In October 2018 the NHS Digital App was launched amidst claims it will be the “digital NHS ‘front door’” to a range of services. Similar to apps such as “Push Doctor” and “GP at hand” it will provide advice, a symptom checker and telephone and video consultations with medical professionals. No doubt some people will find this is a more convenient entry point for care services but it also opens up new possibilities for backdoor privatisation. For example, companies like Babylon Health see this as an opportunity to deploy the Uber model of service delivery into healthcare. If all our NHS interactions happen through them they can make commissions and get access to valuable data by mediating our interactions with services.
Today’s most successful companies, like Google and Facebook, are platforms. Their revenue usually comes from the collection, analysis and exploitation of user data. Or, in the case of Amazon, from the control of network infrastructure. Platform companies aim to “disrupt” existing markets by acting as a mediator different groups, personalising their service or undercutting competitors. These are only possible by hoovering up lots of data and pushing workers into casualised and low paid positions. This can be seen in Amazon’s personalised recommendation systems and Uber’s precariously employed drivers. Babylon Health could follow a similar model if they are given access to our health data and allowed to position their platform between patients and the healthcare services they need.
The NHS Digital App is part of the new “digital-first primary care” which includes a commitment that:
Over the next five years every patient in England will have a new right to choose this [digital] option – usually from their own practice or, if they prefer, from one of the new digital GP providers.
To facilitate this the NHS will “create a new framework for digital suppliers to offer their platforms to primary care networks on standard NHS terms” opening up new markets for digital platforms. However, may signal a wholesale shift of our engagement with healthcare services to a platform system. Babylon Health was accused of “poaching” patients from the NHS by not properly informing them that when signing up to their service they lost their registration with their local GP.
Health Secretary Matt Hancock’s enthusiasm for digital health platforms is well documented. Babylon Health, are one of his favourites and were the first to be approved by the Care Quality Commission. However, Hancock’s journalistic puff pieces promoting the company may have breached ministerial codes. The company’s founder, Ali Parser, is a former investment banker who advocates for privatisation and believes that “[t]he Government should not be in charge of running hospitals”. Their mission “to put an accessible and affordable health service in the hands of every person on earth” is a great way of harvesting huge amounts of health data and becoming the dominant health platform.
While many of us give away masses of data on our shopping to Amazon or viewing habits to YouTube, health data is much more personal and sensitive. These data will also be given to a private company compelled to generate value for shareholders rather than to the publicly accountable NHS. Also, the “appification” of healthcare could lead to the removal of more human aspects of care. Just as fewer of our interactions with companies take place face-to-face today (and an increasing amount involve engaging with a “chatbot”) we could find ourselves being told we are going to die by a doctor on a video screen as happened recently to someone in California.
For example, one of Babylon’s Health’s main services is their “Ask Babylon” artificial intelligence (AI). This service “understands symptoms you enter and provides you with relevant health and triage information”. Although its accuracy and reliability is shaky at best, the company sees it as an important part of their future, and they have secured $60 million of investment to further develop their AI. They also partnered with social network giants WeChat to offer their “chatbot” services to Chinese users (and collect even more data). Babylon Health are pushing hard into this area because they are aware that for platforms there is a significant “first mover advantage” with early entrants into a market usually becoming the dominant player due to “network effects”. This is used to describe a system which is more beneficial for users the more others are using it. So, Facebook is more essential the more of your friends and family use it as their main form of communication and Uber is more effective when there are more users and therefore drivers so availability is better.
But “network effects” are also significant for the platform themselves as the AI behind them is data hungry and to get more data they need more users and to capture more areas of their users’ lives. To develop “intelligence” these systems need to gather data on huge numbers of users and interactions. This is why the most sophisticated systems (Alexa, Siri, etc) are owned by companies with the most extensive intrusion into our lives.
However, all of these business models are only as good (i.e. profitable) as the data that underpins them and determines their business model. An enduring problem for health platforms is the notoriously disconnected health data systems (particularly in the context of the NHS). Matt Hancock’s stated aim to make it an NHS priority to “mandate and rigorously enforce technology standards […] to ensure data is interoperable and accessible” is a crucial one for companies like Babylon to be able to access useful data. To get data which will feed their AI they need standardisation and central processing. All platforms crave the role of central mediator and data processor of interactions and this role provides them with the power to monitor and control all interactions.
The “digital first” strategy means that data previously held by the NHS is now in the hands of private companies. They don’t serve taxpayers, patients or the NHS, only their own investors. In Babylon’s case, these include the founders of Google’s Deepmind. A company who have had their own patient data controversies.
Babylon’s cosy relationship with the Health Secretary will help them achieve their aims. So will the close connection between other ministers and platform health companies. After losing her parliamentary seat Conservative health minister Nicola Blackwood got a job at Push Doctor (another health platform). She later got a seat on the “health tech advisory board” for the NHS. Subsequently, she left Push Doctor to rejoin the government as a health minister. This kind of “revolving door” scenario tends to enable companies unprecedented access to public assets and services.
Just how far the platformisation of healthcare will go is unclear. But the NHS’s “long term plan” offers a further clue. It suggests that:
There is also emerging experience that digital GP models can help expand the GP workforce participation rate by offering flexible opportunities to part-time GPs”.
This sounds reminiscent of an Uber or Deliveroo model of employment. The full-scale ‘uber-isation’ could well be just around the corner with American consultancy group Huron ominously advocating for “bringing the gig economy to healthcare.