As published in Public Sector Focus, by Dr Alex Ashman, NHA party co-leader
The new Health Secretary Matt Hancock has gone on record stating that he wants to see a ‘tech transformation’ within the NHS. Most health professionals are familiar with the benefits of modern technology, which is gradually forcing out the ageing fax machines, pagers, and paper case notes still present in many hospitals. Smart phones are indispensible for today’s junior doctors, and patients have access to a vast array of information through apps and the internet. Why, then, is news of Hancock’s digital push being met with dismay in some quarters?
The current state of NHS IT is one reason. Back in 2005 the Department of Health began the process of throwing £6 billion at “the world’s biggest civil information technology programme”. A flurry of outsourcing was followed by technical issues, disputes, and even legal action as contracts folded. By 2011 ministers could only salvage a few components from a failed top-down reform that had cost the equivalent of 10% of the NHS budget.
Meanwhile, poor funding for the basics meant that in 2017 many NHS computers were running Windows XP (launched 2001) and lacked the security updates to protect them from the 'cyber-attack' in May last year. This caused significant operational difficulties and put actual lives at risk. So when health professionals voice concerns that splurging on big projects will divert funds away from basic infrastructure, they have a precedent.
That’s not the only reason for concern, though. Matt Hancock has voiced support for the Babylon Health app, claiming that his GP is now “through the NHS on Babylon Health”. Putting aside the moral concerns that the app cherry picks the worried well and then allows them to jump the queue to see out-of-area NHS GPs, there is a more urgent problem with the Babylon app. The triage aspect of the app, which uses a ‘chatbot’ to quiz the user on its symptoms, has been shown to misdiagnose potentially life-threatening illnesses.
Twitter user DrMurphy11, reportedly an NHS consultant with an interest in tech, has posted numerous examples of this. Symptoms of a heart attack are diagnosed as a panic attack, a simple bladder infection is labelled prostate cancer, and a complaint of a nosebleed leads to a diagnosis of erectile dysfunction. Elsewhere, meningitis, ectopic pregnancy, acute limb ischaemia, and giant cell arteritis are all missed. Were the Babylon Health app an actual doctor, it is likely that they would end up being struck off after only a few weeks on the job. Instead, we understand that an anonymous doctor has already referred Babylon to the regulatory body, the Medicines and Healthcare products Regulatory Agency (MHRA).
Babylon Health have already entered the NHS market with the GP at Hand app. The way the app is being trialled shows that there are concerns about its safety. The app's website made it clear that only fit and well individuals should use it; pregnant women, the elderly and those with pre-existing health conditions were deterred. As any good researcher knows, excluding a large chunk of the study population means your results won’t be generalisable to the population as a whole. So excluding patients with existing conditions implies that the app is not currently capable of ensuring their safety. When Babylon tried to roll out the app across multiple GP practices outside of London, NHS England objected on the basis that the app had reportedly not been “formally evaluated” and could result in “unintended consequences”.
Elsewhere, there is other evidence that the tech just isn’t ready to do the job. Internal documents from IBM have revealed that its Watson supercomputer had produced “multiple examples of unsafe and incorrect treatment recommendations” when asked to assess hypothetical cancer cases. The Push Doctor app, which offers private online access to GPs, has been hit by a damning report from the Care Quality Commission (CQC) after findings that medications had been prescribed inappropriately and essential clinical information was missing from records. And two digital providers, HR Healthcare Ltd and MD Direct, have been suspended after failing their CQC inspections.
Essential safeguards are applied when licensing new medicines and medical technology. New treatments and techniques are assessed by the National Institute for Health and Care Excellence (NICE), who make recommendations based on the current evidence and value for money. Why should mobile apps be treated any differently? The NHA strongly recommends that any apps to be used in the NHS should be fully tested to the standard of other medical devices, should be fully secure to protect patient confidentiality, and should be proven to be value for money through formal assessment by NICE.
Technology in the NHS can be a wonderful thing, but it has to be done right. Until we see independently-verified, peer-reviewed evidence, we have to consider the risk that private healthcare apps will allow their vested interest in the success of their app to come before a rigorous appraisal of its safety. There is also the risk that private firms will focus on the 'easy' patients with a service that the elderly and impoverished are unlikely to be able to access. And with Hancock’s obsession with a ‘tech transformation’, there is every chance that a misdirection of funding into unproven mobile apps will divert much-needed cash away from critical NHS infrastructure.