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Inspection Summary


Overall summary & rating

Good

Updated 12 July 2019

Inspection areas

Safe

Good

Updated 12 July 2019

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. The clinical lead was the Designated Safeguarding Officer and had completed additional training to support this role. All the GPs had received level three child safeguarding training and were working towards level three adult safeguarding training. It was a requirement for the GPs registering with the service to provide evidence of up to date safeguarding training certification.

The service did treat children. The service enabled people with health insurance to name family members on their policy who could also access the remote GP service. Children under 16 could not book appointments themselves and the policy holder was required to be present at the beginning of the consultation, to confirm their identity.

Monitoring health & safety and responding to risks

There were adequate systems to assess, monitor and manage risks to patient safety.

The administration team carried out a variety of safety checks either daily or weekly. These were recorded and formed part of a clinical team weekly discussion.

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.

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.

GPs knew how to identify and manage patients with severe infections including sepsis and 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 policies, any significant incidents 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 and be registered with the General Medical Council (GMC) on the GP register with a license to practice. They had to provide evidence of an up to date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act. The service ensured all GPs had professional indemnity cover (to include cover for video consultations) by organising and paying for the cover.

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.

We reviewed two 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

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 GPs could issue a private prescription to patients. The prescribing policy had a list of medicines that would not be prescribed. This list included controlled drugs and medicines liable to abuse or misuse. When emergency supplies of medicines were prescribed, there was a clear record of the decisions made and the service advised patients to share the information with their patient’s regular GP.

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 did not prescribe any off-label medicines.

The service policy was to not routinely prescribe repeat prescriptions or for patients with long term conditions that would need to be monitored, such as asthma or diabetes. If a patient requested an emergency supply for a medicine for a long-term condition (such as asthma inhalers) the GP would only prescribe this medicine once if it was deemed clinically appropriate.

The clinical lead reviewed 100% of all prescriptions generated. The prescribing rate for 2019 so far was 2.8% of all GP consultations resulted in a prescription being issued.

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

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 were sent their prescription by 1st class post and could take this to a pharmacy of their choice.

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 four incidents and found that these had been fully investigated, discussed and as a result action taken in the form of a change in processes.

Learning from incidents was communicated to all staff via email and discussed at team meetings to review and analysis any trends.

We saw evidence from one incident 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.

Effective

Good

Updated 12 July 2019

Assessment and treatment

We reviewed 10 examples of medical records that demonstrated 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. We saw that adequate notes were recorded, and the GPs had access to all previous notes.

We were told that each consultation lasted for 20 minutes. If the GP had not reached a satisfactory conclusion there was a system in place where they could contact the patient again.

Patients requested a consultation via a mobile application. They were given the choice of two appointment times, usually one with a male and one with a female GP. If those times were not suitable the patient could then generate a further two appointments until they had a suitable and convenient date and time.

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 clinical lead reviewed all prescriptions on a weekly basis to ensure they were appropriate. If there were any concerns this was fed back to the prescribing GP.

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 prescribing reviews and audits of consultation records.

Staff training

All staff completed induction training which consisted of health and safety, basic life support, work place stations assessments, information governance and confidentiality. Staff also completed other training on a regular basis such as Safeguarding training to the appropriate levels. The service manager monitored training to identify when training was due.

An induction log was held in each staff file and signed off when completed. There was regular communication sent out when any organisational changes were made. The GPs told us they received excellent 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 training.

Administration staff received regular performance reviews. All the GPs had to have received their own appraisals before being considered eligible at recruitment stage. The service had identified that staff were due an in-house appraisal once they had been working within the service for 12 months and were in the process of scheduling this.

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.

All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP when initially registering with 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, 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, the service provided the consultation record to the patient to enable the patient to send this information to their own NHS GP.

The service had undertaken a survey which showed that 30% of patients consented to sharing and had shared their consultation records with their NHS GP, 29% of patients stated that they would not use the service if their consultation notes were routinely shared with their NHS GP.

Any test results were reviewed on the day they were received by the administration team. This was usually actioned by the referring GP but to avoid delay could be reviewed by the clinical lead or another GP.

Supporting patients to live healthier lives

The service identified patients who may be in need of extra support, in their consultation records we found patients were given advice on healthy living as appropriate.

Caring

Good

Updated 12 July 2019

Compassion, dignity and respect

We were told that the GPs undertook video consultations in a private room and were not to be disturbed at any time during their working time. The provider undertook an assessment of the environment the GP would be working in before they could commence consultations. This was done, if possible, with a visit to the environment or via a video call.

The provider carried out random spot checks 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 day of the inspection. However, we reviewed the latest survey information. At the end of every consultation, patients were sent a survey asking for their feedback on the following three questions.

  • Was your health query dealt with in full today?
  • How would you rate the GP you saw today (out of five)?
  • How would you rate the app for ease of use?

For March 2019, we saw the average GP rating was 4.8 out of 5. We saw that 85% of patients felt their health query was dealt with in full, and the ease of use of the app was rated as 4.4.

The provider followed up with any GP who had a rating of less than three and used this as a performance management indicator.

Involvement in decisions about care and treatment

Patient information about how to use the service and technical issues were available via the support team to respond to any enquiries.

Patients had access to information about the GPs working for the service and could book a consultation with a GP of their choice. For example, whether they wanted to see a male or female GP.

After every consultation the records were available via the app for patients to review.

Responsive

Good

Updated 12 July 2019

Responding to and meeting patients’ needs

The service offered a GP remote consultation service to patients who have private health insurance with a specific company. The consultations were accessed and booked through a mobile application and conducted via a video call. The opening hours of the service were Monday to Friday 8am to 7pm and Saturday 9am to 1pm

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 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 maximum length of time for a consultation was 20 minutes. However, we were told that GPs could contact the patient back if they had not been able to make an adequate assessment or give treatment.

Tackling inequity and promoting equality

The provider offered consultations to anyone who requested and had the appropriate insurance policy and did not discriminate against any client group.

Patients could access a brief description of the GPs available. Patients could choose either a male or female GP.

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 and actioned appropriately. We reviewed two complaints out of two 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

The service was provided via a health insurance company and there was no direct cost to the patient for accessing the service. The website had a set of terms and conditions and details on how the patient could contact them with any enquiries.

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.

Well-led

Good

Updated 12 July 2019

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 that covered future plans and arrangements.

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. These included random spot checks for consultations, reviewing of feedback following each consultation and the auditing of all prescriptions generated. The information from these checks was used to produce a clinical team report that was discussed at regular team 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.

Care and treatment records were complete, accurate, and securely kept.

Leadership, values and culture

The clinical lead took responsibility for any arising medical issue and there was a deputy lead when they were not available. The clinical lead was based in the main office and was available for advice when required.

The service had a clear vision and strategy to deliver high quality, sustainable care.

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.

The service had a culture that placed safety first. For example, staff told us that if during a consultation a patient became unwell or required emergency treatment then the service would reschedule their work for the next hour to enable them to deal with it thoroughly. They told us that the clinical lead would discuss the scenario with them as soon as possible after the event to ensure that the member of staff was ok and that they had dealt with the situation appropriately. This was in response to a significant event and the learning identified from this. Each GP video consultation was 20 minutes long and a 20 minute break was scheduled every hour to ensure GPs had enough time to rest, whilst providing additional time for administration and record keeping if required.

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 could rate the service they received following every consultation. 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 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.) The Clinical Director was the named person for dealing with any issues raised under whistleblowing.

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. However, as the management team and IT teams worked together at the headquarters there was ongoing discussions at all times about service provision.

There was a quality improvement strategy and plan in place to monitor quality and to make improvements, for example, through clinical audit.