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Babylon Healthcare Services Ltd Good

Inspection Summary


Overall summary & rating

Good

Updated 4 December 2019

Inspection areas

Safe

Good

Updated 4 December 2019

We rated safe as

Good

because:

  • The service provided care in a way that kept patients safe and protected from avoidable harm.

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen the service learnt from them.

  • The service prescribed medicines in a safe way.

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. All staff had access to the safeguarding policies and where to report a safeguarding concern. This included contact phone numbers and email addresses for all the different safeguarding localities and departments across England. All the GPs had received adult and level three child safeguarding training and key members of the senior team had received adult and level four child safeguarding training with one member of the senior team always on call for escalating concerns. In addition, the medical director who acted as the designated executive lead for safeguarding was supported by an external level five trained safeguarding advisor for dealing with complex cases.

Admin staff were trained to level two. It was a requirement for the GPs registering with the service to provide evidence of up to date safeguarding training certification. In addition, the provider had employed a safeguarding lead nurse whose role was to lead the internal safeguarding team and strengthen safeguarding procedures.

To further strengthen safeguarding procedures there was a ‘tagging’ function in place whereby consultations with a potential or actual safeguarding concern could be highlighted for follow up by the Safeguarding Team. Cases requiring an urgent response were dealt with immediately by the team, and this response time was closely monitored. A multidisciplinary safeguarding meeting was held weekly to review all cases and any less urgent reports to ensure that appropriate actions were taken.

The service offered consultations to children with strict protocols in place to ensure the identity of both the child and adult and the establishment of parental authority. Consultations with children would only take place where consent had been given for details of the consultation to be shared with the child’s NHS GP.

We saw evidence that consultations with children were audited to ensure that the identity of the child and responsible adult were recorded by the consulting GP, along with the relationship between them.

Monitoring health & safety and responding to risks

The provider headquarters was located within modern offices which housed the IT system and a range of administration staff. Patients were not treated on the premises as GPs carried out the online consultations remotely; usually from their home. All staff based in the premises had received training in health and safety including fire safety.

The provider expected that all GPs would conduct consultations in private and maintain patient confidentiality. Each GP used an encrypted, password secure laptop to log into the operating system, which was a secure programme. GPs were required to complete a home working risk assessment to ensure their working environment was safe and appropriate for them to provide video consultations in.

All consultations were recorded and available for review by both the patient and the service. Calls into the contact centre were also recorded for monitoring purposes and we saw evidence of this.

There were processes in place to manage any emerging medical issues during a consultation and for managing test results and referrals. The service was not intended for use by patients with either long term conditions or as an emergency service. In the event an emergency did occur, the provider had systems in place to ensure the location of the patient at the beginning of the consultation was known, so emergency services could be called.

There was a ‘risk tagging’ system in place where the consulting GP could flag on the patient record high risk patients for follow up by the senior medical team, safeguarding team, pharmacy team or care coordination team whichever was appropriate. We were given an example of the effectiveness of the system where a suicidal patient was flagged for immediate help resulting in the emergency services being contacted. The senior team followed up with the patients NHS GP to ensure safe handover. There were protocols in place to notify Public Health England of any patients who had notifiable infectious diseases.

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 improvements to the consent policy, 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 majority of consulting GPs were employed on salaried basis however the service employed some locum GPs, who 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 registered with the General Medical Council (GMC), on the GP register with a license to practice. They had to provide an up to date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act. The service provided indemnity cover for the consulting GPs that covered the scope of their practice.

Newly recruited GPs were supported during their induction period and an induction plan was in place to ensure all processes had been covered. We were told that GPs did not start consulting with patients until they had successfully completed several test scenario consultations. The GPs we spoke to told us that the on boarding process for new GPs was extremely thorough.

We reviewed six 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.

Prescribing safety

Patients had to register with the service before they were able to access a GP consultation. All medicines prescribed to patients during a consultation were monitored by the provider to ensure prescribing was evidence based. If a medicine was deemed necessary following a consultation, the GP issued a private prescription to the patient. The GPs could only prescribe from a set list of medicines which the provider had risk-assessed. For the most common conditions, additional guidance was available to the GPs to encourage selection of evidence-based treatment options. There were no controlled drugs on this list. When emergency supplies of medicines were prescribed, there was a clear record of the decisions made and the service contacted the patient’s regular GP to advise them.

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. If a medicine was prescribed for an unlicensed indication, patients were given an information leaflet to explain the implications of this.

The provider did not offer a repeat prescription service. A patient had to have a consultation with a GP each time a prescription was issued. The provider acknowledged that they were not best placed to manage patient’s with long term conditions or patients who required high risk medicines requiring monitoring. For example, the provider did not prescribe warfarin, methotrexate or lithium.

In the management of long term conditions (for example, asthma), we saw that there was a maximum quantity of salbutamol inhalers that the provider could prescribe before having to refer the patient back to their own GP. The service encouraged good antimicrobial stewardship by only prescribing from a limited list of antibiotics based on national guidance. In addition, an antibiotic prescribing review was completed to ensure that they were prescribed in line with National Institute for Care and Excellence (NICE) and Public Health England (PHE) guidelines.

The service prescribed some medicines for unlicensed indications, for example, acute altitude sickness. Medicines are given licences after trials have shown they are safe and effective for treating a particular condition. Use of a medicine for a different medical condition that is listed on their licence is called unlicensed use and is a higher risk because less information is available about the benefits and potential risks. There was clear information discussed during the consultation to explain that the medicines were being used outside of their licence. Additional written information to guide the patient when and how to use these medicines safely was supplied with the medicine.

GPs were encouraged to prescribe from a set formulary which did not include controlled drugs, high risk medicines, or medicines liable to abuse or misuse. In addition, the provider had a system to ensure that any prescriptions for ‘blacklisted’ medicines were double checked by a member of the Senior Medical Team. The prescription was then approved before being dispensed, or if inappropriate, the prescription was rejected. Examples of blacklisted items include: broad spectrum antibiotics, antipsychotics, and injections. GPs received individual feedback relating to blacklisted prescription items.

The Pharmacy Team carried out a comprehensive set of regular compliance and safety audits on all prescribing on a daily, weekly, fortnightly and monthly basis.

There were protocols in place for identifying and verifying the patient and General Medical Council guidance, or similar, was followed.

We were advised that patients could choose a pharmacy where they would like their prescription dispensed. The prescription could be dispensed and delivered direct to the patient or to their preferred local pharmacy for collection by the patient.

Information to deliver safe care and treatment

On registering with the service, and at each consultation patient identity was verified. 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 five incidents from the last 12 months and found that these had been fully investigated, discussed and as a result action taken in the form of a change in processes. For example: A member of the support team sent a patient the incorrect referral letter which was addressed to another patient. As soon as the staff member became aware of the incident they asked the patient to destroy the document and the correct document was made available to the patient. The incident was fully investigated and training provided to staff to minimise the risk of recurrence.

There was evidence of monthly newsletter circulated to all staff by the governance team. The newsletter focused shared learning including key themes from incidents and significant events.

We saw evidence from five 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.

The provider had systems in place to comply with medicines and safety alerts such as those received from the Medicines and Healthcare products Regulatory Services (MHRA).

Effective

Good

Updated 4 December 2019

  • Care was delivered in line with current evidence-based guidance and standards.

  • The service demonstrated quality improvement activity.

  • Staff received support and training to carry out their roles effectively.

  • The service sought patient consent appropriately.

Assessment and treatment

We reviewed six examples of medical records (including a recording of the video consultation) that demonstrated that each GP generally 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.

We were told that each video consultation lasted for ten minutes. If the GP had not reached a satisfactory conclusion we were told that GPs had the flexibility to extend the consultation.

When registering for the service, patients were able to input details about their past medical history. GPs completed notes of the consultation using a set template, which included the reasons for the consultation and the outcome, along with any notes about past medical history and diagnosis. From the notes (and recording of the video consultation) we reviewed we found some inconsistences. For example, safety netting was not always documented, and GPs did not always document past medical history or allergy status as well as checking their understanding or asking if they had any further questions. We raised this with the medical director who agreed that the consistency of clinical record keeping was an area for improvement. However, although we found some inconsistencies in the consultation notes the provider showed us evidence of a comprehensive audit system for monitoring standards with a 95% compliance over the previous two quarters.

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.

The service monitored consultations and carried out consultation and prescribing audits to improve patient outcomes.

The provider demonstrated they had systems in place to assure that the app used to deliver digital consultations conformed to the requirements of the digital standard DCB 0129. (This standard provides a set of requirements suitably structured to promote and ensure the effective application of clinical risk management by those organisations that are responsible for the development and maintenance of Heath IT Systems for use within the health and care environment). They also demonstrated compliance with the digital standard DCB 0160 which relates to the deployment of such health technology by the provider.

Quality improvement

The service collected and monitored information on patients’ care and treatment outcomes.

  • The service used information about patients’ outcomes to make improvements.
  • The service took part in quality improvement activity, for example audits, reviews of consultations and prescribing trends. Examples of completed audit cycles included;
  • A musculoskeletal audit to determine the appropriateness of referrals to physiotherapy and orthopaedic specialists. The initial audit carried out in February 2019 showed that only 50% of referrals were appropriate. Following the initial audit educational sessions were provided to GPs and as a result a re-audit showed that 90% of referrals were appropriate.
  • A dermatology audit to determine whether patients were managed and referred appropriately. The audit was carried out by a GP with special interest in dermatology. The initial audit carried out in March 2019 showed that 30% of 48 patients reviewed had not been managed appropriately. Following the initial audit educational sessions were provided to GPs and also dedicated dermatology clinics led by a GP with a special interest in dermatology set up for other GPs to refer patients into. As a result, a re-audit showed that 90% of referrals were appropriate.

Staff training

All staff completed a comprehensive training programme which consisted of practical induction, systems and processes, policies, health and safety and information governance. GPs completed a phased induction including mock consultations, peer review and probation review. Staff also completed other training on a regular basis including safeguarding, basic life support and infection control. The training and development department had a training matrix which identified when training was due.

The GPs had to complete specific induction training prior to treating patients, an induction log was held in each staff file and signed off when completed. Supporting material was available, for example, in short instructional videos and embedded within policies and guidance. We saw evidence that information was distributed to GPs to enable them to keep up to date with both internal and external changes, this was done via an internal messaging system. The GPs received support if there were any technical issues or clinical queries and could access policies. When updates were made to the IT systems, the GPs received further online training. GPs told us that training was very structured and thorough. Other regular training provided to both new clinical and support staff included training on incidents and complaints handling.

Administration staff received regular performance reviews. All the GPs had to have received their own appraisals before being considered eligible at recruitment stage and ongoing systems were in place to ensure that GPs kept up to date with their appraisal and professional registration.

Coordinating patient care and information sharing

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. We were told that 57% of all patients prescribed medicines consent to have information shared with their NHS GP and 51% of all patients consent to share information with their NHS GP and we saw evidence that information was shared with the patient.

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, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.

Where a patient required a referral to an external service, details were completed by the GP, and the referral was then sent to the appropriate service by the dedicated admin team responsible for referrals. We saw evidence that this team kept up to date records of referrals requested by GPs, and monitored when these were processed. When a referral was refused by the external organisation, this initially came to the admin team, who had a process for monitoring refusals and identifying common trends in order to address any systemic issues. The service was able to provide examples of issues they had encountered in the past with referrals to certain external services being declined, which had been resolved following liaison with the provider to agree on an acceptable process. In these instances where referrals had been initially refused we noted that the provider had checked that affected patients were subsequently referred and checked they had been seen.

The service monitored the appropriateness of referrals/follow ups from test results to improve patient outcomes.

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 and via social media platforms. For example, lowering alcohol consumption, the benefits of regular exercise and information on smoking cessation and weight management.

In patient consultation records we found that advice was given on healthy living as appropriate.

Caring

Good

Updated 4 December 2019

  • Patients reported that they were treated with kindness, dignity and respect.

  • Feedback from patients about the service was generally very positive.

  • Patients reported that they were involved in decisions about care and treatment.

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. The provider carried out random spot checks by listening to recordings and looking at consultation notes to ensure the GPs were complying with the expected service standards and communicating appropriately with patients. Feedback arising from these spot checks was relayed to the GP. Any areas for concern were followed up and the GP was again reviewed to monitor improvement.

We did not speak to patients directly on the days of the inspection. However, the provider had processes in place to gather feedback from patients at the end of every consultation. Patients were asked to provide a star-rating out of five; where a patient scored their consultation as three stars or less, this would flag with the service’s clinical governance team and prompt a review of the consultation. Evidence provided by the service showed that four and five-star ratings were consistently above 93%. We also requested feedback from patients prior to our inspection which was sent directly to the CQC. From 21 respondents, 18 reported positively about the service provided, two respondents provided mixed views and one respondent reported negatively about the service, however there were no common themes. The majority of people reported that the service was professional, and they were treated with care and respect. People could see a GP at their convenience and they were impressed with the calibre of staff hired. They said that the service was well organised and efficient.

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 could access notes of their consultation by signing in to their account (either online or via the app); this included viewing a video of their consultation.

Patients could book a consultation with a GP of their choice. For example, whether they wanted to see a male or female GP. However, this could not be done through the app. To request a GP of a particular gender patients had to call the customer services centre. We were told at the inspection that the service was making progress to provide this as an in-app function.

Patients reported that during their consultations the GPs take time to talk, understand their history and prescribe a course of treatment. They said that they felt involved in decisions relating to their care and the GPs took time to listen to any concerns. Where patients commended a particular GP, the feedback on the GP was very positive.

Patients could access notes of their consultations by signing into their account (either online or via the app); this included viewing a video of their consultation.

We were told that the service was about to roll out a carers project for the private patients. A carers champion was in post and action was being taken to raise awareness with the GPs that patients with carer responsibilities may need signposting for extra support.

Responsive

Good

Updated 4 December 2019

  • Patients reported that they could access consultations at any time that suited them.

  • Complaints were handled in a timely way and the service learnt from them.

Responding to and meeting patients’ needs

The provider demonstrated exceptional access with consultations available 24 hours a day, seven days a week, 52 weeks a year with a waiting time of less than two hours for 50% of patients and four hours for 75% of patients. Support staff were available by phone and email from 7.30am to 10pm seven days a week and senior clinical, support and technical staff on call 24 hours a day all year round for escalation.

The 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 NHS111.

The digital application allowed people to contact the service from abroad but all medical practitioners were required to be based within the United Kingdom. Any prescriptions issued were delivered within the UK to a pharmacy of the patient’s choice. Patients signed up to receiving this service on a mobile phone (iPhone or android versions that met the required criteria for using the app) or online.

The provider’s website gave clear information about the available pricing structure for accessing the private service. Patients had the option of signing up to an annual plan which included unlimited consultations or paying on a per-consultation basis. There were no extra charges for any other primary care services such as issuing prescriptions. The provider made it clear to patients what the limitations of the service were.

Patients requested an online consultation with a GP and were contacted at the allotted time. The allocated length of time for a consultation was 10 minutes; however, we were told that GPs could extend a consultation if clinically necessary. The provider showed us evidence that 50% of appointments were booked in under two hours and 75% in under four hours which demonstrated prompt access to appointments.

The digital application included wider technology to help patients manage their health status and manage their own conditions in the form of a symptom checker and health assessment tool.

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.

There was no information available on the service’s website about the GPs available. If a patient wished to consult with a GP of a particular gender or with a specific GP, they had to contact the service’s customer service centre in order for this to be arranged. There was no facility for patients to select a specific GP via the online booking system or app, however we were told that this facility would soon be available as an in-app function.

We were told “type talk” was available for visually impaired patients, and Language Line could be used by patients who required language translation.

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. A specific form for the recording of complaints has been developed and introduced for use. We reviewed the complaint system and noted that comments and complaints made to the service were recorded. We reviewed five complaints out of 19 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.

There was evidence of monthly newsletter circulated to all staff by the governance team. The newsletter focused shared learning including key themes from complaint reviews and lessons learnt from investigations, as well as tips for best practice.

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. There was no additional cost for the service issuing a prescription or medical certificate.

All GPs 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. When providing care and treatment for children and young people, staff carried out assessments of capacity to consent in line with relevant guidance. Where a patient’s mental capacity to consent to care or treatment was unclear the GP assessed the patient’s capacity and, recorded the outcome of the assessment. The process for seeking consent was monitored through audits of patient records.

Well-led

Outstanding

Updated 4 December 2019

We rated well-led as

Outstanding

because:

  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care and treatment.

  • The provider demonstrated an outstanding level of staff support, engagement and training including connections of dispersed personnel into a cohesive team.

  • There was evidence of strong collaboration, team-working and support across all functions to deliver the service’s objectives.

  • There were comprehensive systems to monitor all aspects of the service provided including

    detailed quality assurance and mentoring programme for GPs, a monthly programme of clinical audits had been introduced and daily, weekly, fortnightly and monthly reviews of all prescribing by a dedicated prescribing team.

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. The provider had a mission to provide the best possible digital service in the UK. The mission statement was supported by a business plan and detailed strategy document that was reviewed regularly. All staff we spoke to understood the mission of the service and demonstrated enthusiasm and commitment to deliver it.

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 regularly and updated when necessary. The chief medical officer was supported by a multidisciplinary senior management team comprised of medical, nursing and management expertise who between them provided oversight of support staff and the clinical workforce. The delivery of the online digital service was supported by a whole department dedicated to ensuring the technology, IT infrastructure, digital and information security was constantly monitored so that threats and issues were mitigated, and support offered to all staff as required.

The service worked closely with the Clinical Safety Officer of the technology provider who advised on the design process to ensure safety and governance at all stages of the product design.

There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service. These included:

  • A 1% monthly review of consultations for each GP.
  • Weekly reviews of detailed indicators for each GP, including prescribing, timing, note- keeping, coding and patient feedback metrics.
  • A detailed quality assurance and mentoring programme for GPs.
  • A monthly programme of clinical audits in key areas of clinical practice.
  • Daily, weekly, fortnightly and monthly reviews of all prescribing by the dedicated prescribing team.

There was a structured quality assurance process in place for each GP with key performance indicators to meet. Where a GP fell below the standards, the senior management team intervened quickly providing support and training to improve performance. The information from these checks and other performance indicators was used by the service’s clinical governance team in order identify issues and trends and was presented to the senior management team at monthly governance meetings. This ensured a comprehensive understanding of the performance of the service was maintained.

There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. A monthly Quality and Governance Committee, comprised of multidisciplinary members from across the company was held to review all complaints, incidents, risks and emerging governance topics. The provider demonstrated a commitment to risk management systems and processes by continually improving the systems and processes and ensuring staff had the skills and knowledge to use the systems and processes effectively.

There was evidence of systems to extensively monitor all aspects of the service provided. Data such as waiting times, patient satisfaction, prescribing rates and clinical coding were monitored daily. Daily clinical and support staff meetings were held to review this data and to ensure that any emerging risks were identified and responded to. Care and treatment records were securely kept.

Leadership, values and culture

The medical director had responsibility for any medical issues arising. They attended the service daily or were otherwise available. There were systems in place to address any absence of this clinician.

The senior management team demonstrated they were a driving force dedicated to delivering the mission of the service. All staff we spoke to felt valued by the leaders and said there was a high level of staff support and engagement. They were enthusiastic about their work and had a positive attitude towards the service and its values. There was evidence of strong collaboration, team-working and support across all functions to deliver the service’s objectives.

The provider could evidence the high level of staff support and engagement through delivering a number of initiatives to support staff and to improve well-being. For example, the provider had organised a mental health awareness week for staff. Activities included talks on mental health, balancing work and life, yoga and meditation and mindfulness sessions. The provider had also funded nine staff to attend a two-day course to qualify as mental health first aiders. The course taught in depth skills for providing first aid to staff who may be experiencing mental health issues such as depression, anxiety and psychosis. The provider supported the development of a number of ‘Power of Diversity Groups’ across the organisation. For example, a LGBTQ+ group had been established with an aim to create a safe space for conversation and discussion on any issues, establish a feedback mechanism to report any issues if they occur (both in person and anonymously), review the service’s policies to ensure they are inclusive and reflect the needs of all staff and to represent the provider at external events.

Other staff initiatives included a group to support women working in industry, weekly stand-up sessions for staff to openly voice their opinions and concerns, open door sessions with individual members of the senior management team for one to one feedback and regular social events amongst other initiatives. One staff member we spoke to told us that the provider was funding them to complete a master’s degree in an area of study that would help them develop their career. Staff spoke highly of the culture and were proud of the organisation as a place of work. There were channels through which peer comments and compliments were shared amongst staff to celebrate success and develop staff morale, and social media chat groups where all staff (including remote staff) could ask questions and provide support for one another when necessary.

The provider used tools to measure and improve staff engagement and well-being. Trends from which were used by the Senior Management Team to elicit change. For example, staff expressed a desire to know more about the wider company and health services. As a result, the provider set up a regular ‘Lunch and Learn’ session with internal and external speakers invited to share a topic of interest with all staff. The service had an open and transparent culture. Staff told us of a no blame culture when mistakes were made, and they were supported by the leaders to improve their performance.

The GPs we spoke to told us they were encouraged to become clinical champions. For example, one GP said that they had become a transgender medicines champion and offered support and advice to other GPs with this area of practice through the social media chat groups.

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.

Safety and Security of Patient Information

The provider had a comprehensive information governance and security framework with policies and procedures to support the security of information. All remote staff worked on computers that were encrypted and controlled centrally to ensure no information could be downloaded or shared.

The service could provide a clear audit trail of who had access to records and from where and when. All staff received annual data security training and there was a dedicated Data Protection Officer and associated team who were responsible for ensuring the protection of personal data, and providing access to data when required under GDPR.

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. The service was ISO 27001 accredited (ISO 27001 is an information security standard) and recently approved for ISO13485 (represents the requirements for a comprehensive quality management system for the design and manufacture of medical devices).

Seeking and acting on feedback from patients and staff

Patients could rate the service they received. This was constantly monitored and if it fell below the provider’s standards, this would trigger a review of the consultation to address any shortfalls.

There was evidence that the GPs were able to 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.

The provider told us they had a process of constant feedback and surveillance through in-app star ratings and comments box. Written and verbal feedback gathered by email, telephone, social media, review sites, user research and focus groups. Feedback was collated and discussed widely as a team to improve the service provided. Evidence provided by the service showed that 4 and 5-star feedback was consistently above 93%.

We saw evidence of an action plan based on user feedback and evidence that the provider had acted on complaints. For example, as a consequence of a complaint relating to a consultation that did not go ahead as planned, the service reviewed the processes in place for booking clinical rotas.

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.

The provider had a whistleblowing policy in place. (A whistle blower is someone who can raise concerns about practice or staff within the organisation.) There was an in-house team responsible for dealing with any issues raised under whistleblowing.

Continuous Improvement

The service consistently sought ways to improve. The service demonstrated that leaders were responsive to previous CQC inspection feedback and implemented change and improvement. 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. The inclusive culture of the service encouraged staff to contribute in discussions about how to run and develop the service. Innovation was encouraged. Regular departmental team meetings took place, alongside full team meetings. However, as the management team and IT teams worked together at the headquarters there was ongoing discussions at all times about service provision. Since our inspection in February 2019 the service had made a number of improvements. For example:

  • Transformed audit activity into a programme of outcome-led quality improvement. The provider had established a clinical effectiveness group whose role was to develop quality improvement including a clinical audit program focusing on areas appropriate to the service provided. Quality improvement topics included musculoskeletal medicine, sepsis recognition, mental health, dermatology, eye health, women’s and men’s health, medicine management and travel health.
  • Improved the management of risk in consultations through reviewing the prescribing formulary and daily, weekly and monthly checks on all prescribing carried out by the pharmacy team.
  • Improved whistleblowing procedures including updating policies, providing monthly ‘open door’ clinics with senior management for staff to raise any concerns on a one to one basis and implementing systems to allow anonymous feedback from staff.
  • Improved consent procedures for sharing information with patients’ NHS GP.
  • Establishing a number of new digital clinics.
  • Launching of new computer software system for risk management to integrate governance across all areas, and the development of a structured oversight dashboard to monitor progress in all areas of the service provided.

Other areas of continuous improvement:

  • The provider actively shared their knowledge and drew knowledge from similar organisations both in England and abroad.
  • The provider was an active member of working groups formed to develop and improve online services from both the public and private sector.