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Inspection Summary


Overall summary & rating

Good

Updated 4 June 2019

Letter from the Chief Inspector of General Practice

We rated this service as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Index Medical Limited on 16 April 2019 as part of our inspection programme.

Index Medical Limited provides an online primary care consultation service and medicines

ordering service. Patients register for the service on the provider’s website.

At this inspection we found:

  • There were comprehensive systems in place to check patient identity for safe prescribing.
  • There were systems in place to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service had risk assessed conditions that could be treated by the service and information was shared with the patients’ own GP appropriately.
  • There were checks and alerts in place to prevent misuse of the service and appropriate prescribing by GPs.
  • The service routinely reviewed the effectiveness and appropriateness of the care provided by conducting regular consultation audits. It ensured that care and treatment was delivered according to evidence- based guidelines and appropriate medical records were kept.
  • All patient data was encrypted and securely stored.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • There was evidence of continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

  • The provider had coordinated and collaborated with other providers to develop a risk-based identification verification standard, for all digital services. These standards were being fully implemented by Index Medical Limited and also included photographic identification for all patients under the age of 20.

The areas where the provider should make improvements are:

  • Continue to develop consultation questionnaires in order that GPs have sight of information that may be necessary to support rationale for prescribing, specifically relating to contraception and travel health.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 4 June 2019

We rated safe as Good because:

Keeping people safe and safeguarded from abuse

Staff employed at the headquarters had received training in safeguarding and whistleblowing and knew the signs of abuse. Staff had access to the safeguarding policies and where to report a safeguarding concern. Contact details for local safeguarding teams were included in the policy. If contact with safeguarding teams elsewhere was necessary the policy stated, that the local safeguarding team would be contacted for advice. All the GPs had received adult and level three child safeguarding training. It was a requirement for the GPs registering with the service to provide evidence of up to date safeguarding training certification. Administrative staff had also received safeguarding training.

The service did not treat children. The provider had added safeguards to their systems so that if a date of birth was entered which indicated the patient was under the age of 18, continuation with the consultation was disallowed. Additionally, for all patients under the age of 20, photographic identification was a requirement of the service.

Monitoring health & safety and responding to risks

The provider headquarters was located within a residential house. Patients were not treated on the premises as GPs carried out the online consultations remotely; usually from their home. All staff had received training in health and safety and had undergone work place risk assessments for to ensure that their working environments were safe.

The provider expected that all GPs would conduct consultations in private and maintain patient confidentiality. Each GP and members of staff used an encrypted, password secure laptop to log into the operating system, which was a secure programme.

The service was not intended for use by patients with either long term conditions, other than those diagnosed with asthma, or as an emergency service. The providers website detailed that the service was not to be used in emergencies and informed patients of what they should do in an emergency situation.

A range of clinical and non-clinical meetings were held with staff, where standing agenda items covered topics such as significant events, complaints and service issues. Clinical meetings also included case reviews and clinical updates. We saw evidence of meeting minutes to show where some of these topics had been discussed, for example a significant incident and clinical pathways in line with national guidance.

Staffing and Recruitment

There were enough staff, including GPs, to meet the demands for the service and there was a rota for the GPs. There was a support team available to the GPs during consultations and a separate IT team. The prescribing doctors were paid on a sessional basis.

The provider had a selection and recruitment process in place for all staff. There were a number of checks that were required to be undertaken prior to commencing employment, such as references and Disclosure and Barring service (DBS) checks. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)

Potential GP employees had to be currently working in the NHS (as a GP if applicable) and be registered with the General Medical Council (GMC) (on the GP register – if applicable). They had to provide evidence of having personal professional indemnity cover (the provider also had professional indemnity cover in place), an up to date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act.

All GPs working with the service had been in post since the launch of the service and were all experienced in online consulting using assessment questionnaires.

We reviewed four recruitment files which showed the necessary documentation was available. The GPs could not be registered to start any consultations until these checks and induction training had been completed. The provider kept records for all staff including the GPs and there was a system in place that flagged up when any documentation was due for renewal such as their professional registration, which was checked annually.

Prescribing safety

All medicines prescribed to patients from online forms were monitored by the provider to ensure prescribing was evidence based. If a medicine was deemed necessary following a consultation, the GPs could issue a private prescription to patients. If approved by the prescriber, medicines via the Dr Fox website were dispensed, packed and delivered by a third party, tracked and secure, courier service. The service had a system in place to assure themselves of the quality of the dispensing process. There were systems in place to ensure that the correct person received the correct medicine. Medicines prescribed via the Fast Doctor website were collected from an affiliated pharmacy chosen by the patient at the time of ordering. The GPs could only prescribe from a set list of medicines which the provider had risk-assessed. There were no high risk medicines such as controlled drugs or medicines that could become addictive on this list. The service’s website advertised which medicines were available and there were systems in place to prevent the misuse of these medicines. For example, measures were in place to prevent over-ordering and duplicate accounts. All newly registered accounts were scrutinised and if similarities were identified, the accounts were amalgamated, and the patient notified. Medicines supplied had to be signed for on delivery and post office boxes or collection depot services were not allowed. Clinicians had access to the patient’s previous records held by the service.

For predefined conditions, medicines were only available for prescribing if the patient had agreed for the information to be shared with their registered GP, for example, asthma inhalers and contraceptives. Letters seen in records sampled sent to the registered GP, informed them of what had been prescribed and that the patient had confirmed that they had received regular reviews. Where the GP responded that a patient had not been reviewed, the service ensured the patient received no further prescriptions from their service.

Once the GP prescribed the medicine and dosage of choice, relevant instructions were given to the patient, regarding when and how to take the medicine, the purpose of the medicine and any likely side effects and what they should do if they became unwell.

The service encouraged good antimicrobial stewardship by only prescribing from a limited list of antibiotics which was based on national guidance.

The service prescribed some unlicensed medicines, and medicines for unlicensed indications, for example for the treatment of jet lag and altitude sickness. (Medicines are given licenses after trials have shown they are safe and effective for treating a condition. Use of a medicine for a different medical condition that is listed on their license is called unlicensed use and is a higher risk because less information is available about the benefits and potential risks). There was clear information on the consultation form to explain that the medicines were being used outside of their license, and the patient had to acknowledge that they understood this information. Additional written information to guide the patient when and how to use these medicines safely was supplied with the medicine.

Prescriptions were monitored for any form of abuse such as excessive requests. For example, predefined limits were set within the IT system to prevent over prescribing.

Information to deliver safe care and treatment

There were protocols in place for identifying and verifying the patient and General Medical Council guidance, or similar, was followed. This included photographic identification for all patients under the age of 20 and for certain medicines being requested, for example, contraception. Accounts would not be activated, thereby allowing patients to request medicines, until identity verification was completed by the administrative team.

The GPs had access to the patient’s previous records held by the service.

Management and learning from safety incidents and alerts

There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members. We reviewed four incidents and found that these had been fully investigated, discussed and as a result action taken to reduce the risk of reoccurrence. For example: When a relative of a patient communicated to the service concerns over the mental health of a patient and the potential for self- harm, the service immediately removed the medicine from the patient’s account and a patient note was added to the medical record. The information was cascaded to all staff that the medicine had become popular as means of self-harm and for all to have awareness when being requested by patients.

We saw evidence from incidents which demonstrated the provider was aware of and complied with the requirements of the duty of candour by explaining to the patient what went wrong, offering an apology and advising them of any action taken.

We were shown records of appropriate action taken in response to recent patient alerts.

Effective

Good

Updated 4 June 2019

We rated effective as Good because:

Assessment and treatment

We reviewed eight examples of medical records that demonstrated that each GP assessed patients’ needs and delivered care in line with relevant and current evidence-based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence-based practice.

The provider used consultation questionnaires which were specific to treatments and medicines supplied. Each treatment area had its own bespoke online consultation and patient information pages which formed part of the consultation process. The consultation questionnaires updated with advisory text as the questionnaire was completed. The patient would be informed if the service was unable to supply the medicine and the patient would be advised to consult with their own GP. We reviewed eight medical records which were complete records and adequate notes were recorded. The GPs had access to notes of previous consultations the patient had with the service.

The GPs providing the service were aware of both the strengths (speed, convenience, choice of time) and the limitations (inability to perform physical examination) of working remotely from patients. They worked carefully to maximise the benefits and minimise the risks for patients. If a patient needed further examination, they were directed to an appropriate agency. If the provider could not deal with the patient’s request, this was explained to the patient and a record kept of the decision.

Quality improvement

The service monitored consultations and carried out consultation and prescribing audits and monitored information on patients’ care and treatment outcomes to improve patient outcomes. Examples of this were:

  • Prescribing audits for all GPs were conducted regularly by the clinical director. These included antibiotic monitoring to ensure appropriate antimicrobial guardianship. Over the previous 12 months, approximately 14,000 antibiotic prescriptions had been issued by the service and demonstrated a reduction from 8% to 6.5% by ensuring greater awareness and monitoring of adherence to local antibiotic guideline
  • Consultation questionnaires were audited on a regular basis to ensure these remained in line with up to date, evidence-based practice by the GPs working for the service.
  • Administrative contact with patients were monitored and audited to ensure appropriate communications were being sent to patients. This facilitated identification of trends in questions asked by patients which could lead to improved information on the services website.

Staff training

All staff completed induction training which included, health and safety, basic life support, work place stations assessments, General Data Protection Regulation and confidentiality. Staff also completed other training on a regular basis, for example, safeguarding to the appropriate levels and conflict resolution. The service manager had a training matrix which identified when training was due.

Administration staff received regular performance reviews. All the GPs had to have received their own appraisals before being considered eligible at recruitment stage. GPs received annual appraisals with the clinical director in addition to their own appraisals.

Coordinating patient care and information sharing

Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment. When requesting malaria prevention medicines and medicines to treat traveller diarrhoea, patients were able to follow links within the consultation questionnaire, from which they were able to determine which would be the most appropriate medicine to request. However, the GPs did not have sight of the travel destination which would confirm that the correct medicine had been requested. We raised this on the inspection and were told post inspection that work was being carried out to amend the questionnaires to accommodate this information.

All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.

The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, those for the treatment of long-term conditions such as asthma and contraceptives. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with General Medical Council guidance.

The service did not carry out testing or referrals to other services. If this was necessary patients were signposted back to their own GP.

Supporting patients to live healthier lives

The service identified patients who may be in need of extra support and had a range of information available on the website (or links to NHS websites). For example:

  • Travel health advice regarding altitude sickness, bit avoidance and traveller diarrhoea and a link to an NHS travel advice website
  • A link to free support from NHS stop smoking advisors
  • A medical information page was available for each condition the service prescribed medicines for. For example, advice for patients requesting inhalers for asthma included the need to visit their GP regularly for a review and how to recognise signs of worsening asthma and when they should contact their GP.
  • Additional advice was given within consultation questionnaires, which may be dependent on selected answers and there was also the ability to ask a question of a GP for further information.

Caring

Good

Updated 4 June 2019

We rated caring as Good because:

Compassion, dignity and respect

We were told that the GPs undertook online consultations in a private room and were not to be disturbed at any time during their working time. Messaging to patients by both GPs and administrative staff was monitored. Any concerns would be fed back to the individual concerned.

We did not speak to patients directly during the inspection. However, we reviewed the latest patient survey information. An independent survey conducted via an online review platform showed: In the previous 12 months approximately 7000 reviews had been received and 98% of reviewers found the service to be excellent.

The provider also conducted its own patient survey following each consultation which asked eight questions. For example, did you feel you were treated with dignity and respect to which 89% of responders answered positively.

Involvement in decisions about care and treatment

Patient information guides about how to use the service and technical issues were available. There was a dedicated team to respond to any enquiries.

Patients had access to information about the clinicians/GPs working for the service and which GP of these GPs was dealing with their request.

The latest survey information available showed that from the responses received:

  • 82% of patients felt involved in their treatment.
  • 93% felt at ease with the online consultation and the information on the website was easy to understand.
  • 86% felt that the online consultation suited their needs.

Patients had full access to their medical records on their account section of website. This included, messages between the GP and the patient, letters sent to their own GP and completed consultation questionnaires.

Responsive

Good

Updated 4 June 2019

We rated responsive as Good because:

Responding to and meeting patients’ needs

Consultations were provided seven days a week and access via the website to request a consultation and complete the consultation questionnaire was 24hours a day. Access to call administrative staff was available Monday to Friday 9am to 5pm. This service was not an emergency service. Patients who had a medical emergency were advised to ask for immediate medical help via 999 or if appropriate to contact their own GP or NHS 111.

The digital application allowed people to contact the service from abroad, but any prescriptions issued were delivered within the UK to the pharmacy affiliated to the service. Patients who accessed the service through the Fast Doctor website had their prescription issued to the pharmacy that the patient had attended. All medical practitioners were required to be based within the United Kingdom.

The provider made it clear to patients what the limitations of the service were. There was an approved list of medicines and conditions that patients could request treatment for.

Tackling inequity and promoting equality

The provider offered consultations to anyone who requested and paid the appropriate fee and did not discriminate against any client group other than those under the age of eighteen, to whom services were not provided. Patients could access a brief description of the GPs available and their General Medical Council registration numbers.

Managing complaints

Information about how to make a complaint was available on the service’s web site. The provider had developed a complaints policy and procedure. The policy contained appropriate timescales for dealing with the complaint. There was escalation guidance within the policy. We reviewed the complaint system and saw comments and complaints made to the service were recorded. We reviewed the five complaints received in the past 12 months. The provider was able to demonstrate that the complaints we reviewed were handled correctly and patients received a satisfactory response. There was evidence of learning as a result of complaints, changes to the service had been made following complaints, and had been communicated to staff.

Consent to care and treatment

There was clear information on the service’s website with regards to how the service worked and what costs applied including a set of frequently asked questions for further supporting information. The website had a set of terms and conditions and details on how the patient could contact them with any enquiries. Information about the cost of the consultation was known in advance and paid for before the consultation appointment commenced. The costs of any resulting prescription were handled by the administration team at the headquarters following the consultation.

Once approved by the prescriber, medicines prescribed via the Dr Fox website were dispensed, packed and posted and delivered by a third-party courier service. Medicines prescribed via the Fast Doctor website were collected from an affiliated pharmacy chosen by the patient at the time of ordering. Following dispensing of medicines patients were contacted to follow up on the effectiveness of the treatment and to ask for feedback about the service. The provider had developed the website to make it easily accessible from a number of different devices, including mobile phones.

All GPs and staff had received training about the Mental Capacity Act 2005. Staff understood and sought patients’ consent to care and treatment in line with legislation and guidance.

Well-led

Good

Updated 4 June 2019

We rated well-led as Good because:

Business Strategy and Governance arrangements

The provider told us they had a clear vision to work together to provide a high-quality responsive service that put caring and patient safety at its heart. We reviewed business plans covering 2019/20, which included further IT developments and introducing the option for patients to collect dispensed medicines from a post office.

There was a clear organisational structure and staff were aware of their own roles and responsibilities. There was a range of service specific policies which were available to all staff. These were reviewed annually and updated when necessary.

There were a variety of checks in place to monitor the performance of the service. The information from these checks were discussed informally on a daily basis and formally at the six-monthly governance meeting. Minutes of the governance meetings demonstrated all aspects of

the business was discussed. This included complaints and incidents, training needs, prescribing reviews, clinical updates.

There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. Care and treatment records were complete, accurate, and securely kept.

Leadership, values and culture

The Medical Director and IT director had overall responsibility for the service. Administrative support was provided by a governance manager and two administrators. There were systems in place to address any absences. The service had an open and transparent culture. We were

told that if there were unexpected or unintended safety incidents, the service would give affected patients reasonable support, truthful information and a verbal and written apology. This was supported by an operational policy. Staff told us that there was an open relationship with their employers and that it was a very positive culture in which to work.

The values of the service were to provide a safe, responsive digital healthcare service by delivering a respectful supportive connection to patients. The service had developed key values underpinning the service delivery and a shared ethos throughout all staff. These included, patient centred care, integrity and openness and reflective and active learning

Safety and Security of Patient Information

Systems were in place to ensure that all patient information was stored and kept confidential.

There were policies and IT systems in place to protect the storage and use of all patient information. The service could provide a clear audit trail of who had access to records and from where and when. The service was registered with the Information Commissioner’s Office. There were business contingency plans in place to minimise the risk of losing patient data.

Seeking and acting on feedback from patients and staff

Patients had the opportunity to rate the service on an online system called “Trusted Shops” which was an open system provided by a third-party supplier. The provider also undertook their own patient feedback surveys. Following every consultation, patients were sent an email asking for their feedback. Patient feedback was published on the service’s website. Actions were taken as a result of patient feedback. For example;

  • The provider worked with the company who delivered the medicines to improve the quality of the packaging ability to track parcels more effectively.
  • Prescription fees were reduced.
  • Development of a local collection service from post offices.

There was evidence that the GPs could provide feedback about the quality of the operating system and any change requests were logged, discussed and decisions made for the improvements to be implemented.

Continuous Improvement

The service consistently sought ways to improve. All staff were involved in discussions about how to run and develop the service and were encouraged to identify opportunities to improve the service delivered.

We saw from minutes of staff meetings where previous interactions and consultations were discussed.

Staff told us that the team meetings were the place where they could raise concerns and discuss areas of improvement. All staff worked remotely, but discussions were held daily between staff. Formal face to face meetings were held six monthly and we saw that these were minuted. The management team and the IT teams worked closely together and told us there were ongoing discussions about the quality of service provision.

There was a quality improvement strategy and plan in place to monitor quality and to make improvements, for example, the service was considering integrating pathology testing service for the benefit of patients. Other development plans were:

•To redesign of the services website

•The improvement of web interface for assessing consultations and prescribing.