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Inspection Summary


Overall summary & rating

Good

Updated 26 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? – Outstanding

We previously inspected Push Dr Limited in February 2017, August 2017 and April 2018. The full comprehensive reports for these inspections can be found by selecting the ‘all services’ link for Push Dr Limited on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at Push Dr on 13 May 2019. The purpose of this inspection was to follow up the requirement notice we issued following our last inspection undertaken in April 2018; and in accordance with our updated methodology to inspect all key questions and provide a quality rating.

This inspection identified that Push Dr had implemented action to meet the requirement notice issued at the previous inspection for regulation 12 Safe care and treatment. Systems to monitor antibiotic prescribing and prescribing practice in accordance with national guidelines were safe and effective.

Push Dr are an online (digital) GP service that offers private appointments to patients through the use of a software application on either a smart phone, tablet or laptop computer. The software allows the patient and GP to have a face to face video consultation. This is a fee based service, which is available in England. Consultations are available to adults and children following identity verification.

Push Dr also has a contract with a very large GP practice partnership (Modality Partnership) and provides NHS appointments via video to patients registered with this GP practice.

At this inspection we found:

  • The Push Dr leadership team were a driving force, united in their commitment to deliver and prioritise safe care to private and NHS patients. They effectively used the skills and abilities of their staff team to provide innovative and accessible care, treatment and support to their patients.

  • The service’s underpinning ethos was that patient safety was central to all its activities. It strived to ensure care and treatment was delivered according to evidence- based guidelines.

  • The service had clearly defined and embedded systems to minimise risks to patient safety. A comprehensive quality improvement strategy effectively monitored the service provided to assure safety and patient satisfaction.

  • Staff demonstrated commitment and engagement with the vision for the service. They were proud to work for the organisation.

  • Patient satisfaction with the service they received was monitored and action taken to ensure a safe effective service was provided.

  • There was a commitment and appetite to work with external partners including the NHS and the third sector to make the service as accessible as possible.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw two areas of outstanding practice:

  • The culture of the service was underpinned with the ethos ‘patient safety first’. The leadership team facilitated this culture by investing in staff training and development, encouraging team work and innovation, listening to patient feedback and implementing a continuous quality improvement audit programme.

  • Comprehensive systems for the monitoring of service delivery were established, with 10% of all GP consultations reviewed monthly. Where areas for development and improvement were identified this was shared with the GP and they were asked to reflect on the issues and directed to additional training as required. The GPs really valued this for their professional development as well as service improvement.

The areas where the provider should make improvements are:

  • Continue to encourage the evidence-based prescribing of antibiotics to improve antimicrobial stewardship

  • Review the information supplied to patients when medicines are prescribed ‘off-label’.

  • Implement the planned improvement strategy identified at inspection, including the referral review and pathway.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 26 June 2019

We rated safe as

Good

.

Keeping people safe and safeguarded from abuse

The service had reviewed its systems and service delivery to ensure a comprehensive safeguarding framework was established and effective. This was underpinned with the principle that all staff employed by Push Dr had a responsibility to act on any suspected or actual abuse.

Staff employed at the main Push Dr office had received training in safeguarding and whistleblowing and knew the signs of abuse. The Chief Medical Officer was the designated safeguarding lead and was trained to safeguarding level 5. One other medical officer was also trained to level 5 in safeguarding and other members of the senior management team were trained to level 4. The GPs providing the online consultations (platform GPs or PGPs) were all trained to a minimum safeguarding level 3 and had to provide evidence upon recruitment to the service of this training and on annual basis thereafter. Platform GPs were unable to work without the provision of evidence of this training.

All staff had access to the safeguarding policies and information that included contact telephone numbers and email addresses for all the different safeguarding localities and departments in England. Platform GPs also had the support of the Push Dr medical support team and the customer support team to ensure concerns were responded to quickly and effectively. A self-assessment audit review (Section 11 of the Children’s Act 2004) was scheduled to be undertaken in June 2019 by an external reviewer.

Push Dr offered consultations to children following the implementation of clear protocols to check the identify of both child and adult and the establishment of parental authority to allow the consultation to take place. We noted that parents using the Push Dr service did have the right to refuse the sharing of the consultation (GP Share) with the child’s NHS GP. In these situations, Push Dr’s policy was not to prescribe for the child or young person. Following discussion with Push Dr about the potential risks of not sharing information with a child’s NHS GP they implemented within 48 hours a complete stop on all consultations with children until their electronic system and platform was amended to ensure GP Share for consultations with children was always enabled. In addition, Push Dr confirmed they would undertake a retrospective review of all consultations with children who had accessed the service five times or more to mitigate any potential risks to that child. The Push Dr website was updated to reflect this change and it provided clear concise information explaining why and what they were changing. Push Dr confirmed they would undertake a retrospective review of consultations of children who had accessed the service five time or more to mitigate any potential risks to those children.

The Push Dr GP consultations on the NHS platform were not offered to anyone under the age of 18 years.

Monitoring health & safety and responding to risks

An overarching risk management framework was in place and this was underpinned by a risk management strategy that was linked to each strand of service delivery. A clear leadership structure for each department, supported with up to date polices and protocols and real time business intelligence monitoring allowed the service to identify and respond to potential and actual risks quickly. Patient safety was the priority for the service. Interviews with staff from different teams and platform GPs all confirmed there was a sustained shift in service focus with patient safety as the number one priority. Regular team meetings were undertaken where information and performance were reviewed. Platform GPs were updated with alerts and bulletins and were unable to start consulting until these had been read.

Push Dr had established working relationships with the NHS GP provider they were working in partnership with. Regular reports and reviews of service delivery were undertaken and discussed.

Push Dr headquarters was located within modern spacious offices which housed the IT system and a range of different support teams including leadership, medical, operations, IT and customer support. Patients were not treated on the premises as platform 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.

Push Dr required all platform GPs to conduct consultations in private and maintain patient confidentiality. Each GP used an encrypted, password secured laptop to log into the operating system, which used a Secure File Transfer Protocol (SFTP) 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. GPs could refer patients for tests and make referrals to secondary care services. A significant incident identified in March 2019 had resulted in a review by Push Dr of how the service managed and responded to feedback following secondary care referral and test results. As a result of this incident all investigation reports were reviewed by a medical officer before the patient was contacted. In addition, the service had scheduled an audit of patient referrals for June 2019 to review the whole referral pathway.

Platform GPs who provided the online service to NHS patients recorded the consultation directly into the NHS GP patient record. Referral requests made by the platform GP and test results for the NHS patients were managed by the NHS GP practice.

The service was not intended for use by patients for routine care and treatment for long term conditions and it was not an emergency service. In the event an emergency did occur, the provider had systems in place to respond to this. A significant incident in September 2018, resulted in one GP receiving additional training in using the emergency assistance system. The service analysed the use of the emergency assist ‘button’ by GPs and this identified the process to be safe and effective.

The service confirmed they had systems in place that allowed them to track a patient’s location. However patient confirmation of their location at the beginning of the consultation was not formally requested. We discussed this with Push Dr and following the discussion the service sent out a bulletin to all platform GPs requesting the location of the patient was obtained and recorded in the patient’s notes at the start of the consultation. The service also confirmed they would explore other options of safety-netting to improve location accuracy.

Platform GPs had a range of clinical pathways to assist them in supporting and treating patients and their health needs during the consultations. GPs had access to additional support from medical officers and the chief medical officer should this be required. In addition, monthly audits of the GPs’ consultations and prescribing practices were undertaken, and areas identified for improvement were discussed directly with the GP. The five platform GPs we spoke with all confirmed the service provided a supportive framework which promoted their development.

Mechanisms to report issues and concerns appropriately were in place and this included protocols to notify Public Health England (PHE) 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. We saw evidence of meeting minutes to show where some of these topics had been discussed, for example improvements to the mental health policy, public health notification process mapping and incident management training. The service provided online communication channels for different teams. Push Dr held webinars to share learning from case reviews and provide updates to platform GPs. GPs we spoke with confirmed these to be very useful. In addition, more immediate communication channels were established, and these were known as ‘slack’ channels. GPs were updated or made aware quickly of clinical updates and changes in protocols.

Staffing and Recruitment

Push Dr was an expanding service and in line with this had expanded its staffing team.

There were enough staff, including GPs, to meet the demands for the service. GPs both for the private and the NHS service provided their availability to work on the platform and they were scheduled as required. Platform GPs were supported with a range of different teams including a customer service team, a medical support team and IT support.

GPs could apply to work on either the private patient online platform or the NHS online platform. GPs who were recruited for the NHS online platform could also apply to work on the private patient GP platform at weekends. The GPs for both the private and NHS service were paid on a sessional basis. Push Dr imposed restrictions on the number of hours a platform GP could work for them per day and per week to ensure they were fit and fresh.

The provider had a recruitment and selection process in place for all staff. There were several 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) and listed on the GP performers list. They had to provide evidence of having professional indemnity cover including cover for video consultations, an up to date appraisal and certificates relating to their qualification and training in safeguarding, the Mental Capacity Act, and information governance.

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.

A spreadsheet tracker of all employees was available, and this identified all the requirements, including training necessary to work for the service. We reviewed five recruitment files which showed the necessary documentation was available. The GPs could not be registered to undertake any platform 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

If a medicine was deemed necessary following a consultation, GPs issued a ‘prescription notification’ which was faxed to a pharmacy of the patient’s choice. The GP then printed a prescription which was signed in wet ink and posted to the dispensing pharmacy. Each prescription had a unique identification number which the dispensing pharmacist checked by telephone before supplying the requested medicine. This reduced the chances of a prescription being dispensed more than once. Once the GP prescribed the medicine, 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.

The customer service team supported the transfer of prescriptions to patients. They contacted the patient’s chosen pharmacy to advise them of the prescription and the process to follow if they encountered any issues. The customer service team told us they had developed positive, productive working relationships with different pharmacists. If problems were encountered they offered immediate support both to the patient and the designated pharmacy. Issues were also escalated as per the service’s significant incident policy.

There was a system in place to effectively verify patient identity before each consultation took place. The provider had risk-assessed the treatments on offer and GPs were encouraged to prescribe from a set formulary. Where a non-formulary item was selected, a second review was triggered to ensure prescribing remained safe and appropriate. A ‘do not prescribe list’ was in place which included controlled drugs and medicines liable to abuse or misuse.

Action had been taken since the last inspection in April 2018 to improve antibiotic prescribing. The provider had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance. For example, they had audited overall antimicrobial prescribing rates and could demonstrate a significant reduction in antibiotic prescribing over the last 12 months. In addition, audits of higher risk or less favourable antibiotic choices also showed improvements in prescribing decisions.

It was possible for doctors to prescribe medicines for unlicensed indications. 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 not listed on their licence is called unlicensed or ‘off-label’ use and is higher risk because less information is available about the benefits and potential risks. GPs gave patients information during their consultation to explain when medicines were being used outside of their licence, however no additional written information was supplied to patients about how the use of the medicine may differ from that contained in the manufacturer’s patient information leaflet.

The provider had a process in place for the safe handling of requests for repeat medicines and patients had to undergo a consultation each time a medicine was supplied. However, we found GPs did not always request sufficient evidence of patients having previously taken a medicine or evidence of monitoring relating to some medicines. The provider was aware this needed improving and showed us an updated prescribing policy which emphasised the need for clinicians to obtain sufficient information to prescribe safely, although this had not yet been fully implemented.

Information to deliver safe care and treatment

On registering with the service, and at each consultation patient identity was verified. The service did not provide a service to patients unless they could provide valid identification. The GPs had access to the patient’s previous records held by the service. Platform GPs consulting with NHS patients had access to the patient record held by the patient’s own NHS GP.

Patients using the Push Dr NHS GP service, accessed the service through their NHS GP practice. NHS patients using the service through their NHS GP could not be private patients on the private Push Dr platform.

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. A spreadsheet logging all significant incidents was available and this logged 34 incidents in the year between April 2018 /19. The log detailed briefly the incident, the risk assessment, the immediate actions implemented, the outcome of the event, and further actions and lessons learned.

We reviewed three incidents and found these had been fully investigated, discussed and as a result action taken in the form of a change in processes. For example: one NHS patient had been prescribed strong painkillers. The investigation identified that the platform GP believed they could prescribe medicines as they would normally as a NHS GP and did not need to comply with Push Dr’s medicine prescribing policy, which would have precluded this prescription. As a result of this incident all platform GPs were reminded that they were not allowed to prescribe medicines on Push Dr’s exclusion list. Discussions were undertaken with the NHS GP provider and a new flowchart implemented for GPs to follow regarding patient treatment. In addition, the Push Dr pharmacist checked all prescriptions and ran regular two weekly audits on prescribing practice.

The senior management team had undertaken an analysis of the significant events recorded in the year to April 2019 and identified themes which included platform GP development from induction (onboarding) to effective introduction of new or updated pathways such as the Mental Health review pathway. A further decision following this review was to undertake significant event analysis every quarter.

We saw evidence from three incidents (complaints) 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 a system in place to receive and act on medicines and safety alerts, such as those issued by the Medicines and Healthcare products Regulatory Agency (MHRA). All platform GPs were made aware of these.

Effective

Good

Updated 26 June 2019

Assessment and treatment

We reviewed 24 examples of medical records that generally demonstrated that patients’ needs were assessed, and care and treatment was provided in line with relevant and current evidence-based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence-based practice. Systems were established to monitor GP prescribing every two weeks and where prescribing did not follow evidence-based guidance and the provider’s policies this was discussed with the relevant GP. There was evidence Push Dr took action to ensure GPs complied with guidance and policies.

Online GP consultations lasted for 10 minutes. Private patients could either subscribe with an annual subscription and reduced appointment fee or patients could pay a one-off fee for the ten minute appointment. The appointment time could be extended if the needs of the patient required this. This could incur an additional charge. Patients accessing the NHS online platform received a ten minute appointment slot, which could be extended if required. NHS patients did not pay for this service. Platform GPs could be scheduled up to a maximum of four appointments each hour. Push Dr’s customer support team were available to both the patient or the GP should there be an issue with the consultation. If the GP had not reached a satisfactory conclusion there was a system in place where they could contact the patient again.

Push Dr had a consultation policy in place which detailed the expectations and requirements for platform GPs to follow in relation to patient consultation, confidentiality, consent, triage and chaperoning. As part of the GP consultation process patients were requested to provide information about themselves including their past medical history. There was a set template for the GP to complete for the consultation that included the reasons for and the outcome of the consultation. GPs had to complete each step of the consultation template to progress through and complete the record. We reviewed nine consultation records which were complete records. We saw that adequate notes were recorded, and the GPs had access to all previous notes.

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. Push Dr had developed a range of clinical assessment tools and pathways to support GPs. For example, there was a mental health policy and pathway template in place and an audit of this was scheduled for quarter two of 2019. GPs also had access to NICE and best practice guidance and the service policies and procedures. If a GP could not deal with the patient’s request, this was explained to the patient and a record kept of the decision.

Comprehensive systems of monitoring service delivery were established, with 10% of all platform GPs’ consultations reviewed each month by the service’s medical officers. This review looked at the quality and content of the consultation and the prescribing of medicine for appropriateness. Where areas for development and improvement were identified this was shared with the GP and they were asked to reflect on the issues and directed to additional training as required. The same rigorous review process was undertaken with records for patients who had been consulted on the NHS platform. The platform GPs we spoke with stated they valued this level of support and it promoted their professional development.

Alongside the monthly reviews of patient consultations, regular medicine prescribing audits for all GPs were undertaken, this included antibiotic prescribing.

Quality improvement

The service collected and monitored information on patients’ care and treatment outcomes and used this information to improve outcomes for patients. An operational and clinical governance strategy was in place and this was underpinned with a range of policies and protocols. A business intelligence software programme provided real time monitoring of the different strands of service delivery.

The service implemented a continuous quality improvement cycle which included a clinical/diagnostic audit plan, regular GP consultation reviews, and fortnightly medicine prescribing audits. Alongside the clinical aspects of the service delivery, the service actively reviewed incidents, complaints and patient feedback to ensure the service provided was safe and effective and met patient expectations. Platform GPs and staff employed at the main base for the service were also consulted on how to improve service delivery both to patients and for the staff.

Staff training

All staff completed induction training which consisted of topics such as equality and diversity, information governance and GDPR (General Data Protection Regulation), the mental capacity act, safeguarding for adults and children and whistleblowing. Other training included health and safety and fire safety. Role specific training was also provided to staff and this included Caldicott guardian, fire marshal and first aid.

A training matrix for all staff was in place and this flagged up team members due for update or refresher training.

A comprehensive induction training package was in place for new platform GPs and this included online one to one training support. The operations team who provided this GP support also built up working relationships with the GPs. Part of the induction training included using a simulation environment to support new GPs with the technology for online face to face consultations and the use of mock consultations. Induction and use of the training simulation included patient identity checks, note taking, raising an emergency, safeguarding processes and the management of prescriptions. Following induction, the GP could book a maximum of six hours working on the live platform and a medical review of 10 consultations was undertaken. If consultations were assessed as satisfactory, the GP was able to book further hours. If areas of improvement were identified additional training and further review was offered.

Induction training for NHS platform GPs was similar but also incorporated accessing the systems used by the patient’s NHS GP practice for recording patient records. This training could be location specific as GP practices operated their own systems of clinical workflow.

Supporting material was available to GPs, and refresher training if a platform GP had not worked for a period of time. The service sent out regular information letters regarding changes and updates including patient safety alerts. The GPs told us they received excellent support if there were any technical issues or clinical queries and could access policies as needed. GPs also said the regular review of patient consultations was supportive and promoted their development.

Team members based at the service’s head office received regular performance reviews with personal development plans. Staff member’s development objectives were aligned with the business objectives. At the time of this inspection the service was implementing 360 degree staff appraisals.

Platform GPs had to submit their own previous appraisals as part of the recruitment process. A log of all documents with renewal dates was maintained for the appraisals and other training. If training and or appraisal dates expired the GP was prevented from working until up to date documents were supplied. Regular monitoring checks were implemented.

The service had recently introduced in-house appraisals for GPs. We spoke with one GP who confirmed they had received this. They told us this consisted of a 30 minute development discussion that included feedback from patients, antibiotic prescribing and a review of complex cases.

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. This included self-care.

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 and had developed a list of medicines that were not suitable to be prescribed by the service. This list was available to all platform GPs. The service also imposed restriction on the amount of some medicine to be provided on prescription to ensure patient safety. For example, some types of pain relief were restricted to a limited supply. 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 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. Patients and recipients of documents supplied by Push Dr (such as prescriptions, referral letters and fit notes) were able to validate the authenticity of the documents by accessing a 24-hour automated telephone checking and verification service.

The consultation policy for the service detailed when and how patients should be referred for a face to face GP appointment or referral to secondary care. Referrals for private patients were written by the platform GP and sent to the patient to take to the secondary care service of their choice. For NHS patients the platform GP submitted a task to the NHS GP practice secretary. The patients NHS GP practice monitored these referrals.

The service confirmed that on occasion they received results back from tests and following referral. The medical team at the main office checked the post twice weekly to review these and contacted patients directly to book an appointment so these could be discussed.

The service acknowledged the system of monitoring for private referrals and follow up from test results was an area that required further development. It was reported that work had commenced on this and the engineering team were working to develop an improved process. Medical officers confirmed that as part of this process an audit of the quality of referral letters and the reasons for referral would be part of the review. As a result of our discussion the timescale for this work was prioritised and moved up from quarter three to quarter two.

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 which was accessible to everyone. Several subjects including health and wellbeing, mental health, smoking cessation, specific information on common health conditions and self-care pages provided clearly accessible information in an easy to read format.

In their consultation records we found patients were given advice on healthy living as appropriate. Selfcare leaflets were provided free of charge to patients for common health conditions.

Caring

Good

Updated 26 June 2019

Compassion, dignity and respect

A requirement for working as a platform GP for Push Dr included the provision of a private room so that online video consultations were undertaken appropriately. GPs were provided with additional advice including making sure lighting was sufficient so that the patient could see the online GP. A pre-logging on checklist was undertaken by GPs to ensure their equipment including laptop, camera and microphone were fully functional. Customer support both for patients and GPs was available if problems occurred during a consultation. Systems monitoring GP consultations were established and this included customer feedback and complaints if relevant.

We did not speak to patients directly on the day of the inspection. However, the service was able to provide an overview of the real-time monitoring of all patient feedback. This included monitoring reviews posted on public independent web sites such as Trustpilot, social media sites including Twitter and feedback received directly by the service. Patients were sent an email asking for their feedback following each consultation and this generated a 15% average response rate. All feedback was collated and the results monitored through the service’s intelligence monitoring software. The provider shared data with us that showed overall they were scoring very well for positive feedback from patients. The data provided evidence that satisfaction rates were improving, while prescribing rates were falling.

Evidence was also available that showed Push Dr responded to comments posted on public web sites acknowledging and welcoming the positive feedback and for those reviewers dissatisfied with the service, offering apologies, with the provision of a contact telephone number to discuss the reviewer’s experience further.

The last formal patient survey was undertaken in April 2018. This showed that above 80% of the 241 respondents found it easy to make an appointment with Push Dr and over 80% found the availability of GPs at a time to suit them was very convenient. Respondents rated their experience with the customer service team positively with 58% of those who contacted the team stating they were very helpful and 27% stating they were fairly helpful. 64% of respondents rated the service they received as very caring and concerned, 24% fairly caring and concerned, 7% not very caring or concerned and 6% not all caring and concerned. The Push Dr team analysed the results from this survey and implemented actions to improve the patient experience.

Involvement in decisions about care and treatment

Patient information guides about how to use the service and technical guidance were available on the website. There was a dedicated customer service team to respond to any enquiries and to assist prospective and existing customers to access the Push Dr service. Patients could use the online support, live chat or the telephone for this support. The customer services team was available seven days a week from 7am to 8pm.

The website for Push Dr offered prospective patients’ videos of real patients providing feedback on the service they received.

Patients could book an appointment at a time convenient to them. They could log on to the service before their appointment and wait in the virtual patient waiting room. Patients were allocated a platform GP as one became available. This did not allow for specific requests for a gender specific clinician. However, we were told that patients could request a gender specific clinician by contacting the customer service team first who would manually allocate a GP of the requested gender to the patient. The service advised that there had been very little demand for gender specific GP consultations but would review this if it became an issue for patients.

The patient survey carried out in April 2018 showed that 64% of respondents were very happy their concerns were addressed with the consultation and almost 20% of respondents were fairly happy with the consultation. A total of 57% of respondents rated their overall experience with Push Dr as excellent, 19% rated it good, 10% rated it okay and 14% rated it poor. The action plan in response to the feedback allocated department leads and prioritised action to respond to the feedback.

Push Dr did not record or retain the video consultation with patients. Platform GPs received induction training regarding the content and quality of consultation notes required for each patient seen. As part of the service’s clinical governance strategy 10% of each platform GPs consultations were reviewed monthly. Where issues were identified these were discussed with the GP.

Patients could download copies of their consultation notes by logging into their account.

Responsive

Good

Updated 26 June 2019

Responding to and meeting patients’ needs

Consultations were provided seven days a week between 7am and 8pm, but access via the website to request a consultation was available 24 hours a day. A dedicated customer support service was available seven days a week between 7am and 8pm. 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.

GP consultations were only undertaken if the patient was in the UK. Prescriptions for medicines could not be sent to someone who was out of the country. Push Dr required all their platform GPs and the doctors working at the head office to be practising NHS GPs living in the UK. Any prescriptions issued were delivered within the UK to a pharmacy of the patient’s choice.

The Push Dr website offered clear information about the available pricing structure for accessing the private service. People had the option of signing up to an annual contract that charged a monthly fee (currently £3) and a reduced consultation fee (£20). Consultations were not time limited to ten minutes and there was no administration fee for the provision of a prescription. Alternatively, there was an option for a one-off appointment (£30) for a ten minute appointment, additional time was charged at £15 per ten minutes and there was an administration fee (£8) for the generation of a prescription.

Appointments with GPs providing NHS consultation were available to patients between 9am and 6pm and again in an evening 6.30pm until 8pm Monday to Friday. Patients accessing the service through the NHS platform were not charged a fee for the consultation.

Push Dr’s digital platform allowed people to install registration software on a smart phone, tablet or personal computer. NHS patients accessing the service received instructions and a code to access the platform from their own NHS GP practice. Push Dr’s customer service team were available to assist people with installation and accessing the service. People could use live chat, email or telephone for support. There were also videos available to show people how to download and access the service.

The service offered flexible appointments between 7am and 8pm to meet the needs of their patients. The provider made it clear to patients what the limitations of the service were and these were detailed clearly in the terms and conditions of the service.

The digital technology used to deliver the service was encrypted from the start of the service to completion. A full range of data protection policies and risk assessments were in place and monitored to ensure patient information was safeguarded.

Push Dr undertook regular market research to ensure the service they were providing was accessible and met the needs people who used the service. The marketing team had developed a research tool, Patient, operations, Doctor (PoD). The PoD’s objective was to provide a patient centred service. Working with an external research company, members the PoD team interviewed existing patients, prospective patients, platform GPs and operations staff, including NHS staff to seek their views and opinions on different aspects of the service. For example, a recent PoD meeting requested feedback from a participant on the pricing of the service, the navigation around the Push Dr website and what people’s views were around using social media as a tool for engagement.

Tackling inequity and promoting equality

Push Dr offered private consultations to anyone who requested and paid the appropriate fee. NHS consultations were available to patients registered with the NHS GP service that was working with Push Dr.

NHS patients could access the online video consultation with Push Dr through their own NHS GP surgery.

Push Dr had approximately 100 GPs registered and working on their platform. Patients could view videos of some GPs talking about their work with Push Dr on the practice website. Patients could request a GP of a specific gender by contacting the customer service team. For those who had a hearing impairment the facility for the GP to type information during the video consultation was available.

Managing complaints

The service’s web site had a link for patients to use should they wish to complain about the quality of their consultation. 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. Designated team members monitored and responded to patients’ complaints. A comprehensive register of all complaints was available, and this listed 194 complaints since July 2018. The complaints log detailed the level of risk and the progress in responding to the complainant with timescales.

The complaint process included sending an acknowledgement to the patient, a full review of the patient’s consultation by a medical officer and action in response to the findings of the complaint. A final letter following investigation was sent to the complainant and we noted apologies were also provided where the complaint was substantiated or partially upheld. We noted that some complaints were also reviewed as part of the significant incident process. A specific form for the recording of complaints had been developed and introduced for use.

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 relating to administration of prescriptions, referrals and fit notes were also displayed clearly on the service website.

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. 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 26 June 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.

Business Strategy and Governance arrangements

There had been a significant shift in culture and mind set since our previous inspection in April 2018. The provider and all staff we spoke with emphasised their number one focus was ‘patient safety first’. Everyone we spoke with demonstrated enthusiasm and commitment to delivering a safe dynamic service to patients.

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 three medical officers who between them provided support and advice to staff and platform GPs. 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.

Clinical governance and operational governance policies with supporting risk management frameworks and actions plans were established and implemented. There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions.

There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service. These included a 10% review of consultations for each platform GP every month, a review of all prescribing every two weeks, systems for reviewing and responding to requests for non-standard formulary and regular monitoring and review of significant incidents and complaints. The information from these checks, and other performance indicators was monitored by the clinical team and reported on. Each of the different teams undertook their own monitoring of performance and this was collectively reviewed at full team meetings monthly. This ensured a comprehensive understanding of the performance of the service was maintained.

Push Dr were finalists in the Patient Safety Awards for 2019 in the category Quality Improvement Initiative of the Year. The winner of this award category will be announced 2 July 2019. The Push Dr team delivered a presentation on the ‘Perfect Week’ quality improvement initiative undertaken by the service. (The Perfect Week quality improvement programme is an NHS initiative, where a service/department/ hospital focus on the service they deliver to make sure the patient journey or pathway through its service is safe, effective and smooth).

The focus of the Push Dr’s ‘Perfect Week’ initiative reviewed antibiotic prescribing and the challenge to standardise this for digital health. The improvement initiative looked at best practice guidance, research papers, patient expectations and culture around prescribing antibiotics. It identified GP education (webinars on antibiotic prescribing and antibiotic guardians), patient education, self-care fact sheets, web design and social media as influencing factors in changing culture; and identified rapid audits and customer feedback to support evidence of change.

Leadership, values and culture

Push Dr recruited a new Chief Medical Officer (CMO) in July 2018 and this we were told had been the biggest influential factor in shifting the culture and focus to patient safety. The CMO was supported by a chief executive officer and a leadership structure for the different departments. The inspection provided clear and compelling evidence that all teams were working to the same objectives.

The new leadership team were a driving force, united in their commitment to deliver safe care and treatment to all their patients. The change in culture and values had been facilitated by involving the staff to identify what they wanted the values to be and why. Platform GPs and patients were asked what they wanted their care to be like. The outcome of this process identified the core values as Empathy, Ambition, and Resilience. Following on each department was engaged in reviewing how their work, role and responsibilities contributed to the organisation’s values and the CQC key questions and key lines of enquiry. The office walls were used by staff individually and as part of their team to identify what and how they contribute to delivering a safe, effective, caring responsive and well led service.

All staff were considered valuable members of the team and those we spoke with were clear on their contribution to providing the best and safest service to patients. Staff were proud of working at Push Dr. Platform GPs valued the regular reviews of their consultations and prescribing practice and told us that the support they received promoted their professional development.

Push Dr were developing a culture of partnership and collaboration between themselves, the NHS and third sector organisations. A patient engagement forum held in September 2018 included representatives from range of organisations including Healthwatch, Alzheimer’s Society and the National Association for Patient Participation. Further forums were planned for 2019.

Safety and Security of Patient Information

Comprehensive information governance policies were established within a risk management framework and these included for example General Data Protection Regulation (GDPR), data security, data retention and network security. Designated leads with responsibility for different areas of information governance were in place and staff had received role specific training for this.

The service could provide a clear audit trail of who had access to records and from where and when. Following discussion with Push Dr they implemented additional action to mitigate potential risks of patient information being accessible to platform GPs following a consultation with a patient. All GPs had been contacted to remind them to delete patient information they had downloaded and work had commenced with the engineering team to review controls and restriction on downloading information. In addition, Push Dr advised us they would develop and implement a specific policy in relation to this and update platform GPs terms and conditions to include legally binding requirements with regards to patient information.

Seeking and acting on feedback from patients and staff

Push Dr constantly monitored customer feedback and used the Net Promoter Score (NPS) system to monitor customer satisfaction. The NPS system measures the willingness of customers to recommend a company's products or services to others. Push Dr collated feedback regarding their service from patients following each consultation, from review sites (Trust Pilot) and other social media sites. This provided them with regular updates on how they were performing. At the time of this inspection visit it was reported the NPS for Push Dr in May was 70.3 (above 70 is excellent). This was achieved with a decreasing overall prescribing rate. The service’s research department consulted with patients and external groups to identify how they could improve their service. The service proactively responded to negative feedback on public websites requesting additional contact from the reviewer. Complaints and incidents triggered full reviews including reviews of consultation records as required.

There was a strong emphasis on the safety and well-being of all staff. Push Dr used the NPS system to measure employee satisfaction and additional software (Peakon) was used to measure employee engagement performance. Action plans to improve staff satisfaction and engagement were being implemented and these linked to the business strategy, organisational, team and individual development and performance indicators.

Platform 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.

A whistleblowing policy was available and the staff we spoke with were aware of this and the avenues they could use to raise issues and concerns. (A whistle blower is someone who can raise concerns about practice or staff within the organisation.)

Continuous Improvement

The service consistently sought ways to improve. We observed clear evidence that leaders were responsive to inspection feedback and implemented change and improvements. An executive team meeting was scheduled for the day after the inspection to respond to findings and actions were implemented immediately. These changes were a team effort. There was a quality improvement strategy and plan in place to monitor quality and to make improvements, for example, through clinical audit, patient and external stakeholder feedback and engagement with the NHS.

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 were held, alongside full team meetings.