem, each time consulting a database of every symptom and illness in the world.
After the trial, however, the app was not adopted by the North West London Collaboration of CCGs. In a statement the organisation noted that in focus groups patients were more interested in using the app to avoid waiting lists. The report from the CCGs noted that “Patients who might use the app could mainly do so because they believed it would get them faster access to GP appointments…..The focus groups had also commented that there is a risk of some people gaming the symptom checker to achieve a GP appointment.” This could involve overstating symptoms to get an appointment sooner. As a result, the CCGs decided to discontinue testing.
NHS England's report on the four online tools, including Babylon's NHS 111, published in January 2018, found that all four provided a “safe service”, were far cheaper and faster than a phone call, and “did not seemed to generate extra demand” for 111 services.
An investigation by HSJ published in September 2018, found that Babylon had spoken to at least four CCGs (Dorset, Southern Derbyshire, Hardwick, North Derbyshire and Dorset) about adopting its NHS 111 Online product. However, NHS England has ordered CCGs to pick the NHS Pathways system.
GP at Hand
Babylon Health's GP at Hand smartphone app began operating in London from a single Fulham surgery site in 2016. In November 2017 Babylon Health, under a contract with NHS England, launched GP at Hand with a further five sites in London. The company promises that patients will be able to 'book an appointment within seconds' and have 'a video consultation with an NHS GP typically in under two hours of booking, anytime, anywhere'.
Babylon is working with the GMS practice of Dr Jefferies and Partners, based in Lillie Road, Fulham in West London. Under the Government’s ‘GP Choice’ scheme, which allows GMS practices to sign up patients from outside their traditional boundaries, Babylon has been able to target patients who live across London and those who work in zone 1 to 3. Patients who sign up for GP at Hand are de-registered from their own GP’s list and re-registered on the list of Dr Jefferies and Partners as an out-of-area patient. In the four months, since GP at Hand was offered out of area, the Lillie Road Medical Centre's total list size increased from 4,970 to 23,997.
Data from NHS Digital released in April 2018 show that a total of 85% of new registrations since November have been from patients aged between 20 and 39 years old. Of all new patients signing up since GP at Hand was opened up to out-of-area patients, 94% were aged between 20 and 49.
By April 2018, GP at Hand had 200 GPs on its roster, working for its private and NHS services. According to Pulse, Babylon offers a full-time salary of around £90,000 to work from home, or £108,000 if office based. The company also told pulse that it will have over 40,000 users of the NHS GP at Hand service once it has finished processing applications.
In November 2018, NHS England lifted all restrictions on the type of patient that can register with GP at Hand.
In February 2019, NHS England cleared the way to GP at Hand expanding to Birmingham. Patients who sign up in Birmingham will be registered at the Fulham surgery, although the company will have a physical clinic in Birmingham. The service was launched in summer 2019.
In June 2019, Babylon Health was granted primary care network status by NHS England, however this is only a temporary arrangement until April 2020 when new out-of-area rules will be applied, following a review by NHS England.
There are a large number of concerns surrounding the GP at Hand app.
Babylon has advertised its GP at Hand service being suitable for ‘people of all ages whether you are in good health or not’, but its site lists 10 types of patients that the service may be ‘less appropriate for’. This includes patients with complex mental health conditions, learning difficulties, pregnant women or frail elderly. Babylon Health has noted that NHS England originally put restrictions on the type of patient that it could sign up; in November 2018, NHS England lifted all restrictions on the type of patient that can register with GP at Hand.
Both the RCGP and BMA criticised the scheme for 'cherry picking' younger, healthier patients, leaving other GP practices to deal with patients requiring more complex care. Even with the restrictions lifted, this type of digital service is more likely to appeal to a younger, fitter, healthier demographic and is unlikely to be used by older patients with complex needs.
A report in November 2018 by GP Online confirmed the predictions that the GP at Hand service will attract younger, fitter patients. It found that in April 2017, 16% of patients at the Lillie Road surgery were aged between 20 and 29 years old, but by November 2018 this had risen to 49%. Of the 31,519 new patients who have signed up with GP at Hand over the previous 12 months, 87% are aged between 20 and 39 years old. Patients that are over 65 now made up just 1% of the population registered with the service - compared with around 10% in April 2017.
Destabilization of local health economy
Warnings that Babylon Health's business strategy would destabilise the local health economy have been proved correct with Hammersmith & Fulham CCG, where GP at Hand is based, now in serious deficit.
The possibility of destabilisation was discussed In a March 2018 article written for Pulse, Dr Simon Brownleader, chair of Tower Hamlets GP Care Group, Dr Sam Everington, chair of Tower Hamlets CCG and Dr Jackie Applebee, chair of Tower Hamlets LMC, discussed the damage done to the local CCG by the GP at Hand model of business.
The article notes that GPs rely on risk pooling and cross subsidy in that the capitation fee for younger fitter patients, who consult less often, provides the funds to care for the more complex and elderly patients. Operating models like GP at Hand threaten this system and risk diverting resources away from those who need them most to those who need them least.
In the same month, Pulse reported that the success of GP at Hand was leaving the local health service with a deficit. Hammersmith and Fulham CCG has said the growth of the service could drive up costs by more than £10m and push it into deficit during 2018/19. In May 2018 the CCG reported that it would need an additional £18 million in extra funding to cope with the influx of patients due to the GP at Hand app. In June 2018, the CCG was given £1 million by neighbouring CCGs to help it cope with the influx of patients.
In January 2019, Hammersmith and Fulham CCG reported a deficit of £2.5 million. The CCG stated that Babylon GP at Hand is the ‘key driver’ of cashflow issues, and it expects the situation 'to worsen in the near future'. In January 2019 the CCG noted in its board papers that Babylon continues to run advertising campaigns across London for new patients and so things are likely to get worse. The board papers also noted that the costs associated with the Babylon GP at Hand practice could ‘jeopardise' other health and care services in the area. Pulse reported in February 2019 that the CCG is in discussions with NHS England over how and when the costs associated with GP at Hand will be recovered.
In 2019/20 GP at Hand patients are calculated to add £21.6 million to the CCG's costs. After discussions, NHS England has agreed to meet these costs. The local Hammersmith MP Andy Slaughter is pushing for the CCG to be compensated £35 million, the total costs incurred by Hammersmith and Fulham CCG since GP at Hand was opened up to out-of-area patients in November 2017 to the end of 2019/20.
Deskilling of GPs
There are concerns about the affect on GP skill levels; GPs that move to work for Babylon will not face the great variety of cases seen in a normal practice. In particular, the GPs will lose skills in the area of care of the elderly and frail and in mental health.
In an article for Pulse, Tower Hamlets LMC chair Dr Jackie Applebee, who said practices in her area have so far lost around 1,500 patients to GP at Hand, said: 'I can see why it is attractive to go and work for them, because they are offering flexible working hours, I imagine a good salary, and it's an easy workload if it's young single-issue patients. But it's the long-term impact of dividing the GP workforce into those who look after complex patients and those who look after the more simple patients. It de-skills us as a profession.'
In June 2018, the HSJ reported that there are issues with referrals for mental health services and community care. Other London CCGs and providers have said they are unable to accept referrals. After Hammersmith and Fulham CCG intervened and agreed to pay for the patients’ treatment, most neighbouring CCGs and services agreed to accept referrals. However, some have continued to refuse. The issue is complicated as the majority of patients registered with GP at Hand in Hammersmith & Fulham CCG live outside the CCG area. H&F CCG is now having to pay for a large amount of out-of-area treatment.
Babylon was highly critical of the CCGs refusing referrals, noting in a statement that “some senior individuals in a few London CCGs and providers” were to blame, for placing “their narrow business interests or ideology ahead of patient care and NHS policy”.
Babylon has published a research paper comparing its AI with a doctor or nurse. The paper was published on the non-peer reviewed site arXiv. It showed Babylon's AI outperforming doctors and nurses in laboratory conditions. In September 2017, however, David Wong, professor of health informatics, and Hamish Fraser, associate professor in eHealth, at the Leeds Institute of Health Sciences together with WiredUK found Babylon Health's app the "least accurate" in a test of three symptom checker apps - Babylon’s AI, Ada and You.MD.
In an article for Wired, the academics noted that there needs to be stronger governance around this type app: "The great concern is that somebody puts information in and they have a serious illness and they get reassurance they're ok and that's a false negative situation, which could be life threatening."
An anonymous NHS doctor who Tweets under the name @DrMurphy11 has tested the Babylon app repeatedly, highlighting problems, including when he posed as 48 year old, 40 a day male smoker who wakes “with a shoulder pain radiating down his arm” - the Babylon app told him his symptoms could be managed at home with a cold compress and painkillers, when a heart attack should have been considered. Other footage shows a bizarre series of triage questions for the symptom "I have a nosebleed". Dr Murphy has a series of tweets known as the 'bad bot threads' that highlight the issues with the Babylon Health AI.
In July 2017, an inspection of the service provided by the Babylon app resulted in a critical report, which raised concerns about the potential for prescription misuse and lack of information sharing with a patient's primary GP. However, the report also stated that most services “were safe, effective, caring, responsive and well-led.” Babylon Health tried to suppress the publication of this report, taking the CQC to the High Court in December 2017. The high court ruled that the report could be published; Babylon then criticised the CQC and questioned whether the regulator has the ability to regulate digital health services. In late December 2017, Babylon dropped the legal case against the CQC and agreed to pay £11,000 in legal costs.
In June 2018, Babylon Health made a claim that its GP at Hand app is able to provide clinical advice to patients that is ‘on par’ with doctors. Babylon tested the app using diagnostic questions from trainee GP exams and reported that its AI scored 81% compared to an average mark for real-life doctors of 72%. The RCGP said the claims were ‘dubious’.
The GP at Hand app is undergoing an independent evaluation by Ipso Mori, commissioned by NHS England, however this will not be able to make robust conclusions about its safety and effectiveness. It will also 'not include a comprehensive assessment' of the artificial intelligence (AI) symptom checker the service uses to triage patients.
Ipsos Mori identified the limitations in an interim report published by Hammersmith & Fulham CCG. The final report on the service was published in March 2019.
In October 2018 the Advertising Standards Authority (ASA) upheld complaints about Babylon Health's adverts on the Underground in London. The complaints were that the ads were misleading because they did not make clear that in order to use the services advertised consumers must leave their current GP; and the GP at Hand service, including its in-person consultations, was only available to consumers who lived or worked in the catchment area of specific GP surgeries. The complainants also challenged whether the claim “See an NHS GP in minutes” in the ads was misleading. The ASA told Babylon Health that the ads must not appear again in their current form.
By January 2019, six other complaints made to the ASA regarding Babylon Health's advertising had been resolved informally, according to the ASA website.
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