Archived: The Tower of London Surgery

Updated 27 March 2017

The Tower of London Surgery is a practice located within the grounds of Her Majesty’s Tower of London and the practice list is restricted to residents of The Tower of London. The practice currently provides GP primary care services to approximately 90 people. The majority of residents consist of Yeomen Warders of Her Majesty's Royal Palace and Fortress the Tower of London and their families. Yeomen Warders are recruited from retired senior non-commissioned officers of the armed forces who have a minimum of 22 years of active service. Yeoman Warders may stay in post until the normal retirement age of 67, at which age they leave the service and cease to be residents at The Tower of London.

A medical practice has been located in the grounds of The Tower of London for several centuries, and up to 1969, the service was provided by medical staff of the British Armed Forces. In 1969, the military ceased the formal provision of medical services and a succession of doctors were appointed by the authorities at The Tower to the role of ‘Medical Officer’ at the location. Although these appointees had no formal relationship with the NHS, their role was acknowledged and the surgery was permitted to remain at the location without direct support from the NHS. Initially, appointees were retired senior military medical officers but more recent appointees have had no military connections. In the mid-1980s, administrative responsibility for The Tower of London passed to a self-governing charity known as Historic Royal Palaces and efforts were made to formalise the status of the practice as a branch surgery of an established local practice. This was not successful and the status of the practice and its relationship with the NHS has continued to be informal and undefined. The practice has been operating as a sole provider by the GP who was appointed to the role of medical officer in 1989. Although this appointment was confirmed by NHS management in 1993, the practice does not have a contract with the NHS and the incumbent medical officer is currently unpaid for their services.

There is currently one male GP and no other staff at the practice. There is no formal appointment system. The practice provides two formal GP sessions per week, between 6pm and 8pm on Monday and Thursday evenings and these are managed as walk-in sessions. However the GP lives on site and by tradition, patients can also visit the medical officer’s residence without an appointment and we were told this is the preferred option for many patients. All patients may request a home visit. The location has particularly stringent security arrangements in place which means that there are regular periods when no-one is permitted to enter or leave the grounds. Consequently, the practice provides its own out of hours service and the GP is on call twenty four hours per day.

The practice is registered with the Care Quality Commission to provide the regulated activity of treatment of disease, disorder or injury.

The practice is located in a single consulting room within the grounds of The Tower of London. There is a waiting room adjacent to the consulting room but this is shared as a rest area for Yeoman Warders. The consulting room used by the practice is several centuries old and its structure and decoration have been listed as Grade 1 by Historic England and as a World Heritage Site by the World Heritage Committee of UNESCO. (Buildings which have been listed as Grade I have been identified as being of exceptional national interest and are obliged to retain historical features).

The GP lives on-site in the Medical Officer’s Residence which is situated a short distance away.

The practice had not previously been inspected.

Updated 27 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Tower of London Surgery on 10 January 2017. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There were arrangements in place to safeguard children and vulnerable adults from abuse
• Risks to patients were assessed and well managed. Although the practice did not have its own portable defibrillator, several were available and accessible in the immediate vicinity and the practice had the support of The Tower of London’s trained first aid responders.
• The practice had a range of clinical equipment available to diagnose and treat patients and had recently put arrangements in place to have this equipment checked to ensure it was working properly.
• The practice was clean and had undertaken annual infection control audits but there were issues, for instance, chairs used by patients could not be wiped clean and arrangements to manage clinical waste did not reflect best practice.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• The GP assessed patients’ needs and delivered care in line with current evidence based guidance.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to access the GP and there was continuity of care, with urgent appointments available the same day.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Put arrangements in place to mitigate risks associated with infection by providing chairs which are easily cleaned and a suitable container for clinical waste.
• Review arrangements to provide chaperones to determine whether these should include a process to carry out DBS checks on persons carrying out the role.
• Consider developing a process to compare patient outcomes at the practice with those of neighbouring practices and national averages until such time as the practice participates in the Quality Outcomes Framework (QOF) programme.
• Ensure there is an effective and accessible system for identifying, receiving, handling and responding to complaints from people using the service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 27 March 2017

Numbers in the population group of people with long-term conditions were insufficient for CQC to pass comment, so we did not rate it. It must be noted, however, that the practice demonstrated an awareness of the needs of people with long-term conditions and all patients with these conditions were able to continue working normally with the care and support of the practice.

Updated 27 March 2017

There were a very small number of families with children aged under 18 years of age registered with the practice. Numbers in this population group were therefore insufficient for CQC to pass comment, so we did not rate it. It must be noted, however, that the practice demonstrated an awareness of the needs of families, children and young people.

Updated 27 March 2017

There were no patients over the age of 75 registered with the practice, so we did not rate it. It must be noted, however, that the practice demonstrated an awareness of the needs of patients over the age of 75.

Updated 27 March 2017

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• All patients could request home visits and this happened regularly.

• There was a flexible approach to appointments, for instance patients could call to the private residence of the GP at any time and would be seen.

• There was no time limit on the length of time taken during consultations.

Updated 27 March 2017

There were no patients experiencing poor mental health (including people with dementia) registered with the practice, so we did not rate it. It must be noted, however, that the practice demonstrated an awareness of certain cultural barriers which may inhibit the diagnosis of mental health conditions and remained vigilant to the needs of patients who may require additional support with mental health needs even if a diagnosis was not in place.

Updated 27 March 2017

There were very few patients whose circumstances may make them vulnerable registered with the practice. Numbers in this population group were therefore insufficient for CQC to pass comment, so we did not rate it. It must be noted, however, that the practice demonstrated an awareness of the needs of patients whose circumstances may make them vulnerable.