Babylon/GP at Hand – AI vs HI
With all the debate going on it seemed right to tackle the question of AI and in particular Babylon’s grand reveal yesterday.
The stage show was to accompany the latest marketing, not peer-reviewed and published, but designed to look like a scientific paper. The point is that they have trained a computer to pass an exam, for MRCGP.
Exams are necessary but not sufficient to be a GP, as I’m sure they would agree with RCGP, but what have they really achieved with 100 made up vignettes and patients played by GPs? Others will answer much better than me on the safety of the process (follow this brilliant thread by @DrMurphy).
I’ve done my own trial of the AI chatbot based on two diseases I’ve personally had in recent months.
“Toenails brown and broken” I start. “Please rephrase…”
“Brown and broken toenails”, and so on. Absolutely no idea from Babylon, who end up asking, “Do you have any other symptoms?”
So I move on to my next trial:
“Wrist pain”. At least they recognise this, and there follows over four minutes a series of 39 questions, of which only 3 seem to me to be relevant, and the diagnosis comes out as:
“8/10 broken bone in the lower arm. Go to A&E”. I answered everything honestly. What I really had was tenusynovitis, tendonitis of the wrist, and I guess rather more common than a broken arm.
The way we do this with askmyGP is to let the patient type in on the very first screen whatever they want, then search for self-care advice. Try it yourself on
Try anything, medical, colloquial, badly spelled, phrases, anything. It’s not perfect but for example my trials above got me in two clicks to fungal nail infection, and the other to wrist pain where tendonitis was one possibility.
I could dress this up as AI and call it the answer to everything, but really it’s just our own algorithm to search NHS Choices better than its own search. It works, and crucially it’s very fast, much faster than having to register wtih all the details and answer 39 questions one after the other. Remember that most patients’ first concern is speed and convenience and this search costs nothing.
We had a clever history taking algorithm in our version 1 software, and very good it was too, but not good enough. Patients got bored and GPs got fed up with too much irrelevant information.
The much simpler interface, respectful of patients’ ability to express themselves, has proven hugely more popular and that has enabled us to move over half the demand online with practices that really understand the benefits.
You have no doubt heard of Elon Musk, technology billionaire and founder of SpaceX and Tesla motors. On that company’s calamitous production problems, flowing from their overambitious automation, he said last month, “My mistake. Humans are underrated.”
You probably haven’t heard of Dr Ellen Stofan, former NASA chief scientist, who said last year they are sending a human to Mars because they’ll get more information, sooner and cheaper than by sending a robot.
I’m an engineer, as keen as anyone on the benefits of technology for humankind, but to get benefits we have to understand how computers can help, not pretend with smoke and mirrors. They are good at searches, communications and analytics, simple and repetitive tasks. For the tricky stuff, we need HI, human intelligence.
Who knows what they might do in some unknown future, but we have a problem right now in general practice, and it’s not a lack of intelligence.
There’s a fundamental difference between Babylon’s start point and ours. They work from DISEASE and have put together an algorithm to try to convert Q&A into diagnoses.
We work from DEMAND and very simply get it to the right clinician to triage in seconds and decide how to care.
That is only the start and tomorrow I’ll discuss our Systems Thinking approach to intervention, in which we’ll see that technology is but a small part.
Time will tell which gives the greatest benefit. but for a taster of how much can change in only a couple of weeks just listen to this interview with Dr Dave Triska .
Harry Longman
PS If you’re on Twitter, click to follow Dave @dave_dlt for some moving reports of the change they have undergone.
PPS Did you hear about the latest AC – Artificial Caring?
- Published in Comment
Babylon are getting speed and convenience right
You might be surprised to see the title, and unless you’ve been on a different planet recently you can’t have failed to notice the PR. Babylon/GP at Hand (their NHS service) are brilliant at finding the limelight.
The chief reason is: they offer something that people want, speed and convenience in getting medical help. Who knew?
The sites are very nicely designed, and if you think that’s easy, you haven’t tried. At present they are nicer than ours (watch this space) and looking attractive is important – people buy on emotion even if we kid ourselves that we’re logical.
People of all ages expect to do everything online, and with younger people a huge majority expect it to be on mobile. The experience must be seamless and beautiful.
A colleague of mine told how a complete stranger struck up a conversation while shopping last week. He told in amazement how he got help within an hour from GP at Hand.
But how? The business model is fantastic too. Low cost of service, with low estates overheads as so much is done remotely, and low usage from a largely fit, young, male demographic. As you all know they’ve been able to exclude children, the frail, elderly, chronically ill and women in danger of pregnancy – most of the people who need a GP.
NHS England pretty much told them to, incredible as it seems, undermining the shared risk model of local general practice. Malcolm Grant speaking today doesn’t seem to understand what this is doing to existing practices who are left with the rest. Anyway, the theme has been so well rehearsed elsewhere I won’t say more, but the reaction from GPs led by the BMA has been as pathetic as it has been predictable.
“Foul!” “Placards!” “Marches!”. Anyone would think the whole lot of them were a cartel bent on nobbling the competition with their newfangled ideas. But we know better. GPs are a fine upstanding profession who embrace innovation to improve their service to patients.
And that vote at the ARM to put a cap on daily contacts? The perfect gift for Babylon/GP at Hand, who will pick up more of those patients they have turned away. Only the profitable ones mind.
Next time I’ll look at what you can do to reverse the slide, and it won’t involve marching on Richmond House.
Harry Longman
- Published in Comment
The dog and bone that didn’t bark
This time yesterday I was in Plaistow, East London and while Cockney rhyming slang is spoken in these parts, you are as likely to hear any of a dozen East European or South Asian languages on the street. It’s quite deprived and extraodinarily diverse.
I was visiting Balaam St Surgery. As anyone knows in general practice, it is pandemonium first thing in the morning when the phones go over. So here’s what Nihul on reception told me:
“We only had three phone calls between 8 and 9 this morning”
That dog and bone just lay there.
Practice manager Divya came out to ask what was not going on. This is week 7 and the numbers have subsided as they keep giving out the same message:
“Do you have an email address?” – yes
“Do you have a smartphone or internet?” – yes
“Can I tell you about a shortcut to get help from the GP?” – yes
Then they show them the practice website, click askmyGP and take it from there. 80% of demand is now online.
Barry Sullman the GP was working from home that day for family reasons, had all 25 askmyGPs directed to him via VPN and messaged or called them from the home office, bringing some in to see the GP on site.
He tells me Monday – Tuesday are hard work, Weds was fine, he looks forward to Thursday – Friday. This has never happened before. He’s saving money, doesn’t need locums any more, takes the kids to school.
While Pulse moans on about GPs turning patients away, Barry is recruiting patients. He keeps telling me “It’s digital triage. There isn’t the strain of telephone triage. This is the future of the NHS.”
The thing I find difficult is that when I report what they are telling me in their own words, people say it’s too good to be true therefore it isn’t true.
That’s really sad, because while GPs are sitting there moaning and disbelieving, their most profitable patients are turning to GP at Hand to get a service far worse than what Barry and his team are providing from their own local surgery.
Spend 5 minutes in reception when it opens tomorrow morning and see what you could say goodbye to.
- Published in Success Stories
Enjoy the summer?
Looking out on the rain, memories quickly fade of, for once, that glorious bank holiday weekend.
In GP land you may have noticed a lighter week too, because demand is predictably sensitive to weather – whether warm sunshine or heavy snow.
We need to qualify the effect however, because if your system is book ahead and wait, lower demand only shows up as a smaller backlog and maybe less pressure on reception. You will still see the same number of patients who have patiently waited whatever the urgency of their need, and it will feel like a treadmill.
The point of a demand-flow system is that there’s always plenty of capacity for the predicted demand, and if it comes in below prediction, you can enjoy the sunshine. A colleague of mine visited one practice we work with on Thursday lunchtime and there were just no patients, time for chat.
Now with summer on the way it is of course the perfect time to put that demand-flow system in place but let me tell you about a real problem we are struggling with.
I can name three practices right now where they are very clear on the challenges they face, they can’t cope with the workload, they know the service is terrible, and their receptionists are getting abuse every single day.
They’ve done a thorough analysis, all the surveys, know exactly what to do, and four GP partners can hardly wait to get going. But one, or perhaps two, partners have dug their heels in.
I’m a great fan of the partner model for a host of reasons, and I haven’t seen a better one, but it has its drawbacks. One partner can veto any change. They are condemning the others to live with the same or worsening situation. Why isn’t there a veto on doing nothing?
Fundamentally I think this imbalance in favour of inaction is holding GPs back, perhaps the whole profession, even if a majority can see what needs to be done.
Are you in this situation or do you have any suggestions?
Meanwhile two north east practices launch on Monday and let’s hope they enjoy the summer.
Kind regards
Harry Longman
PS: One who did act was Dr Sue Arnott and she joins us for this Thursday’s webinar at 1pm.
Online consultations – what is working and why?
Some background on how she came to be running a 4,700 practice as a single hander here.
Many have asked for the first in the series recorded, so it’s here, 45 minutes, “Exploding the myths of online consultations”
- Published in News
askmyGP case study collection
Increasingly practices ask us how others use askmyGP, so we have collected here examples with agreement to be in the public domain.
Please be aware that they are all busy GP practices so have not committed to answering in person an unlimited number of queries. They are all different in some respects from your practice, yet they all share common features of a registered list of patients whom the GPs are committed to serve.
They are all on a journey of change, which started with Pathfinder – could you be ready?
Concord Medical Practice – 14,500 suburban family practice, north of Bristol. SAPC poster.
Larwood Health Partnership – 32,500 large multisite town practice, Worksop. Video interview with Dr Steve Kell, on NHS England site.
Central Surgery Oadby – 8,700 suburban Leicester. Presentation given to the CCG. Webinar with Dr Chris Thompson Online Consults – Our (very short) Journey of Change
Balaam St Surgery – 5,600 East London practice, blog post of interview.
Burnbrae Medical Practice – 4,800 Shotts ex-mining community N Lanarks. Listen to Dr Sue Arnott on the webinar, skip to 29 mins: Online consults – what’s working and why?
Newarthill Medical Practice – 3,000 N Lanarks. Listen to Dr Ashish Vijayan on the webinar Exploding the myths of online consultations
Witley & Milford Surgeries – 11,200 rural Surrey, two sites. Dr Dave Triska @dave_dlt tweets as launch unfolds. This 45 minute recording could change your life: Witley and Milford launch, as it happens – Dave Triska interview.
Every practice will work out their own mode of operation, and with our help can seek to optimise effectiveness and efficiency. Each of the above sees between 30% and 80% of demand arriving online and their numbers are part of over 70,000 patient episodes managed through askmyGP in the first year of version 2.
This page is not for patients, who must find their own practice website to use askmyGP.
- Published in Success Stories
“You’re costing me a fortune Harry”
“My costs have shot through the roof” says Barry with a chuckle. “It’s the school holidays and I’m taking the family out to restaurants every night” (a list follows, burgers, pizzas, curries). Barry Sullman first made contact with us on 28th Feb and I met some of the family on a video conference because Sunday was the only time he had a minute to spare. He was working until 8pm and secretly wanted to finish at 6pm so he could rejoin the human race. To be on the safe side he told me 5 but I didn’t promise. Two weeks since launch he tells me he’s going home at 4. Except for Thursday when he phoned me at 1, from home, complaining that his salaried GP had nothing to do most of the afternoon, one patient booked at 3.45. So he’s changed his plans to recruit a GP and instead will take on an ANP to run the shift until 6.30, CPR trained, as he’ll refer appropriate patients and his work is done by 4. That should pay for a few nights out. He impresses upon me the difference between telephone triage (which he’s tried) and digital triage: now he doesn’t spend ages on calls which are really non-medical. Reception have done them, or he’s emailed a message. So he’s not drowning or suffocating. He’s prepped for the consultation, may have looked up previous notes. He’s impressed by what the patients write, quite detailed, even helps with the non-English speakers. He’s choosing who to see face to face, no more, and it’s all done today. He doesn’t have to up type all the symptoms, just copies into the clinical system. He has gone straight to 70% of demand arriving online, which is 250 per week, and it’s ever so simple how they’ve done it – while not forcing anyone or shutting the door for those who can’t. Patients are happy, reception is peaceful. Barry epitomises the GP who is self reliant, independent, committed long term to his patients, business oriented and decisive. But his Balaam St practice is different from yours – deprived East London, young, multi-ethnic and many non-English speakers. Maybe your practice is more like Joanna’s: prosperous, elderly, all speaking the purest Somerset. They launched this week too, having just lost a GP partner and another on holiday. With a quarter of their capacity removed, and costs saved, they’ve transformed the service in a single week, all patients sorted. Had to scrabble around to find things for the locum to do on some days. She tells me “We couldn’t have done it any other way. This is infinitely better.” Barry, Joanna, dozens of others: big smiles. You? Feeling overwhelmed, helpless perhaps? What is the difference between them, their practices and you? Nothing at all, just that they made a decision and got on with it. Kind regards Harry Longman
A week later on 27/4/18 a GP in a Welsh practice emailed these questions:
Could I ask you first how long since you launched the system ?
As with any change to our appointment system, there is always a honeymoon period, then the rot sets in again, I wondered if you felt any loss of efficiency the longer you run AskmyGP?
And some more specifics:
1)How did you/ do you manage ‘walk-ins’?
2)Was there any backlash against loss of the GP early morning slots for working folk?
3)Do you work with Nurse Practitioners? We have three who see a lot of our minor illness.
4) Can you give me examples of which appointments you do allow to be booked at reception ( CDM? Nurses?)
PS: One other thing in common, both practices invested in Pathfinder and then Transform themselves. They didn’t wait around for months or years hoping the taxpayer would pay for them. PPS: My colleagues and I absolutely love the work we do with practices like the above. But do spare a thought for us at this difficult time. My least favourite activity is the essay writing contest which is NHS England’s Dynamic Purchasing System for Online Consultations, a Sisyphean task as meaningless as it is mindkilling. If I may use an analogy, our Digital Transformation Strategy Engagement Delivery Leads go to a gallery and see an inspirational painting. A painting can’t be painted without paint, so they think it’s about paint. They specify the paint in finite detail, colours, hues, formulation, viscosity, non-toxicity and so on, with which specification all suppliers must comply. By Monday at 12:00:00. They are surprised however when the outcomes are revealed – instead of a series of Leonardos, Picassos and Monets, the precisely implemented procurement process has produced brown walls.
- Published in Success Stories
O Flower of Scotland
With those lines from the terraces of Murrayfield ringing in our English ears, it’s a night to celebrate north of the border. And there’s more to celebrate for a handful of Scotland’s GPs.
Why are patients flocking to register at Newarthill Medical Practice in North Lanarkshire?
Very simple, the access is brilliant. Where neighbouring practices are making patients wait three weeks, Dr Ashish Vijayan can sort them out the same day.
You know what I’m going to say next, but there’s a surprise to come. Yes, he launched askmyGP as a whole system just three months ago and loves it, along with his patients evidently.
The secret is to have time for the patients who need it, just the right time for the right patients.
If you’ve followed this blog for long you’ll know that’s only about one in three, while the others still need help, but it can by remotely and much faster by phone, and now faster yet by secure message.
When Ashish first got in touch in the autumn he was swamped, not knowing what to do with his high demand population, many quite deprived in the ex-mining and steel area. (you might have seen that North Lanarks is the only place in Britain to offer free school meals at weekends).
But they’ve really gone for it, with a fantastic reception team helping patients to go online, and if they can’t putting them on the system too for the doctor.
They are doing 170 online requests every week, the vast majority of all their demand. It’s the most unlikely place to be leading the digital revulution in general practice.
While this week’s BMA News is a cover to cover Moanathon, Ashish is positively bursting with optimism.
The surprise: he’s a single hander, and from 2,900 patients in December, he’s gained nearly 200 since then.
So that’s 50% more than the average fte GP list. Think about the national shortage of GPs, then think again.
Harry Longman
- Published in Success Stories
Can you imagine this?
So you arrive at your practice on Monday morning, looking forward to what the day may bring. The screen is nearly blank as only one patient prebooked last week, who wanted to wait.
Demand comes in quickly now and about half the patients have kindly written down their problems in some detail. You can quickly triage them, about a third you’ll choose to see, another third you’ll phone, a third you’ll send a message – they wanted that, not to waste their time and yours coming in.
Other patients have left a message with reception and you phone them, or delegate to another clinician. The sense of control comes from you deciding as a GP how to help each patient – you’re good at this.
Now after coffee break the first patients are coming down, and you can give each one the time they need. It feels more personal, you can build relationships because some of them have chosen to see you – which they can, because you’re here today, der.
The afternoon session has less than a third the new demand, so it’s more relaxed with much of the time seeing patients contacted this morning and then catching up on paperwork. After 5 very little comes in so you take it in turns staying until 6.30 to switch off the lights.
It’s such a difference from before you changed. Back then, you were constantly frustrated about endless extras, 14 hour days, and the diabolical duty doctor rota. But this is no longer a problem. Every day is pretty much alike, bar the infinitely intriguing variety of patients.
I’ll stop here because at this stage, I’m quite sure that you are laughing your head off.
The idea of a world where you’re feeling in control from the start of the day, able to offer the best professional help to all your patients, and go home with nothing left undone is the holy grail for most GPs.
It’s something which practices we’ve helped take for granted and achieve easily. It seems to come naturally to them.
And yet it seems to fantastical… So preposterous…. So unachievable…. to you, that I might as well have been describing a world where man has landed on Saturn.
Why is this the case?
Many doctors believe it simply can’t be done. That balance of work and fulfillment cannot happen, because demand is infinite.
I don’t believe that at all, and that’s based on the evidence.
I believe GPs are almost universally making two very significant mistakes when it comes to their operating system – mistakes that are sabotaging their chances of success.
If you overcame them, you would discover that a balanced workload was not out of reach at all.
I’ll tell you about the first one on Monday. Watch out for that email…
Kind regards
Harry Longman
PS by the way, if you are concerned about claims being made for NHS 111 digital, you may be interested in a report which has come to light.
@harrylongman
- Published in Success Stories
Revealed: the tiny take up of NHS111 digital and its alarming dispositions
NHS England has trialled four digital versions of NHS111 in an attempt to shift channel from telephone to online.
An internal report dated December 2017 and obtained through HSJ reveals the astonishingly low take up of these heavily marketed pilots. Download the full report here:
Data contained within the report shows the four trials covered a population of 7.5m for the period February to June 2017. The total completed digital triages came to 8671.
A separate chart shows NHS111 telephone volume at around 1 million per month, for a population of 50m.
The digital trials covered around 15% of the population, and over the 5 months of the trial would see pro rata around (15% x 1,000,000 x 5 months) = 750,000 calls.
Digital triages therefore accounted for 8671/750,000 = 1.2%
We know that the digital option was heavily marketed in the four pilot areas, in the public domain, GP surgeries and through IVR messages. We have no idea of the costs incurred.
We can see by comparing the charts that conversions from “I registered or downloaded the digital solution” to “I completed a triage” range from about 60% for Babylon and Sensely to 30% for Pathways and 10% for Expert 24.
Figures given on dispositions are compared to 111 phone triage dispositions and what is striking is the similarity. Much is made of the 18% advised to self-care. However, it is very disturbing to see 20% advised to call 999 or go to emergency. Compared with GP audits of their demand, which they rate at around 0.5% as emergency, these are astonishing numbers. Work we have analysed with a GP led OOH service showed GP disposition to ambulance at 1.4%.
Following the advice of the algorithms would multiply use of emergency services by a factor of 10 to 20.
Worse than this, we suspect that the low take up means the diseases entered are highly unrepresentative of the overal disease burden, and are likely skewed to conditions which are “easy to triage” and therefore less acute.
Given the above analyses, and if you knew the eye-watering costs incurred, what would you do?
Harry Longman
PS The conclusion of the report’s author may surprise you, page 4:
The learning from these pilots supplemented with data from other health systems and from
other online services would continue to support the case for an online interface for urgent
care. This evaluation does not recommend one product over another but demonstrates that all
products have some similarities and differences but all products tend to support channel shift
and management of demand whilst providing patients with a good experience.
To gain further understanding of NHS111 Online and the impact on the health system, larger
data sets and linked data will need to be considered. Therefore, the expansion of pilots and
further analysis will enable a more robust evaluation.
- Published in News
Babylon/GP at Hand: GPs need to change their game
In this third instalment on Babylon/GP at Hand the cards are on the table, and you’ll see why.
I’ve looked at what they are getting right, patients’ desire for speed and convenience (don’t blame the patient, think of the last time you were one). I’ve looked at their AI claims, partial, unproven but fundamentally a disease based rather than demand led model.
Now the nub of it: GP at Hand is disrupting traditional practice with a city wide (London only for now) service attracting young, fit, male and mobile adult patients – your most profitable demographic. The exclusions effectively mean
Even a normal healthy female would go through four changes of GP to use this service during her lifetime.
Infant – no. Young adult – yes. Mother – no. Older adult – yes. Elderly – no. “All the world’s a stage…” but only bits of it are covered by NHS Babylon. (Kudos to them for getting Malcolm Grant onto their stage on Wednesday night btw. What was he thinking?)
Let me be absolutely clear where we stand: for high quality general practice covering the whole person, life, family and community. Sounds rather like the RCGP, indeed the NHS. It has to be local to do that (and unit size is irrelevant, except to patient satisfaction which goes up as size goes down).
But to compete against the likes of GP at Hand, and to be profitable in ever more squeezed circumstances, you have to work much more efficiently. Not lilttle 3% tweaks, but 30% leaps. That is exactly what we do.
That kind of efficiency gain (Dr Sue Arnott, single hander, has 4,600 patients) is changing the economics.
The normal experience of askmyGP patients is to send a request online, get a response within minutes and for the 30% or so who need to be seen, it’s today. The record posted last week was a feverish child seen within 12 minutes of sending. GP at Hand can’t touch that.
Safety must be paramount, and two features of the system design are crucial. Firstly it enables you to be responsive, easier to contact by phone as well as online, and we know the average practice should expect a couple of emergency presentations each week. I would never have made this claim, but Dave Triska tweeted on Wednesday, “so far I can count 3 lives saved in 4 weeks by this method.”
Secondly, it enables and encourages continuity by allowing patient choice of GP, and giving GPs total flexibility within the day to provide. Here is today’s BMJ paper, better continuity reduces mortality.
Increasing numbers of practices are asking us where to start, without leaping into the unknown (really not unknown, the once familiar delight of being a doctor) and that’s what we do wtih Pathfinder – Could you be ready to change?
It’s the kind of change which is necessary to stay the same. Don’t give in. Don’t see decline as inevitable. Don’t expect bungs or contract changes to bail you out – not this five year plan.
Use the power you already have over your own destiny.
Harry Longman
PS Please don’t believe me. Believe the GPs doing it, and if you haven’t yet, hear the amazing interview with Dr Dave Triska.
PPS This tweet from Dr Lis Flett moved me: “One of the two patients who wanted a face to face appointment this morning (that’s right, 2) sat with me for half an hour. Many problems solved, patient felt listened to: Medicine the way it should be.”
PPPS Just had an email from Babylon “Babylon’s AI is on par with doctors”. You. Could. Not. Make. This. Up.