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Archived: Online Clinic (UK) Limited Good

This service was previously registered at a different address - see old profile

This service is now registered at a different address - see new profile

Inspection Summary


Overall summary & rating

Good

Updated 29 October 2019

We carried out an announced comprehensive inspection at Online Clinic (UK) Limited on 27 August 2019 as part of our inspection programme.

Online Clinic (UK) Limited provides online consultations to patients, through online forms and a messaging system conducted within the patients online record, for a condition selected by the patient themselves. A GP will then review the request, may ask for further information and if appropriate, provide a private prescription to be dispensed by a designated pharmacy.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 29 October 2019

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.

  • There were systems in place to ensure safe prescribing.

  • Patients were safeguarded from the risk of abuse.

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 safeguarding leads had an application installed on their phones which had up-to-date contact details for local authorities in England, so they would be able complete the referral correctly dependant on where the patient resided. All the GPs had received adult and level three child safeguarding training. It was a requirement for the GPs registering with the service to provide evidence of up to date safeguarding training certification.

The service did not treat children. There were safeguards in place at registration, which placed all patients through an identity verification process, and this was used to ensure the patient was over 18 and who they said they were.

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.

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.

Clinical consultations, where a GP was concerned of a risk, this would be sent to the clinical lead and registered manager to be assessed as appropriate. Risks were reviewed at weekly meetings and outcomes and learning disseminated amongst the team. 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 prescribing doctors were paid per consultation.

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’s had to be currently working in the NHS and be registered with the General Medical Council (GMC). They had to provide evidence of having professional indemnity cover, an up to date appraisal and certificates relating to their qualification and training in safeguarding and the Mental Capacity Act.

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

Prescribing safety

All medicines prescribed to patients from online forms were monitored by the provider to ensure prescribing was evidence based. If a medicine was deemed necessary following a consultation by a GP, an additional check was carried out usually by a different GP before a private prescription was authorised. Medicines were dispensed by an affiliated pharmacy and delivered to the patient. The GPs could only prescribe from a set list of medicines which the provider had risk-assessed. 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, if people had consented to sharing their GP details.

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

The service encouraged good antimicrobial stewardship by only prescribing from a limited list of antibiotics which was based on national guidance. The provider did not provide treatment of long term condition and only provided a limited service for repeat prescribing.

The service prescribed some unlicensed medicines, and medicines for unlicensed indications, for example for the treatment of traveller’s diarrhoea and premature ejaculation. 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 on the consultation form to explain that the medicines were being used outside of their licence, and the patient had to acknowledge that they understood this information. Additional written information to guide the patient when and how to use these medicines safely was supplied with the medicine.

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

Prescription were dispensed and delivered direct to the patient by the supplying pharmacy. The service had a system in place to assure themselves of the quality of the dispensing process. There were systems in place to ensure that the correct person received the correct medicine.

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 six incidents 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:

  • An incorrect laboratory form was sent to a patient which resulted in the provider reviewing procedures for sending out test kits to patients.

  • A patient was prescribed medicine for erectile dysfunction outside of protocol which resulted in the provider reinforcing protocol age limits for prescribing the medicine.

Learning from incidents was communicated to staff through regular staff meetings. The clinical lead carried out regular analysis of incidents to look for trends and themes which further minimised the likelihood of recurrence.

We saw evidence from four 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.

There were systems in place to ensure that the correct person received the correct medicine. We were shown records of the action taken in response to recent patient alerts. For example, the service had taken action to ensure patients prescribed a particular antibiotic were not at increased risk of musculoskeletal conditions.

Effective

Good

Updated 29 October 2019

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

  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.

  • Staff had received training to carry out their roles.

Assessment and treatment

We reviewed 12 examples of medical records that demonstrated that each GP assessed patients’ needs and delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence based practice.

Patients completed an online form that was specific to the presenting complaint which the patient selected at the start. There was a set template to complete for the consultation that included the reasons for the consultation and the outcome to be manually recorded, along with any notes about past medical history and diagnosis. We reviewed 12 medical records which were complete records. We saw that adequate notes were recorded, and the GPs had access to all previous notes. We were told that each online consultation lasted as long as was necessary.

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. The GPs could request photos if appropriate or recommend testing for some conditions to aid in clinical assessment. If the provider could not deal with the patient’s request, this was explained to the patient with alternative pathways signposted and a record kept of the decision.

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. Recent quality improvement included an asthma audit to ensure that clinicians were following asthma protocols, a urinary tract infection audit to measure compliance with National Institute for Care and Excellence (NICE) guidance on antimicrobial prescribing and an audit of erectile dysfunction prescribing to ensure the clinicians were following written protocols.

Staff training

All staff completed induction training which consisted of topics such as information governance and safeguarding. Staff also completed other training on a regular basis such as equality and diversity, mental capacity and consent. The service manager had a training matrix which identified when training was due.

The GPs registered with the service received specific induction training prior to treating patients. This was provided by the clinical lead and covered areas such as reviewing clinical protocols for conditions the service treated as well as GMC guidance for remote prescribing. Time was also spent with the registered manager and IT lead to ensure staff fully understood the clinical system and the ways in which support was available. An induction log was held in each staff file. During the probationary period of a GP, the clinical lead reviewed any prescribing to ensure it was in line with the providers’ policies.

Quarterly clinical meetings were held at the headquarters and as well as standing agenda items and updates to areas requiring review there was time set aside for continuous professional development training which was often provided by external speakers. Administration staff received regular performance reviews. All the GPs had to have received their own appraisals before being considered eligible at recruitment stage. There were checks in place to assure the provider that the scope of practice required by the GPs matched their skills and expertise.

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 on each occasion they used the service. The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, 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.

The provider offered patients referrals to private specialists when appropriate. When a referral was offered, a letter would be generated and sent to the patient to take to the specialist of their choice. The service provided the contact details of two national provider organisations. A letter would be sent to a patients NHS GP if the patient consented.

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 (or links to NHS websites or blogs). For example:

  • Regular news articles covering topical areas cervical screening during cervical cancer prevention week.
  • Smoking cessation and sexual health information was available.
  • Leaflets were sent with medicines, in addition to standard information leaflets, to encourage healthy living.
  • In their consultation records we found patients were given advice on healthy living as appropriate.

Caring

Good

Updated 29 October 2019

  • Staff involved and treated people with compassion, kindness, dignity and respect.

  • Patients were involved in decisions about care and treatment.

Compassion, dignity and respect

We were told that the GPs working remotely undertook online consultations in a private room and were not to be disturbed at any time during their working time. The provider carried out annual health and safety reviews of working environments to ensure the GPs were complying with expected service standards.

We did not speak to patients directly on the day of the inspection. However, we reviewed the latest survey information which showed that from 517 respondents, 91% rated the service as ‘excellent’, 8% ‘good’ and 1% average. A consumer review website showed that out of 6,280 reviews the service had received a five star ‘excellent’ rating.

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 by email or phone.

Patients had access to information about the GPs working for the service and could request a consultation with a male or female GP. Translation services were available.

Feedback from patients praised the service for the follow up care provided and the involvement they experienced through the consultation process.

Patients could have a copy of their online consultation only if they made a written request for a copy of the recording to the provider.

Responsive

Good

Updated 29 October 2019

  • Patients could access care and treatment from the service within an appropriate timescale for their needs.

  • Complaints were handled in a timely way.

  • Consent to care and treatment was sought in line with legislation and guidance.

Responding to and meeting patients’ needs

Patients accessed the service through the website, which was available 24/7, and completed an online form after selecting the relevant condition they presented with. Consultations were provided through the online messaging service within the patients online account and were available 24 hours a day, seven days a week. The provider made it clear to patients what the limitations of the service were. 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. A telephone line was open daily for assistance with the website or issues arising from consultations.

Any prescriptions issued were delivered to a dedicated pharmacy to be dispatched to an address of the patients choice.

Patients requested an online consultation with a GP and were contacted at the allotted time. There were no time constraints for an online consultation.

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.

Patients could access a brief description of the GPs available. Patients could choose either a male or female GP and translation services were available. Type talk was available.

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 six complaints out of 17 received in the past 12 months.

The provider was able to demonstrate that the complaints we reviewed were handled correctly and patients received a satisfactory response. There was evidence of learning as a result of complaints, changes to the service had been made following complaints, and had been communicated to staff.

Consent to care and treatment

There was clear information on the service’s website with regards to how the service worked and what costs applied including a set of frequently asked questions for further supporting information. The website had a set of terms and conditions and details on how the patient could contact them with any enquiries. There was a transparent cost presented to the patient for a medicine if it was seen as the appropriate treatment, however if no prescription was required, the consultation was free.

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. 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

Good

Updated 29 October 2019

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

  • There were effective governance arrangements and leadership.

  • The service sought and acted on feedback from patients and staff.

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 the next 12 months.

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 such as when learning from a complaint or incident had triggered a change.

There were a variety of checks in place to monitor the performance of the service. These included random spot checks for consultations conducted daily to ensure care was delivered in line with the provider’s guidance to weekly reviews of prescribing by the clinical lead and monthly audits of performance. This, in conjunction with regular meetings 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 registered manager had overall responsibility of the day to day operation of the service. They were in daily contact with the clinical lead who had responsibility for any clinical issues arising and the performance of the GPs working remotely for the provider. The registered manager and clinical lead communicated daily with each other vis phone and email and they met face to face to review all areas of the service on a six weekly basis. There was resilience within the availability rota of GPs to cover any absence and the clinical lead was able to provide consultations if necessary.

The values of the service were to provide a safe, effective and caring service for patients in a convenient way.

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.

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

The provider conducted annual patient satisfaction surveys. The service provided evidence that any negative reviews were followed up with the patient. The provider had made improvements to the service from patient feedback. For example, they had recruited additional GPs to reduce the waiting time experienced by patients for consultations. The provider also gathered feedback from a consumer review website. Patient feedback was published on the service’s website.

Staff could provide feedback through regular staff meetings, a staff suggestion box and performance reviews. There was a smart phone messaging app used as a forum where staff could ask questions, seek advice and support each other on clinical and non-clinical topics.

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 registered manager 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.

The provider was planning a number of service enhancements over the next 12 months;

  • An exercise consultant to provide online coaching for patients who need to lose weight.
  • A dietician service for patients prescribed weight loss medicines.
  • Online physiotherapy services.
  • A new prescription service, where prescriptions direct to a local pharmacy will be offered as an alternative to next day delivery.
  • Morning sickness treatment, social anxiety treatment and blood glucose testing for high risk patients.