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Inspection Summary


Overall summary & rating

Good

Updated 27 November 2019

We carried out an announced comprehensive inspection at MedicSpot HQ on 19 September 2019 as part of our rated inspection programme. We previously inspected this service on 30 November 2017 using our previous methodology, and found the service was compliant with the relevant regulations. At that inspection, we did not apply ratings.

MedicSpot HQ offers an online doctor service providing both pre-booked and walk-in video consultation appointments for patients at clinical stations based within pharmacies.

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

Inspection areas

Safe

Good

Updated 27 November 2019

We rated safe as Good because:

Keeping people safe and safeguarded from abuse

Staff employed had received training in both adult and child safeguarding relevant to their role and knew the signs of abuse and to whom to report them. All the GPs had received level three child safeguarding training and were on the NHS Performers Lists. It was a requirement for the GPs registering with the service to provide evidence of up-to-date safeguarding training certification and the provider ensured appropriate safeguarding training for adults and children was completed by the GPs prior to any patient facing interactions for the service.

All staff had access to safeguarding policies and could access information about who to report a safeguarding concern to. The safeguarding policies for both adults and children contained contact details of safeguarding teams for each local authority in the UK. The online consultation system also provided GPs with details of local safeguarding contacts in the area that the patient was located in.

The service offered treatment to patients aged 5 years and over. It was company policy that any patients aged between 5 and 14 years of age must be accompanied by an adult. Photographic identification was required for patients under 18 years of age and for both the parent/guardian and child at the beginning of any consultation with a child.

Monitoring health & safety and responding to risks

The provider’s headquarters office housed its managerial and administrative staff. Service users did not attend the headquarters premises as GPs carried out online video consultations remotely, usually from their home, and patients attended participating pharmacies to access the service.

All staff based in the headquarters premises had received training in health and safety including fire safety. Staff working remotely were required to complete a risk assessment to ensure their working environment was safe. Participating pharmacies were responsible for monitoring the health and safety of their own premises.

The clinical stations based in the participating pharmacies were provided with an equipment tower by MedicSpot. This included a blood pressure machine, a stethoscope (to listen to the heart and lungs); an otoscope (to look into the ears); a pulse oximeter (to measure oxygen levels and pulse rate); and a thermometer. This equipment was provided by MedicSpot who were responsible for maintenance, repairs and annual calibration. Pharmacy staff were responsible for cleaning and checking the equipment between patients and had been provided with support from the provider about how to do this.

The provider expected that all GPs would conduct consultations in private and maintain the patient’s confidentiality. Staff used a two-factor authentication access code to log into the operating system, which was a secure programme.

All clinical consultations were assessed by the GPs for risk. For example, if the GP thought there may be serious mental or physical issues that required treatment they were unable to provide they were able to discontinue the consultation and arrange a refund of the fee paid by the patient and refer them to a more appropriate care setting.

The service was not intended for regular use by patients with long term conditions or as an emergency service. In the event an emergency did occur, the provider had systems in place to manage the situation and patients were supported with onsite pharmacists. There were also 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.

Staffing and Recruitment

There were enough staff, including GPs, to meet the demands for the service. There was a support team available to the GPs during consultations including the Chief Executive Officer and Medical Director both of whom were GPs, a pharmacist and a separate IT team. The prescribing doctors were paid on an hourly basis.

The provider had a selection and recruitment 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) with a license to practice and 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 held a professional indemnity policy, which covered all clinicians who worked for them.

Newly recruited staff were supported during their induction period and a plan was in place to ensure all processes had been covered. We reviewed four recruitment files which showed the necessary evidence was maintained and available. Staff could not commence health coaching consultations until induction training had been completed. The provider kept records for all staff and there was a system in place that flagged up when any documentation was due for renewal such as relevant professional registrations. All staff were subject to annual appraisals, which we saw were up to date.

Prescribing safety

GPs diagnosed patients’ conditions and prescribed treatment according to the clinical need of the patient. GPs told us they prescribed medicines from the British National Formulary with the exception of controlled drugs and injections including insulin and glucagon-like peptide-1. If a medicine was deemed necessary following a consultation, the GP issued a private prescription for the patient. All medicines prescribed to patients during a consultation were monitored by the provider to ensure prescribing was evidence based and any form of abuse such as excessive prescription requests was prevented.

The service had a prescribing policy in place and GPs told us they generally prescribed a maximum of two months’ supply of medicines with the exception of some high-risk medicines, including antidepressant initiation. These medicines are limited to a 14 - 28 days’ supply and patients are required to book another consultation before any further prescriptions are issued.

When booking their consultation, patients were required to choose a pharmacy (from a list of participating pharmacies) where they would like their consultation to take place and if required, their prescription dispensed. The dispensed medicines were not included as part of the overall service offered to the patient.

There were protocols in place for identifying and verifying the patient, and General Medical Council guidance was followed. Patients registering with the service were required to provide photographic identification and the picture was then compared to their image on screen.

The provider’s website included guidance on the type of ailments the service was able to treat. The website also provided clear guidance on conditions which the service did not treat which included suspected heart attack or severe chest pain, neurological deficit or suspected stroke and seizures, severe or heavy bleeding, severe or sudden onset of pain, severe mental health issues, pregnancy related complication, major trauma on any part of the body and unrelenting high fever. In July 2019, the provider ceased the prescribing of controlled drugs. These medicines had been assessed by the provider as posing too high a risk to prescribe remotely.

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.

All individual patient consultations were recorded. GPs could check if patients had accessed the service previously. We reviewed a sample of patient records and found that they had not been prescribed repeat quantities of medicines inappropriately. We were told that if the GP felt it was important that information was shared with the patient’s own GP they would actively encourage the sharing of information, and if refused would consider if treatment was still appropriate.

A system was in place to ensure that only one authorised copy of the prescription could be presented and the pharmacists we spoke with assured us that the system was used effectively by MedicSpot and all prescriptions were correctly reconciled within 72 hours as is required by legislation.

The service prescribed some unlicensed medicines and medicines for unlicensed indications if appropriate. (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). Clear information was given to the patient by the GP to explain that the medicine was 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. The patient record system also included a prompt to the GP to alert that they were prescribing an unlicensed medicine to ensure they alerted the patient.

GPs prescribed to current evidence-based guidance and standards, including National Institute for Health and Care Excellence (NICE) evidence-based practice. The service encouraged good antimicrobial stewardship by only prescribing from a limited list of antibiotics which was based on national guidance.

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 to deal with medicine safety alerts. The Medical Director was signed up to receive MHRA (Medicines and Healthcare products Regulatory Agency) patient safety alerts and disseminated any relevant information to the doctors and pharmacists as appropriate. Staff told us MHRA alerts were disseminated within 24 hours and since our last inspection, a new system had been introduced to assure the provider that staff had read any alerts disseminated to them.

There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members. We reviewed the three incidents that had occurred in the previous 12 months and found that these had been fully investigated, discussed and, if required, action taken in the form of a change in processes. We saw evidence that the provider learned from incidents. For example, a GP had prescribed an incorrect dose of an antibiotic after failing to double check the prescription before sending it to the pharmacy. Learning from this incident identified that GPs should ensure all processes in the software are followed and not bypassed.

Monthly clinical meetings were held and attended by all clinical staff. Standing agenda items included discussion of significant events. The Medical Director also told us that GPs were able to submit ‘case studies’ and 'reflections' which did not constitute significant events but were opportunities to reflect and share learning with the clinical team. The provider retained a summary of all incidents in order to identify and analyse trends. We saw evidence from the incidents we reviewed which demonstrated the provider was aware of and complied with the requirements of the Duty of Candour by contacting the patient when things went wrong, offering an apology and advising them of any action taken. etailed findings narrative goes here…

Effective

Good

Updated 27 November 2019

We rated effective as Good because:

Assessment and treatment

We reviewed 18 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. We saw evidence of up to date NICE guidance available on the shared drive which all GPs had access to. GPs told us they used NICE guidance for treating MedicSpot patients in the same way as they did working in general practice. Staff gave us an example of where a MedicSpot GP had shared a hormone replacement therapy (HRT) flowchart with the service which was taken from their own GP practice to support MedicSpot GPs with the prescribing of HRT.

Patients were not required to complete an online consultation form to describe details of the condition or their past medical history. An online form was completed by the patient when booking the consultation appointment, but this only required details of the patient’s identity, such as name address, telephone number and date of birth. All relevant medical history was obtained during the video consultation and recorded by the consulting GP in the patient’s record. This included the reasons for the consultation and the outcome, along with any notes about past medical history and diagnosis.

A consultation checklist was available for use by the GP to ensure the consultation procedure was adhered to. We saw that adequate notes were recorded, and the GPs had access to all previous notes. All consultations were recorded free text and allowed the doctor to make a detailed record of the discussions they had with the patient and their diagnosis.

We were told that no limits were imposed on consultation times, but the appointments were available in 15 minute slots. All patients were required to provide an email address or telephone number to facilitate any follow-ups as required. If the service could not deal with the patient’s request, this was explained to the patient and a record kept of the decision.

Quality improvement

The service 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.

Staff told us prescribing audits of all GPs was carried out on a quarterly basis which involved a review of a random sample of ten consultations per GP. In addition to these prescribing audits, record audits were carried out on a bi-annual basis in addition to observation of practice which the Medical Director undertook with patient consent.

A number of specific prescribing audits were undertaken on a regular basis including the monitoring of antibiotic prescribing. We saw evidence of a two-cycle audit of antibiotic prescribing in which the first cycle demonstrated 71% of antibiotics were appropriately prescribed. The pharmacist explained to us how following this first cycle audit, the prescribing of antibiotics was discussed with the GP team and the revised guidance from NICE regarding antibiotic stewardship was shared with them. The second cycle of this audit demonstrated an improvement from 71% to 86%. The service told us they planned to re-audit this further.

Staff training

All staff had to complete induction training when joining the organisation. This included terms and conditions of employment; safeguarding, health and safety; work duties; and learning and training needs. An induction and staff training policy were in place.

GPs had received specific induction training prior to treating patients. An induction log was held in each staff file and signed off when completed. GPs received support if there were any technical issues or clinical queries and could access policies remotely. When updates were made to the IT systems or policies and procedures GPs received updates and training if required.

Administration staff received regular performance reviews. All the GPs had to have received their own GP appraisals before being considered eligible at recruitment stage. GPs had to provide evidence of participating in the GP appraisal scheme (a copy of the most recent appraisal was retained in the staff record). All GPs were required to include reference to their video consultation work in future GP appraisals.

Staff told us GPs were provided with training and support if any individual GPs lacked any knowledge or expertise in a particular area of prescribing. For example, the pharmacist gave us an example of when a GP was not comfortable in prescribing an injectable contraceptive to a patient who was visiting the UK and lived overseas. This case was discussed amongst the GPs and the patient was then consulted by another GP in the service who was knowledgeable about the medicine and had prescribed it in general practice previously. This GP then shared their knowledge about this area with the MedicSpot GP team.

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 and examples of letters sent to patients GPs to request them to carry out any recommended blood or diagnostic tests which the service was not able to carry out.

Supporting patients to live healthier lives

The service identified patients who may be in need of extra support and GPs could signpost patients to sources of advice and information as necessary.

In their consultation records we found patients were given advice on healthy living as appropriate.

Caring

Good

Updated 27 November 2019

We rated caring as Good because:

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 however, we were unable to secure evidence to corroborate this due to our inspection being undertaken at the service headquarters.

At the end of every consultation, patients were sent an email asking for their feedback. We did not speak to patients directly on the day of the inspection. However, from the patient feedback we reviewed we saw that the vast majority of patients were satisfied with the way they were treated, and prompt action was taken in response to negative comments. For example, one comment had been received on Trustpilot regarding the sanitation of equipment and the service took immediate action to address this issue and ensure that MedicSpot sanitation policies were upheld by all the participating pharmacies.

The clinical stations where patients were able to access the video consultations were situated within private rooms in the pharmacy where patient confidentiality could be maintained. If patients needed help with any of the equipment they were able to call a member of the pharmacy staff to support them. Between consultations the equipment was cleaned and checked for the next patient.

Involvement in decisions about care and treatment

Patient information guides about how to use the service and technical issues were available on the website. Patients could contact the service by post, email, instant messaging service, and telephone.

Patients had access to information about the GPs working for the service but could not book a consultation with a GP of their choice. However, staff told us patients could request a consultation with a male or female GP through the office and a specific GP if they were returning to the service.

The latest survey information indicated that the vast majority of patients were satisfied with the service they received. All negative comments were reviewed, analysed and actions for improvement identified and implemented.

Video consultations were not recorded but patients could access their consultation records.

Responsive

Good

Updated 27 November 2019

We rated responsive as Good because:

Responding to and meeting patients’ needs.

Patients carried out a booking to arrange a video consultation appointment with a GP and were required to attend the appropriate pharmacy at the allotted time where they were shown to a private room containing the clinical station. There were no set time limits for a consultation. Consultations could be booked between 9am and 9pm daily. However, this was also dependent on the opening times of individual pharmacies and the availability of appointments. Access via the website to book a consultation was available 24 hours a day. The service was not an emergency service. Patients who had a medical emergency were advised to ask for immediate medical help via 999 or if appropriate to go to the Accident and Emergency Department (A&E) or NHS 111.

The provider made it clear to patients on the website what the limitations of the service were and consulting GPs explained fully to patients if they felt it was inappropriate to provide treatment. We saw examples of patients being refunded the consultation fee when the GP felt it was inappropriate to prescribe medicines demanded by a patient. When the provider could not deal with the patient’s request, this was explained to the patient and a record kept of the decision.

Patients were asked to complete a post-consultation feedback form immediately after the consultation. The vast majority of feedback was positive, but the provider reviewed all negative comments and identified actions for each issue raised to improve the service.

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 on the service website however patients were not able to choose a specific GP for their initial consultation.

Managing complaints

Information about how to make a complaint was available on the service website. The provider had a complaints policy and procedure in place which contained appropriate timescales for dealing with complaints. A link was available on the website for the reporting of complaints. We reviewed the complaint system and noted that comments and complaints made to the service were recorded and action taken where appropriate.

We reviewed the two complaints received in the past 12 months. The provider was able to demonstrate that the complaints we reviewed were handled correctly and patients received a satisfactory response. There was evidence of learning as a result of complaints, changes to the service had been made following complaints, and had been communicated to staff.

Consent to care and treatment

There was clear information on the service’s website with regards to how the service worked and what costs applied including a set of frequently asked questions for further supporting information. The costs of any resulting prescription were handled by the pharmacy when the prescription was dispensed. 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 27 November 2019

We rated well-led as Good because:

Business Strategy and Governance arrangements

The provider told us they had a clear vision to improve accessibility to high quality healthcare, improve health outcomes for patients, bring digital healthcare into mainstream and lower demand on NHS services. We reviewed a business plan that covered the next three years.

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 and updated when necessary.

There were a variety of monthly and quarterly checks in place to monitor the performance of the service. These included a random audit of consultations and prescribing for each GP every quarter and observed patient consultations with patient consent. In addition, any consultations rated by patients with a score of five out of ten or below, were reviewed. Information generated from these checks were discussed at monthly staff meetings. This ensured a comprehensive understanding by all staff 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. The service had arrangements in place outlined in a records policy, to store clinical records in line with legislation should they cease trading.

Leadership, values and culture

The Chief Executive Officer (and founder) of the service had overall responsibility for the service and shared the operational and clinical management of the service with the Medical Director, both of whom were qualified GPs. The Chief Executive Officer and Medical Director had responsibility for any medical issues arising and either attended the service’s head office or were available remotely daily.

The Chief Executive Officer was also the Registered Manager for the service. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

All staff were clear about the values of the service which included an overarching aim to provide convenient, high-quality and safe healthcare through the use of information technology. 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.

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. Service data was stored on a secure server, with the system requiring multifactor authentication to access.

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. All patients were asked to complete a post-consultation feedback immediately after their appointment. Patient feedback was constantly monitored; any ratings of five out of ten or below were automatically reviewed by the management team. Patient feedback was published on the service’s website. From the data we were shown, the vast majority of patient feedback was positive.

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

The provider had a whistleblowing policy in place. (A whistle blower is someone who can raise concerns about practice or staff within the organisation.) The Chief Executive Officer was the named person for dealing with any issues raised under whistleblowing.

Continuous Improvement

The service consistently sought ways to improve. Incidents and good practice cases were analysed and presented at clinical meetings to ensure learning and the development of the service.

All staff were involved in discussions about how to develop the service and were encouraged to identify ways to improve the service delivered. We saw minutes of staff meetings where previous interactions and consultations were discussed. The management team and the IT teams worked closely together and there were ongoing discussions at all times about service provision.

Staff told us that they could raise concerns and discuss areas of improvement at any time including at team meetings. There was a quality improvement strategy and a plan in place to monitor quality and to make improvements, for example, through clinical audit and reviews of patient consultations.

In addition to plans to develop the business, the provider had also identified several areas for development in order to improve the service for patients. For example, the provider was working with Warwick University to assess externally what the service was doing well and what needed to be improved; discussions were underway with Health Education England to explore the possibility of allowing GP registrars to observe and participate in the video patient consultations; and the provider was investigating ways to improve the process for sharing patient consultations with patients GPs.